Nothing to Lose but Our Chains
2017; Elsevier BV; Volume: 69; Issue: 4 Linguagem: Inglês
10.1016/j.annemergmed.2017.02.006
ISSN1097-6760
Autores Tópico(s)Healthcare Policy and Management
ResumoA walk through practically any US business district in recent decades shows independent pharmacists replaced by CVS or Walgreen's and mom-and-pop cafés supplanted by Starbucks or Peet's. In some industries, the consolidation of multiple smaller businesses into a few national-scale organizations is pervasive, yet the phenomenon does not go unlamented. Economies of scale can bring benefits, at least to some participants; something can also be lost—perhaps tangible, perhaps ineffable—when control of a proprietorship passes from identifiable and accountable individuals to a corporate entity. The effects of such a process on the practice and business of medicine, naturally, are far more complex than the effects seen in chain stores. Group practice in the United States, dating back to the founding of the Mayo Clinic in 1892, expanded after World War I and accelerated significantly after 1969; although the distribution of physicians among small and large groups, according to American Medical Association data, remains skewed toward the former, the latter (defined as groups larger than 100 physicians) now have the fastest rate of growth.1Madison D.L. Notes on the history of group practice: the tradition of the dispensary.Med Group Manage J. 1990; 37 (56-60, 86-93): 52-54PubMed Google Scholar, 2Smart D. Physician Characteristics and Distribution in the US. American Medical Association, Chicago, IL2013Google Scholar, 3Burns L.R. Goldsmith J.C. Sen A. Horizontal and vertical integration of physicians: a tale of two tails.in: Friedman L.H. Goes J. Savage G.T. Annual Review of Health Care Management: Revisiting the Evolution of Health Systems Organization. Emerald Group Publishing Limited, Bingley, UK2013Crossref Scopus (82) Google Scholar The physician practice management firms of the 1980s and 1990s peaked and to a large extent crashed, yet consolidation continues in various forms: single- or multiple-specialty group practices, salaried relationships with hospitals or health plans, contractually based physician-hospital organizations, independent practitioner associations, and newer risk-sharing arrangements such as accountable care organizations. To obtain the benefits of outsourcing business-side concerns to nonphysicians without ceding too much control, emergency physicians and other specialists have launched their own practice groups. Several have expanded to the regional or national scale: organization names such as ApolloMD, CEP (formerly California Emergency Physicians), EmCare, Hospital Physician Partners, Schumacher, Sheridan, Team Health, and US Acute Care Solutions (USACS) will be familiar to any emergency physician who has reviewed job listings in the field. Some, such as EmCare and Team Health, were founded by physicians but later acquired by corporate investors; others have remained in the hands of physicians. Large-scale practice groups with physician ownership or operational control, say their officials and proponents, can offer an alternative to corporate contract management groups with majority nonphysician ownership, ensuring that the professional dog wags the business tail, not vice versa. As these groups have proliferated and consolidated, however, some critics ask how different they really are from contract management groups4Anonymous. An open letter to contract group CEO's. 2016. Available at: https://forums.studentdoctor.net/threads/an-open-letter-to-contract-group-ceos.1195036/. Accessed January 31, 2017.Google Scholar and whether they realize the promised benefits for physicians and patients. “No one in health care is immune to the forces of consolidation,” said Dominic J. Bagnoli, MD, chief executive officer of USACS, one of the nation's major physician-owned practice groups. “That goes for payers, hospitals, device manufacturers, and providers. It’s a cycle that plays out in every industry, and if you don’t participate, there’s a potential to be left behind.” USACS is one of the larger national players, a hybrid organization formed when Canton, OH–based Emergency Medicine Physicians joined with capital partner Welsh, Carson, Anderson & Stowe in 2015, anticipating synergies between medical and financial expertise. USACS, 1 of 12 firms in Welsh Carson's current health care portfolio, also includes several regional groups among its founding partners, which include Emergency Medicine Physicians; Emergency Service Partners in Texas; Ergentus, Apex Emergency Group, and Emergency Physicians at Porter Health in Colorado; Tampa Bay Emergency Physicians in Florida; and MEP Health (formerly Medical Emergency Professionals) in Maryland. “USACS is majority physician owned,” Dr. Bagnoli reported. “That’s a big difference. USACS was created to ensure the physician-ownership model for the long term.” Another growing firm, Schumacher Clinical Partners, launched in Lafayette, LA, in 1994 as a small emergency medical group, aligned with its first hospital (Opelousas General) the same year, and expanded steadily during 2 decades, merging with Hospital Physician Partners of Hollywood, FL, in 2015 and with Traverse City, MI–based ECI Healthcare in 2016 to become a national behemoth, operating 450 facilities in 31 states, with more than 7,200 providers serving more than 8 million patients. Schumacher has diversified from its original single-specialty status to include hospital medicine, telehealth, employer-provider linkage, and consultancy. The firm remains privately owned and led by board-certified emergency physicians, including its founder, William C. “Kip” Schumacher, MD. Randy L. Pilgrim, MD, Schumacher's chief medical officer, attributes some of the firm's growth to a combination of standardization, resource scale, and organizational culture, all of which can insulate a practitioner or small group from administrative headaches in the era of close Medicare scrutiny, private-insurance complications, and Patient Protection and Affordable Care Act–related disruptions. “The most consistent driver that we hear from people that are not part of a consolidated effort comes from individual physician practices or very small groups that say they're having trouble keeping up with the practice demands, the administrative demands, and the meteoric increase in all of the above,” he said. Consolidation offers standardization of both administrative and clinical processes, Dr. Pilgrim continued: “The 3 tenets that we use for increasing quality are to deliver high-quality evidence-based care, to reduce the variation in that care across providers and provider communities, and then to trend positively…. Smaller practices frequently use all of their resources in the practice itself, as opposed to supporting it and developing the practice itself.” Physician ownership is only one of the essential variables, he added. “You can have management, influence, control, and direction without majority ownership. You can have it with majority ownership as well. The real question is, what culture does the organization have?” In emergency medicine, consolidation has taken a firmer and earlier hold than in most other specialties.5Flynn G. A clash of practice models: debate roils around mega-group medicine.Ann Emerg Med. 2006; 47: 347-350Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Physicians and scholars who have analyzed the phenomenon cite a range of factors, including the timing of the specialty's founding in relation to the increases in group practice, the relatively small number of emergency departments (EDs) nationwide in relation to private offices, the commonalities of expertise in emergency practice, the hospital setting with a central role for the ED in admissions, the energetic entrepreneurialism of certain early entrants in the field, and the incentives and priorities commonly found among emergency physicians. “There are a number of my colleagues that went into medicine so they didn't have to deal with the things that we bring to their practices,” Dr. Pilgrim noted. “They don't want to deal with administrative tasks. They don't want to look into the future and say, ‘What does my practice need to look like 5 years from now?' because that's an eternity for them, and they make decisions to affirm families, lifestyle, other pursuits; and that leaves the work yet to be done, so that's what we do.” Dr. Pilgrim acknowledges critiques of practice management groups over micromanagement but believes critics sometimes confuse the disease and the cure. “I think it's true that there is less autonomy in clinical medicine than there has been in the past decade or two. I think that's true. The question is whether the practice model helps you with that or increases that burden, and it's our view that we actually help you with that. And there are times when we know that we're shot because we're the messenger, or even the solution maker. But over time, that tends not to last because in fact the realities we help people see are not ones we've created. They're ones that we've brought solutions for.” Perspectives differ on whether practice consolidation is a solution or a problem in its own right. The corporatization of emergency medicine was a primary concern in the professional-society schism that led to the formation of the American Academy of Emergency Medicine (AAEM) in 1993. AAEM's founding president, James Keaney, MD, had pseudonymously written The Rape of Emergency Medicine6Keaney J. The Rape of Emergency Medicine.2004http://journals.lww.com/em-news/Documents/The_Rape_of_Emergency_Medicine[1].pdfGoogle Scholar in response to assorted abuses that he correlated with corporate control. In Dr. Keaney's caustic caricature of contemporary practice conditions—later substantiated in some instances by investigations televised on CBS's 60 Minutes7CBS News. 1993: Mike Wallace reports on ER docs. 1993. Available at: http://www.cbsnews.com/news/1993-mike-wallace-reports-on-er-docs/. Accessed January 29, 2017.Google Scholar, 8CBS News. Hospitals: the cost of admission. 2012. Available at: http://www.cbsnews.com/videos/hospitals-the-cost-of-admission/. Accessed January 29, 2017.Google Scholar—the rank-and-file emergency physicians (“scrubs”) were being continually exploited by profiteers (“suits”) who, although some were MDs themselves, infringed on physicians' professional autonomy in every realm, from clinical protocols to coding to personnel decisions, spoke in glibly dishonest corporatese, and added little or no value to medical operations. Such practices, Dr. Keaney charged, had gradually overtaken the specialty, with comically ghastly effects on the quality of care. Dr. Keaney's cautionary tales, one should note, evoked corrective measures. “In my experience, physicians have done a good job protecting patients from the scenarios Dr. Keaney predicted,” said Dr. Bagnoli. “Every physician I know, in every specialty, can offer a tale about ‘bucking the system' for a patient. It’s our responsibility to remain uncomplacent to bad policy decisions.” Dr. Pilgrim noted that in conflicts between hospital management and physicians, “more frequently…a group like us would stand in between the provider and the pressures from the hospital, or hand in hand with them.” Robert M. McNamara, MD, professor and chair of emergency medicine at Temple University's Lewis Katz School of Medicine and second president of AAEM (1996 to 2002), noted that the more flagrant abuses in Dr. Keaney's book, including “the use of unqualified providers,” have diminished, yet “the issue of corporations being in control and running the practices has actually grown since the time of the publication of that book.” Observing that many states prohibit the corporate practice of medicine because of “abuses when you put the business interests between the physician and the patient” (eg, the inherent company-store-style conflicts of interest when early-20th-century industries employed physicians to treat workers), Dr. McNamara found little substantive distinction between such arrangements and today's conditions, in which “they basically get around those laws by using sham professional associations,” the professional corporations and limited-liability companies through which physicians are commonly organized in states with bans on the corporate practice of medicine.9Roth A.B. Gold K.J. Corporate practice of medicine: an old doctrine breathing new life. 2014; (Available at:) (Accessed January 29, 2017)http://www.nortonrosefulbright.com/files/20140625-corporate-practice-of-medicine-an-old-doctrine-breathing-new-life-124249.pdfGoogle Scholar “Emergency medicine unfortunately led this trend, and it was all about money,” continued Dr. McNamara. “The original code of ethics in 1968, the original bylaw of the American College of Emergency Physicians [ACEP], says that you will not make money off of your fellow physician.” Faulting both ACEP's leadership for accommodating corporate interests and the Society of Academic Emergency Medicine's leadership for indifference to practice concerns altogether, Dr. McNamara contended that many colleagues are sitting ducks for corporate rentier interests. “Some of it has to do with the lack of savvy of the people that went into emergency medicine,” he said. “The people who entered the specialty, they're not the typical doctors chasing the almighty buck. They're choosing to work in the emergency department, where you take care of the poor, the homeless, the undesirables.” The material damage to these nonfinancially focused physicians is quantifiable. According to analysis of forms that companies submit for initial public offerings and Forms 10-K for the Securities and Exchange Commission indicating their profit level, Dr. McNamara estimated that “in many cases, doctors are losing for profit 15 to 20 percent of what they're bringing in.” Bundled contracts, he added, often siphon funds from an ED to subsidize hospitalists and other less lucrative areas, “the other issue that's killing the specialty.” Dr. McNamara is under no illusions that the consolidation tide will be reversed any time soon, and he acknowledges that many physicians find salaried positions congenial. “I think everybody appreciates that the business of medicine is complex, and to try to do it yourself like it was done in the old days as just a mom-and-pop shop, but one of the docs being the chair and taking care of the business end, isn't the best or most efficient model. Getting professional help to run your practice—there's nothing wrong with that. But the issue is, if they control your practice, we think there's something wrong with that.” For physicians who seek the advantages of a large organization while viewing their autonomy on certain points as nonnegotiable, Dr. McNamara's organization has launched its own alternative, the AAEM Physician Group. His position during the years has been to promote board-certified emergency physicians' interests through editorial advocacy and AAEM policies,10McNamara RM. Rules of the road for young physicians: the corporate practice of emergency medicine. 2012. Available at: http://www.ypsaaem.org/benefits/rules-of-the-road-for-young-physicians/corporate-practice. Accessed January 29, 2017.Google Scholar, 11McNamara RM. The corporate practice of emergency medicine in Texas. American Academy of Emergency Physicians. Available at: http://www.aaem.org/em-resources/critical-em-and-practice-issues/corporate-practice/texas. Accessed January 29, 2017.Google Scholar supporting physician ownership, democratic procedures within organizations, and transparency in billing. “If there's one solution to moving emergency medicine away from the corporate practice, it would be for every emergency physician to see what's actually paid in their name, to see the amount of revenue they generate…. The majority of the emergency physicians do not see that. They have no idea of their economic worth. And if they ask for it, in the corporate world, they get threatened with termination.” Due process in personnel decisions, he said, is another fundamental right: “The ability to be fired without due process compromises our ability to advocate the best we can for the patients. It's pretty simple. Doctors should be the owners. They're the ones seeing the patients. They're the ones with the medical license. They're the ones there at 2 o'clock in the morning taking care of the sick trauma patient, and they should own it. That's why they went to medical school.” Physician ownership, he finds, is necessary but not sufficient to protect physicians, particularly in groups in which non-MD investors have a substantive interest. “The question is,” Dr. McNamara continued, “what is truly a physicians-owned group? In its purest definition, it's led by physicians; there isn't lay influence. And doctors who join it can become an equal in the group. I mean, that's…the democratic definition, where you join a group; after a trial period, you have an equal share of the profits and an equal say in the decisions affecting the group. That's the ideal model. But you have some large groups, while physician-owned, [that] don't fit that model. So what the American Academy is trying to do with its Physician Group is to basically lay a set of principles down that will ensure fairness [so] that it will be more like a traditional model where people are in it together, working as equals, sharing equally in the profits of the group.” The AAEM's position, Dr. McNamara acknowledged, is not universal among emergency physicians; some are comfortable with the circumstances that large groups offer. “Frankly, it's thought to be part of a generational thing to say, ‘Look, I'm making good money. I know somebody's making a profit off of me, but I just want to go in and do my shifts, and that's how I want to live my life.' And that's fine…. If you look at the ads for some of these companies that actually play on that, they say, ‘Hey, come work for Team Health and you can spend your time surfing, mountain biking….' It's a trade-off, though. You'll make good money—not as much as you could—but you'll also be under the control of an administrator, who will want you to meet metrics, who will want you to have higher patient satisfaction scores, who will want you to basically yield to whatever the hospital administration thinks emergency medicine should be doing. Okay. Who will not support you if you get into a dispute with some other specialist at the hospital. Who will defend the contract, the profit stream from the contract, more than they will you as an individual physician.” Independence from micromanagement in decisions about matters such as shift schedules, patients-per-hour quotas, or Press Ganey surveys, Dr. McNamara added, may become more valuable as emergency physicians progress in their careers. Employee status, he believes, is “a recipe for burnout, to yield to control in a difficult specialty, to be treated like a commodity.” ACEP, representing emergency physicians working in the full range of practice models, remains agnostic among those forms, according to Rebecca Parker, MD, attending emergency physician at West Suburban Medical Center in Oak Park, IL, senior vice president of practice and payment integration for Envision Healthcare, executive vice president for leadership development and education for EmCare, clinical assistant professor of emergency medicine at Texas Tech El Paso, president of consulting group Team Parker, and 2016 to 2017 president of ACEP. “We don't endorse one type of contractual arrangement. It's whatever's best for the physicians.” Dr. Parker said. “Our goal is fair physician treatment and [a] practice environment where people can deliver care. I think there's a lot of pressure on all physicians to make the business work.” “It's all up to the individual physician, what they find meets their best needs,” she continued. “We have publicly traded groups; we have groups that are not publicly traded and have shares, and so there's different ways that they're set up, and they all have their pluses and minuses in terms of how they're run,” provided clinical policies are set by physicians. “If you're a hospital employee, you have no ownership…but there are some physicians that really thrive in that environment. [In] academia, you don't own anything in that practice, in fact; the academic institution owns everything you create. And there are physicians that absolutely love that type of environment.” Hospitals and insurance firms are both consolidating, Dr. Parker observed, and hospitals that previously employed no physicians are hiring them rapidly; one 3-hospital system in Chicago's northwest suburbs, she noted, went from zero to 350 physician employees within a 2-year span. With the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) affecting most emergency physicians' payment procedures, she said, along with compliance with the Health Insurance Portability and Accountability Act and other contractual complications, small groups increasingly see the advantages of contracting with sophisticated billing companies or joining forces with other groups. “It's about having the ability to negotiate,” she commented. “As insurance companies get bigger, you have to have some leverage.” Dr. Parker bases her activities and positions on her own experience in a broad range of settings. “I've started a group,” she reported. “I've done a regional group. I've been an academician…. Right now, I work for a large national company. So I've done it all.” Rather than take sides between independent practitioners and groups, she said, “ACEP really represents all the physicians and people that are in all types of contractual relationships, and that's how we're set up, to support those members” on the business side. Lawton Robert Burns, PhD, MBA, the James Joo-Jim Kim Professor of Health Care Management at the University of Pennsylvania's Wharton School, has spent much of his career analyzing the US medical system's organizational forms, scale, scope (defined as distinct from scale, referring to inclusion of diverse specialties and services), and performance. In a comprehensive overview3Burns L.R. Goldsmith J.C. Sen A. Horizontal and vertical integration of physicians: a tale of two tails.in: Friedman L.H. Goes J. Savage G.T. Annual Review of Health Care Management: Revisiting the Evolution of Health Systems Organization. Emerald Group Publishing Limited, Bingley, UK2013Crossref Scopus (82) Google Scholar of the scholarly literature on various consolidation trends (multispecialty and single specialty; vertical, horizontal, and “virtual”) and in subsequent discussion, he offered grounds for skepticism about some of the benefits frequently claimed for consolidation. Noting that physicians and practice groups seek larger scale to gain bargaining leverage, Dr. Burns drew a distinction between that benefit and others that are sometimes assumed rather than demonstrated. Physicians or small-group leaders who are contemplating consolidation, he recommended, should examine a major group's performance on essential metrics and base a decision to join on evidence, not salesmanship or wishful thinking. “At the end of the day,” Dr. Burns said, a large group is “designed to have some sort of national presence to do national contracting on more favorable terms with hospitals for specialists that may be in short supply in the local market; secondly, to have some leverage over insurance companies, to get better rates in the local market if they're not employed by the hospital. Those are the 2 classic reasons. The other rationales that are often expressed, but for which there's barely any evidence that there are scale economies in doing this, [are that] there are quality advantages; there are cost-reducing advantages, things like this. There are some synergies with having specialists across all these different areas inside the same group or the same company. There's very little evidence that any of that stuff's true. I'm not saying it's totally false, but there's little evidence proving it.” In Dr. Burns and colleagues' review,3Burns L.R. Goldsmith J.C. Sen A. Horizontal and vertical integration of physicians: a tale of two tails.in: Friedman L.H. Goes J. Savage G.T. Annual Review of Health Care Management: Revisiting the Evolution of Health Systems Organization. Emerald Group Publishing Limited, Bingley, UK2013Crossref Scopus (82) Google Scholar graphs representing the distribution of different-sized physician groups commonly show 2 tails, one representing smaller physician-owned practices—still a high proportion of physicians nationwide, and still roughly three quarters single specialty—and another representing those growing rapidly, although not yet accounting for a majority, representing large groups, primarily organized by nonphysician owners. The 2 tails reflect physician preferences that do not follow academic economic theory on scale-based efficiencies in production, marketing, and other costs driving horizontal integration. If economies of scale affected all these operations along with leverage, the small-practice tail would logically be unlikely to persist as a majority, and migration toward the larger-group tail would presumably be more extensive. “All the evidence suggests that for single specialties like emergency medicine,” Dr. Burns continued, “the scale economies are reached pretty quickly: you know, 10 physicians, maybe 20; no more. And so once you get beyond that, you're really not getting any operating efficiencies; what you're doing is getting purchasing efficiencies, and that's basically what economists call bargaining power…. That's another type of efficiency, but it has nothing to do with operating efficiency.” Dr. Burns takes one position that would strike many observers as counterintuitive: he does not view physician leadership or the ownership-leadership distinction as critical. “After having studied the same issue in hospitals for 40 or 50 years, it doesn't really matter who owns the hospital. They still operate the same way. So investor-owned hospital companies don't really operate that differently [from] nonprofit community hospitals.” Despite speculation “that physician-led health systems operate higher-quality, lower-cost care than administratively led health-care systems, there's very little good evidence for that,” he added, and it is more anecdotal than rigorously empirical. “What I hear is that once a doctor takes an administrative position, they start acting like an administrator.” Factors other than MD leadership, he suggested, explain the successes of certain megascale groups. “Does the Cleveland Clinic do well because Toby Cosgrove, a physician, is running it? Or does the Cleveland Clinic do well because of the way it's organized, its medical staff, its clinical institutes? There's so many other factors contributing to the Cleveland Clinic's success other than the fact they've got a doc at the top.” Since his overview's publication in 2013,3Burns L.R. Goldsmith J.C. Sen A. Horizontal and vertical integration of physicians: a tale of two tails.in: Friedman L.H. Goes J. Savage G.T. Annual Review of Health Care Management: Revisiting the Evolution of Health Systems Organization. Emerald Group Publishing Limited, Bingley, UK2013Crossref Scopus (82) Google Scholar Dr. Burns reported that studies continue to show similar patterns. “The handful that have been done,” he said, “suggest that as physicians organize and concentrate, they charge higher prices. It's consistent with the literature on hospital concentration: as hospitals concentrate, they charge higher prices to private payers, and so do physicians. They just don't have as much ability to do so, but there's some evidence that there's a positive effect.” Physicians commonly find themselves engaging in programs or activities too complex to understand fully, Dr. Burns acknowledged, citing a report that 84% of independent physicians do not understand MACRA, but 85% intend to participate in it anyway.12Gooch K. Survey: 84% of independent physicians unsure of MACRA, but 85% say they will participate. 2017; (Available at:) (Accessed January 31, 2017)http://www.beckershospitalreview.com/hospital-physician-relationships/survey-84-of-independent-physicians-unsure-of-macra-but-85-say-they-will-participate.htmlGoogle Scholar The Patient Protection and Affordable Care Act has also added complexities to practice, although commentators agree that it is a less important driver of consolidation trends (and may become a moot point if the current Congress repeals it, with or without replacing it). Dr. Burns sees “all these new payment methods—pay for performance, bundled payment, accountable care—[as] things docs weren't trained to manage and adjust to.” In an atmosphere rife with administrative distractions, “that's why there's a lot of physicians employed: those docs are looking for a safe harbor. Doctors are risk averse.” The key question may be whether any particular harbor also binds its physicians in battleship chains, less appropriate to a profession than to a chain store. Dr. Burns pointed out that the 2 populations he teaches view megascale groups differently. “I teach physicians all the time; I teach all the MBA students here at Wharton all the time. Doctors are the single most influential, powerful actor in the health care system, and they are the best-trained people in the health care system; they're the smartest people in the health care system. They just don't have enough free time to critically analyze and think and study whether or not all the stuff bombarding them is true and worthwhile. So what I tell my class, and what I tell doctors, is they need to engage in a lot more critical thinking, and they're the smartest people to do it. And doctors, pardon my French, can tell bullshit when they see it.” The business students, with more entrepreneurial priorities, view large groups favorably, simply as “bigger things with more revenues flowing through them, and these are classic strategies to do it. So they're a little bit more appealing to my MBA students than they are to my physician students…. I think everybody, not just in health care but in other sectors, ought to have a well-developed bullshit detector. The nice way to phrase that is critical thinking. Just critically weigh everything you hear; try to disprove it; try to triangulate it; come up with other reasons why this might be true.”
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