Where is SEMPA’s Peter Rosen?
Also: Envision still bankrupt, increased EM attrition in 2020, No Surprises that insurers are winning, & hospitals are spending big to recruit nurses.
Top of the Week
This year’s SEMPA360 Conference of EM PAs was well-attended. The optimism was palpable. Emergency physicians, PAs, and nurse practitioners work more closely together now than ever before. PAs and NPs are seeing an increasing share of high-acuity ED patients, especially in rural areas.
However, SEMPA’s leaders are setting up the emergency PA profession for physician backlash.
The emergency physician job market has rapidly shifted from emergency physician scarcity and reimbursement abundance to the opposite on both counts. Practice owners see the availability of lower-cost, less-trained PAs and NPs as a route to margin maintenance. The result is a physician community that feels squeezed.
Scarcity has a way of focusing a community’s attention. The low standards for specialty-specific PA training could be brushed aside when PAs were seeing only low-acuity patients. The paucity of emergency medicine training for PAs was more likely to be ignored when PA presence was seen as propping up physician salaries. Those dynamics are no longer in place, so more emergency physicians are objecting to PAs seeing high acuity ED patients after completing as little as one 4-week emergency medicine rotation in PA school.
In 2022, ACEP revised its “Guidelines Regarding the Role of Physician Assistants and Nurse Practitioners in the Emergency Department”. The document refers in multiple places to the “variable training and experience” of PAs and NPs. Due to the minimal amount of EM-specific training required of PAs and NPs, the guideline recommends “that PAs and NPs should not perform independent, unsupervised care in the ED… The supervising emergency physician for a PA or NP must have the real-time opportunity to be involved in the contemporaneous care of any patient presenting to the ED and seen by a PA or NP.”
ACEP is working on emergency department accreditation standards. It would not be surprising if those standards include more supervision requirements of EM PAs and NPs than SEMPA’s leaders would want.
Peter Rosen and the founders of emergency medicine faced a similar dynamic in the 1970s. When in 1977, emergency physician leaders proposed to the American Board of Medical Specialties the addition of EM as an independent specialty, the proposal was voted down by a margin of 100 to 5. Only after EM’s leaders better defined the standards of emergency medicine training and certification did the ABMS certify the new specialty emergency medicine, in September 1979.
SEMPA’s current stance on EM-specific training is unacceptably weak. Its lack of self-regulation plays into the hands of physicians who object to non-physician providers seeing patients without real-time supervision. For example, see AAEM’s position statement.
The National Commission on Certification of Physician Assistants (NCCPA) has established specialty-specific training standards, called Certificates of Added Qualifications (CAQs). However, only 28% of practicing PAs held CAQ certification, per the latest Medscape survey. Only 5.4% of PAs have completed a post-graduate specialty-specific training program.
From SEMPA’s position statement on emergency medicine CAQs:
“Whereas the CAQ is a mastery level competency process, it cannot be viewed as the entry-level credential for physician assistants beginning practice in emergency medicine, and therefore should not be utilized to define minimum standards for hospital credentialing or employment.
Whereas the CAQ has as a prerequisite valid state licensure and national certification as a PA-C, the CAQ should not be used by any regulatory or credentialing body as a mandatory requirement for practice. Nor for the same reasons should it be viewed by any third-party payer as a mandatory requirement for reimbursement.
SEMPA acknowledges that experienced-based mastery of emergency medicine and maintenance of certification has long been the only available measure of competence, and acknowledges that other measures of competency, such as experience-based practice, are also valid.”
Until SEMPA follows the Peter Rosen model and increases training standards for PAs practicing in EDs, we are likely to see more requirements for real-time supervision of emergency PAs by physicians.
EM Practice
Envision’s internal FAQ memo on its bankruptcy. More details here, here, & here.
Dr. Bryce Pulliam on why his group formed the first-ever emergency medicine union outside of the training setting. “We wanted to ensure that we continued providing our patients with safe, high-quality care. However, we felt that by ourselves we lacked the power or influence to make meaningful changes to the status quo. We knew we could not stand by and be complicit as we watched these seismic shits shake the practice of emergency medicine, and healthcare in general, to its core. Given our deep commitment, not only to our profession, but to our patients, we decided to pull together and explore the possibility of unionizing to ensure our voices were heard.”
Indiana passed a law requiring a physician to be on-site in every emergency department in the state.
An Annals of EM article showed that emergency physician attrition rose to above 8% in 2020. “The male and female emergency physicians’ weighted mean attrition proportion was 5.4% and 5.5% between 2014 and 2019, respectively, compared with 8.0% and 8.6% in 2020.”
House of Medicine
No Surprises Act update. The scales are still tilted in insurers’ favor.
Iowa passed a law allowing PAs to practice independently without physician supervision.
NY Times dives into the causes of corporate giants buying up primary care practices.
The FTC plans to vote on whether to ban non-competes in April 2024.
Private equity deals in healthcare services are slowing down. From Pitchbook’s Q1 2023 report:
Hospitals & Health Systems
Staffing shortages and boarding are still plaguing hospitals.
CommonSpirit lost $1.1b in the nine-month period ending March 31, 2023. ThedaCare posted a Q1 2023 profit.
North Carolina’s state senate unanimously passed a bill exempting UNC Health from antitrust laws. “When partnering with community hospitals and other health systems in various regions of the State, the System is acting according to State policy by ensuring that healthcare is made available to all parts of North Carolina; its activities constitute ‘State action’ for purposes of antitrust law,” the bill reads.
Nursing & Allied Health
Hospitals are offering bonuses of up to $100,000 to hire nurses.
A shortage of Green Cards has slowed hospitals’ hiring of international nurses.
Georgia passed a law to help repay nurses’ student loans.
McKinsey report on the state of nursing in the US.
The Dispo
