Posted on 02/17/2023 11:10:24 AM PST by nickcarraway
Pregnant and scared, Natasha Valle went to a Tennova Healthcare hospital in Clarksville, Tennessee, in January 2021 because she was bleeding. She didn’t know much about miscarriage, but this seemed like one.
In the emergency room, she was examined then sent home, she said. She went back when her cramping became excruciating. Then home again. It ultimately took three trips to the ER on three consecutive days, generating three separate bills, before she saw a doctor who looked at her bloodwork and confirmed her fears.
“At the time I wasn’t thinking, ‘Oh, I need to see a doctor,'” Valle recalled. “But when you think about it, it’s like, ‘Well — dang — why didn’t I see a doctor?’” It’s unclear whether the repeat visits were due to delays in seeing a physician, but the experience worried her. And she’s still paying the bills.
The hospital declined to discuss Valle’s care, citing patient privacy. But 17 months before her three-day ordeal, Tennova had outsourced its emergency rooms to American Physician Partners, a medical staffing company owned by private equity investors. APP employs fewer doctors in its ERs as one of its cost-saving initiatives to increase earnings, according to a confidential company document obtained by KHN and NPR.
This staffing strategy has permeated hospitals, and particularly emergency rooms, that seek to reduce their top expense: physician labor. While diagnosing and treating patients was once their domain, doctors are increasingly being replaced by nurse practitioners and physician assistants, collectively known as “midlevel practitioners,” who can perform many of the same duties and generate much of the same revenue for less than half of the pay.
“APP has numerous cost saving initiatives underway as part of the Company’s continual focus on cost optimization,” the document says, including a “shift of staffing” between doctors and midlevel practitioners.
In a statement to KHN, American Physician Partners said this strategy is a way to ensure all ERs remain fully staffed, calling it a “blended model” that allows doctors, nurse practitioners and physician assistants “to provide care to their fullest potential.”
Critics of this strategy say the quest to save money results in treatment meted out by someone with far less training than a physician, leaving patients vulnerable to misdiagnoses, higher medical bills, and inadequate care. And these fears are bolstered by evidence that suggests dropping doctors from ERs may not be good for patients.
A working paper, published in October by the National Bureau of Economic Research, analyzed roughly 1.1 million visits to 44 ERs throughout the Veterans Health Administration, where nurse practitioners can treat patients without oversight from doctors.
Researchers found that treatment by a nurse practitioner resulted on average in a 7% increase in cost of care and an 11% increase in length of stay, extending patients’ time in the ER by minutes for minor visits and hours for longer ones. These gaps widened among patients with more severe diagnoses, the study said, but could be somewhat mitigated by nurse practitioners with more experience.
The study also found that ER patients treated by a nurse practitioner were 20% more likely to be readmitted to the hospital for a preventable reason within 30 days, although the overall risk of readmission remained very small.
Yiqun Chen, who is an assistant professor of economics at the University of Illinois-Chicago and co-authored the study, said these findings are not an indictment of nurse practitioners in the ER. Instead, she said, she hopes the study will guide how to best deploy nurse practitioners: in treatment of simpler patients or circumstances when no doctor is available.
“It’s not just a simple question of if we can substitute physicians with nurse practitioners or not,” Chen said. “It depends on how we use them. If we just use them as independent providers, especially … for relatively complicated patients, it doesn’t seem to be a very good use.”
Chen’s research echoes smaller studies, like one from The Harvey L. Neiman Health Policy Institute that found nonphysician practitioners in ERs were associated with a 5.3% increase in imaging, which could unnecessarily increase bills for patients. Separately, a study at the Hattiesburg Clinic in Mississippi found that midlevel practitioners in primary care — not in the emergency department — increased the out-of-pocket costs to patients while also leading to worse performance on nine of 10 quality-of-care metrics, including cancer screenings and vaccination rates.
But definitive evidence remains elusive that replacing ER doctors with nonphysicians has a negative impact on patients, said Dr. Cameron Gettel, an assistant professor of emergency medicine at Yale. Private equity investment and the use of midlevel practitioners rose in lockstep in the ER, Gettel said, and in the absence of game-changing research, the pattern will likely continue.
“Worse patient outcomes haven’t really been shown across the board,” he said. “And I think until that is shown, then they will continue to play an increasing role.”
For Private Equity, Dropping ER Docs Is a ‘Simple Equation’
Private equity companies pool money from wealthy investors to buy their way into various industries, often slashing spending and seeking to flip businesses in three to seven years. While this business model is a proven moneymaker on Wall Street, it raises concerns in health care, where critics worry the pressure to turn big profits will influence life-or-death decisions that were once left solely to medical professionals.
Nearly $1 trillion in private equity funds have gone into almost 8,000 health care transactions over the past decade, according to industry tracker PitchBook, including buying into medical staffing companies that many hospitals hire to manage their emergency departments.
Two firms dominate the ER staffing industry: TeamHealth, bought by private equity firm Blackstone in 2016, and Envision Healthcare, bought by KKR in 2018. Trying to undercut these staffing giants is American Physician Partners, a rapidly expanding company that runs ERs in at least 17 states and is 50% owned by private equity firm BBH Capital Partners.
At a two-day company training put on by American Physician Partners in 2020, chief medical officer Dr. Tony Briningstool teaches doctors and nurse practitioners how to safely use sedation in the emergency department. As a money-saving strategy, emergency rooms are employing fewer doctors and relying instead on midlevel practitioners. (BLAKE FARMER FOR KHN) These staffing companies have been among the most aggressive in replacing doctors to cut costs, said Dr. Robert McNamara, a founder of the American Academy of Emergency Medicine and chair of emergency medicine at Temple University.
“It’s a relatively simple equation,” McNamara said. “Their No. 1 expense is the board-certified emergency physician. So they are going to want to keep that expense as low as possible.”
Not everyone sees the trend of private equity in ER staffing in a negative light. Jennifer Orozco, president of the American Academy of Physician Associates, which represents physician assistants, said even if the change — to use more nonphysician providers — is driven by the staffing firms’ desire to make more money, patients are still well served by a team approach that includes nurse practitioners and physician assistants.
“Though I see that shift, it’s not about profits at the end of the day,” Orozco said. “It’s about the patient.”
The “shift” is nearly invisible to patients because hospitals rarely promote branding from their ER staffing firms and there is little public documentation of private equity investments.
Dr. Arthur Smolensky, a Tennessee emergency medicine specialist attempting to measure private equity’s intrusion into ERs, said his review of hospital job postings and employment contracts in 14 major metropolitan areas found that 43% of ER patients were seen in ERs staffed by companies with nonphysician owners, nearly all of whom are private equity investors.
Smolensky hopes to publish his full study, expanding to 55 metro areas, later this year. But this research will merely quantify what many doctors already know: The ER has changed. Demoralized by an increased focus on profit, and wary of a looming surplus of emergency medicine residents because there are fewer jobs to fill, many experienced doctors are leaving the ER on their own, he said.
In a lab at Lipscomb University in 2020, nurse practitioners join doctors in practicing how to place a chest tube to fix a collapsed lung by snaking a rubber hose through a rack of pork ribs. The NPs, who work for American Physician Partners, will have to perform the procedure under a doctor’s supervision before being allowed to do it on their own. (BLAKE FARMER FOR KHN) “Most of us didn’t go into medicine to supervise an army of people that are not as well trained as we are,” Smolensky said. “We want to take care of patients.”
‘I Guess We’re the First Guinea Pigs for Our ER’
Joshua Allen, a nurse practitioner at a small Kentucky hospital, snaked a rubber hose through a rack of pork ribs to practice inserting a chest tube to fix a collapsed lung.
It was 2020, and American Physician Partners was restructuring the ER where Allen worked, reducing shifts from two doctors to one. Once Allen had placed 10 tubes under a doctor’s supervision, he would be allowed to do it on his own.
“I guess we’re the first guinea pigs for our ER,” he said. “If we do have a major trauma and multiple victims come in, there’s only one doctor there. … We need to be prepared.”
Allen is one of many midlevel practitioners finding work in emergency departments. Nurse practitioners and physician assistants are among the fastest-growing occupations in the nation, according to the U.S. Bureau of Labor Statistics.
Generally, they have master’s degrees and receive several years of specialized schooling but have significantly less training than doctors. Many are permitted to diagnose patients and prescribe medication with little or no supervision from a doctor, although limitations vary by state.
The Neiman Institute found that the share of ER visits in which a midlevel practitioner was the main clinician increased by more than 172% between 2005 and 2020. Another study, in the Journal of Emergency Medicine, reported that if trends continue there may be equal numbers of midlevel practitioners and doctors in ERs by 2030.
There is little mystery as to why. Federal data shows emergency medicine doctors are paid about $310,000 a year on average, while nurse practitioners and physician assistants earn less than $120,000. Generally, hospitals can bill for care by a midlevel practitioner at 85% the rate of a doctor while paying them less than half as much.
Private equity can make millions in the gap.
For example, Envision once encouraged ERs to employ “the least expensive resource” and treat up to 35% of patients with midlevel practitioners, according to a 2017 PowerPoint presentation. The presentation drew scorn on social media and disappeared from Envision’s website.
Envision declined a request for a phone interview. In a written statement to KHN, spokesperson Aliese Polk said the company does not direct its physician leaders on how to care for patients and called the presentation a “concept guide” that does not represent current views.
American Physician Partners touted roughly the same staffing strategy in 2021 in response to the No Surprises Act, which threatened the company’s profits by outlawing surprise medical bills. In its confidential pitch to lenders, the company estimated it could cut almost $6 million by shifting more staffing from physicians to midlevel practitioners.
Soon it will be self-server ER. Who needs doctors.
More falsely-named “Government Healthcare”, accurately named “Death Protocol Nightmare”.
Every profession I can think of, including the medical profession, has business aspects. Problems arise when the business aspects take precedence over the profession part.
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Very few in top management of these large health care businesses, and that includes large doctor practices, are doctors.
And, in comes foreign doctors. Here in my city, you hear a lot of Muslims last name doctors. A lot of Mohammed’s etc. as doctors. The aging population with health problems down the road will not have the privilege of good medical coverage our great country used to offer. When we no longer have an abundance of doctors for specialty care, the government will open euthanasia rooms for the elderly. It’s sad to say our powerful blessed by God medical establishment here in the United States has disintegrated like our military might because of their woke policies , greed and affirmative action … everything liberalism, which is a cancer, touches it disintegrates into ashes. We are living in very serious dire straits.😢
The AMA pushed BS since the late ‘60s that caused this.
They used fishy statistics to say that there would be a MD surplus if more med schools were built or expanded in the mid-70s.
Utter, complete BS that was nothing more then paycheck protection.
So now we have something like 25% of the MD population being foreign, usually from India. H1B docs for Chrissakes.
Any medical school will tell you they don’t know what it is that gets somebody in. They have thousands of applicants who actually qualify intellectually. So they have to sort through and look for “something special” or some government mandated discrimination they can apply to decide who gets in.
Try a supply side solution now. Just expand the med schools by ~ 30% and voila, lotsa docs. All home grown, and all qualified. Maybe they make less then some of the older crocodiles counting their millions. So what. It’s a job, and one that will pay well. No flakes from the Punjab needed.
And AI based triage? LPNs / PAs doing screening? Groovy. That’s the way to increase throughput before you see The Big Guy / Girl with the real MD. Make med care available to all, fast. And reasonable, maybe not cheap.
A supply side solution. Lop off some of the mega cash that Bitch and Biden are sending to their Ookrainian butt buddies and that will be more then enough.
It’s also not fair to us NP’s and mid levels.
I’m an NP and I had to run the office so many times while the doc was on his big overseas two week vacation ....and I get paid likely 1/10th of what he’s being paid. Not fair. No bonus, no nothing, with all of the responsibility and liability. I did get a Dunkin Donuts gift card, though. That was big.
Needless to say, I’ve left that practice and am onto other things, thankfully.
So, it’s either pay all docs the big bucks, or pay fewer docs to do the really big specialized stuff and let the mid levels do all the general work.
It’s like that (older) ad, where the guy is on the phone w/a doc, telling him where to make the incision.
They didn’t realize how prophetic their ad was....teledoc ER treatment.
That's the problem. Get those mongrels out of the US and all else will be fixed.
Nurse Practioner?
“midlevel practitioners”
Mideveil practitioners
It’s not government healthcare. It’s a private company that is making these decisions to improve their and their investors’ bottom line.
Dr. ChatGPT will see you now.
"Get the leeches!"
You don’t think government is meddling all over hospitals and ER’s? Think again.
They have that in Britain. It’s called go home and die.
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