Hating HCA won’t fix the system
Also: EM used to be cool, millions about to lose Medicaid coverage, Dragon’s AI, and nurses hounded by hospitals.
Top of the Week
Much of the 2023 post-Residency Match discussion on Emergency Medicine social media (see: EM Docs & Reddit EM) included frustration with HCA’s growing footprint in EM residency training. The concern is that HCA, the largest for-profit hospital system in the US, is rapidly opening residencies because in-house EM residents are profitable for the health system while they are in training, then are simpler to hire on graduation.
If the problem were confined to for-profit health systems, US medical students would rank non-profit and public hospitals above for-profit hospitals. Unfilled spots do not receive Medicare GME funding, so residencies that continually do not fill would close over time. A similar process occurred for anesthesia residencies in the 1990s as a result of increased CRNAs and decreased reimbursement.
This year’s EM Match, however, showed that for-profit residencies can compete for US medical students. The EM match rate at residencies primarily based at for-profit hospitals was 71.7% (208 matched / 290 spots) vs 82.7% for non-profit and public hospitals (2255 matched / 2726 spots). Many of the spots unfilled in the Match have been filled in the scramble (SOAP).
If residency closures at for-profit hospitals are not the solution to EM’s Match challenges, what is? (The following section is excerpted from this article, published today in ACEPNow, written with Drs. Jonathan Fisher and Cedric Dark.)
Emergency physicians, who are trained to improvise and make the most of difficult situations, will need to rely on that ingenuity to reverse the workforce challenges. Many of the factors impairing EM’s desirability to medical students - such as boarding - are out of an emergency physician's control. However, much can be done by emergency physicians to improve the specialty’s popularity.
The most important step is to balance the supply and demand for emergency physician labor. Counterintuitively, decreased interest by medical students is actually beneficial in this process. As EM organizations lack the power to shut down residency programs, decreases in applicants are likely the most effective mechanism for right-sizing the number of EM residents.
The rapid increase in PAs and NPs working in EDs can also be tempered by emergency medicine physician leaders. While individual employer groups are incentivized to hire low-cost, less-trained clinicians, the specialty’s national organizations can push back on hiring practices that harm ED patients and physicians. For example, ACEP is planning to expand its ED accreditation programs. Just as the American College of Surgeons would not accredit a Level 1 Trauma Center that did not staff the correct set of board-certified physician specialists, ACEP’s accreditation can ensure that PAs and NPs are not managing higher acuity patients without proper post-graduate training and active, real-time supervision.
The supply side of physicians can also be addressed. Most EPs traditionally have practiced general EM rather than subspecialization. However, academic emergency medicine programs should increase EP’s access to fellowship training in pain, geriatrics, psychiatry, critical care, and other subspecialties.
EM leaders must create workplaces more conducive to emergency physician career fulfillment. Moral injury can be addressed by advocating for policies that promote high-quality emergency care. For example, psychiatric boarding is a scourge that can be addressed through increasing state-level behavioral health funding.
Establishing financial incentives for hospitals to improve flow can lead to significant downstream improvements. EDs will likely continue being hospital dumping grounds until hospital administrators have financial incentives to move patients out of the ED.
Clinical autonomy can be encouraged by granting ownership to emergency physicians. Ownership matters; no one washes a rented car. Even private equity firms have the ability to grant ownership stakes to their physician employees.
Promoting employer competition for emergency physician labor would incentivize improved working conditions. Currently, crucial information regarding potential alternative workplaces, such as staffing ratios and compensation, is difficult for physicians to find. The information asymmetry decreases physicians’ negotiating leverage and lowers the likelihood that physicians will change jobs. This stagnant marketplace suppresses employers’ incentive to improve and offer competitive compensation. Noncompete clauses similarly hamper flexibility for the physician workforce.
Every system is perfectly designed to get the results it gets. We strongly believe that emergency medicine is a great specialty with a powerful mission, and many medical students agree. There were numerous posts on social media by medical students who received notification they had indeed matched in EM and were excited about their future.
While many were excited to join, the specialty’s workforce structure and clinical climate no longer appeal to many medical students, which has resulted in decreased applications for EM residencies. Emergency physicians have always prided themselves on creative problem-solving. Now is the time for the House of EM to solve its workforce problems.
The complete article can be found at ACEPNow. Thanks to Drs. Jonathan Fisher & Cedric Dark for their work on this article!
EM Practice
The Washington Post weighs in on why EM is no longer “a cool job”. Quote from the article: “It’s really sad to see a field once so competitive have so many extraordinary issues,” said Hopper, 32. “I was told over and over again: ‘If you can see yourself doing anything other than medicine, do that thing.” It’s the same with emergency medicine: If you can see yourself doing anything other than emergency, do that thing.”
How emergency physicians get “trapped” by non-compete agreements. Nearly 90% of physicians support banning non-competes, per a Doximity survey.
ACEP Frontline Podcast: State of the Union of the Pediatric Emergency Medicine Workforce.
House of Medicine
Preview of Q2’s hot healthcare policy topic: Medicaid redeterminations. A large number of poor people, mostly in red states that did not expand Medicaid, are about to lose health insurance.
Dragon (created by Nuance, which is owned by Microsoft) is bringing AI to its dictation tech. ChatGPT is coming to an ED near you soon.
Another cause of physician moral injury: delivering aggressive curative care to terminally ill patients.
Surgeons are using video AI to learn ways to improve techniques in the OR.
Primary care saves lives, but many in the US do not have sufficient access to a primary care physician.
Hospitals & Health Systems
Rural hospitals keep closing, this one in New York State.
Nationally, inpatient volumes are still lower than pre-pandemic levels.
Nursing & Allied Health
States are looking to push back on high travel nursing prices.
“The practice of requiring repayment for training programs aimed at recent nursing school graduates has become increasingly common in recent years, with some hospitals requiring nurses to pay back as much as $15,000 if they quit or are fired before their contract is up, according to more than a dozen nursing contracts reviewed by NBC News and interviews with nurses, educators, hospital administrators, and labor organizers.”
The Dispo
The US is paying a huge amount for a healthcare system that isn’t paying off. Check out “Our World in Data” for a deep dive.