You will notice that the title of this blog is not ‘independent vs. employee model’: I readily acknowledge that I know little about being an employed emergency physician. Having spent my entire career as, initially, an independent contractor, and then as a partner in a large EM partnership; I am not the guy to be making a comparison between these modes of EM practice. However, I recently heard from one of ACEP’s Board members (Dr. Kivela) that approximately 55% of emergency physicians in this country are now employed by hospitals (or was that employed by someone?). In either case, this fact led me inevitably to reflect on these two modes of practice, and the many variations on these themes, and how this trend towards more EP employees and fewer EPs practicing as independent contractors or partners is likely to impact the practice of EM, our patients, our hospitals, and our specialty.
Of course, this is a topic that could never be covered in a blog, perhaps not even in a textbook, but I hope to generate some discussion of these issues here in The Central Line and elsewhere. I have far more questions than answers to offer, as you will see; but these are questions that we should try to answer before they are answered for us. Health Reform is going to put even more pressure on the independent EP practice model as policy makers and insurers push to consolidate providers into vertically integrated health care systems to foster accountability and coordination of care (euphemisms for risk-sharing and cost-cutting). How our specialty and the house of medicine respond to this pressure will have a major impact on the practice of EM, from the choice of meds we use to the professional affiliations we make.
One of the first questions that come to mind when exploring independent and employee models of practice revolve around the corporate practice of medicine. There are only a handful of states that have a bar against the corporate practice of medicine, and enforcement of these bars vary considerably. The rationale for prohibiting corporations from influencing the practice of medicine is nicely summarized by the CA Medical Board: and the gist is that this bar is “intended to prevent unlicensed persons from interfering with or influencing the physician’s professional judgment”. The Medical Board provides examples of “types of behaviors and subtle controls that the corporate practice doctrine is intended to prevent”. Hospitals are sometimes exempted from such state bars, as hospitals are also licensed, but the concept is premised on an obligation to protect consumers (patients) from profiteers, and hospitals are no strangers to the profit motive. First question: Are EPs who are employed by hospitals more or less subject to controls and subtle pressures impacting medical decision-making than EPs who are employed by a medical group, or EPs who are part of a medical partnership, or EPs that are independent contractors? I know for a fact that EPs who practice in the ‘independent mode’ can be subjected to such pressures, geared towards improving the hospital’s bottom line, especially since EM group–hospital staffing contracts can be, and have been, canceled for ‘no cause’; and I suspect that employed EPs are regularly subjected to subtle (and not so subtle) pressures to adjust their practices to accommodate hospital employer expectations and financial goals. Put another way: if you were a patient in an ED, would you have more trust in an EP who was a hospital employee or an independent contractor or a partner in the EM practice? How about if he or she was an employee of your insurance plan? There probably isn’t any data to support your preference, but perhaps there should be. The rise of managed care, risk-sharing ventures, IT demands on investment capital, and the surge of interest in ACOs is going to put increasing pressure on states to eliminate or modify corporate bars on the practice of medicine. Wouldn’t it be appropriate for legislators to know how ‘corporate influences’ impact the care we provide, and how patients feel about that?
Here are some more questions that deserve to be answered: Which practice mode pays EPs more appropriately? Which contributes more towards enhancing the value of EM practice? Is a hospital CEO more likely or less likely to appreciate excellent EP care and service if the EP is an employee or a member of a contract staffing group? To whom do employed EPs look when seeking support for improved salaries or working conditions? Should ACEP develop into a union for these physicians? I heard a rumor that some hospitals have discouraged their EPs from joining ACEP – is that true?
Which mode of EM practice provides greater encouragement or incentive to document their care appropriately so as to assure appropriate third party reimbursement? Are hospital-employed EP salaries indirectly dependent on the ability of staffing-contract EPs to collect fair payment from health plans? Do independent mode EPs have greater or fewer opportunities to move to new communities and keep their ‘tenured’ pay rate? Are they happier with their practice setting? Which has the better malpractice experience? Which offers more support when the provider is sued?
I could go on, but you get the gist. There may be no good way to really answer many of these questions, but this shouldn’t deter us from discussing the issues. Let me give you just one example of why these considerations need to be aired. ACEP is going to be developing strategies for EP participation in ACO risk-sharing, payment bundling, and shared savings arrangements under health reform. I have no doubt that these strategies may be very different for hospital-employed EPs, for academic group EPs, staffing contract model EPs, and medical group employed EPs. ACEP may not have the resources to address each of these strategies for each of these member groups, so where should the emphasis be made? Here’s another: ACEP is increasing its advocacy role in DC, and reaching out to EPs to financially support this effort separate from ACEP dues. Which EPs are more likely to contribute to this effort? Should some ACEP advocacy resources be expended to support the independent practice of EM, or should ACEP be advocating for the right to represent employed EPs, or both?
If you are worried that discussing these questions exposes the soft underbelly of EM, or somehow might precipitate the deconstruction of the cooperative venture that ACEP represents: get over it. The forces aligned to divide and conquer the practice of emergency medicine, and the practice of medicine in general, have already begun their work, and everything that defines our profession is now in play.