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Pregnant and terrified, Natasha Valle came to Tennova Healthcare in Clarksville, Tenn., in January 2021 because she was bleeding. He didn’t know much about abortion, but this seemed like it.
In the emergency room, he was examined and then sent home, he said. She returned when the cramping became excruciating. Then returning home. Valle said it eventually took three trips to the ER over three consecutive days, generating three separate bills, before he saw a doctor who looked at his blood and confirmed his fear.
“I didn’t think at the time, ‘Oh, I need to see a doctor,'” Valle said. “But when you think about it, it’s like, ‘Well – dang – why didn’t I see a doctor?'” It’s unclear if the repeat visits to the ER were due to delays in seeing a doctor, or if she was affected by the care, but the experience worried her. And he still pays the bills.
The hospital declined to discuss Valle’s treatment, citing patient privacy. But 17 months before his three-day trial, Tennova offered emergency rooms to American Medical Partners, a medical company owned by private equity investors. APP is using fewer doctors in its ERs as one of its cost-saving initiatives to increase profits, according to confidential company documents obtained by KHN and NPR.
This staffing policy has penetrated hospitals, and particularly emergency rooms, which seek to reduce the highest cost: physician labor. While diagnosing and treating patients was once the domain of doctors, they have increasingly been replaced by nurse practitioners and physician assistants, collectively the “physician middlemen,” who can perform many of the same services and generate much of the same revenue for less. stipends
“The app has implemented many cost-saving initiatives as part of the company’s continued focus on cost optimization,” the document says, including the “relocation of staffing” between MDs and mid-careers.
In a statement to KHN, the American Medical Association said the plan 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 plan say that the search to save money results in treatment by someone with far less training than the doctor prescribed, leaving vulnerable patients in the midst of misdiagnoses, higher rates of care, and inadequate care. And these fears are backed up by evidence that suggests dropping doctors from ERs is not good for patients.
A working paper, published in October by the National Bureau of Economic Research, estimated about 1.1 million visits to 44 ERs by the VETERANS HEALTH ADMINISTRATION, where nurse practitioners can treat patients without the supervision of doctors.
The researchers found that nurse practitioner medicine resulted in an average 7% increase in the cost of care and an 11% increase in length of stay, extending the patient’s time in the ER by minutes of visits and hours to fewer hours. These gaps between patients with more acute diagnoses have widened, the study said, but could be mitigated by a more experienced nurse practitioner.
The study also found that ER patients cared for by a nurse practitioner were 20% more likely to be discharged from the hospital within 30 days, although the overall risk of discharge remained very small.
Yiqun Chen, who is an assistant professor of economics at the University of Illinois-Chicago and a co-author of the study, said these findings are not an indictment of nurses in the ER. But, he says, he hopes the study will teach how best to develop a nurse: in simpler cases, or in situations when no doctor is available.
“It’s not a simple question whether we can replace doctors with nurses or not,” Chen said. “It depends on how we use them. If we only use them for independent providers, especially … for relatively complex patients, it doesn’t seem to be very well used.”
Chen’s research echoes smaller studies, such as one from the Harvey L. Neiman Institute of Health, which found nonphysician physicians in ERs were associated with a 5.3% increase in imaging, which could unnecessarily increase patient bills. A separate study at the Hattiesburg Clinic in Mississippi found that treating physicians in primary care — not in the emergency room — increased patients’ out-of-pocket costs, while also leading to worse performance on nine out of 10 quality-of-care metrics, including cancer screenings and vaccinations.
But definitive evidence remains elusive that replacing ER doctors with nonphysicians has a negative impact on patients, said Dr. Cameron Gettel, assistant professor of emergency medicine at Yale. Private equity investment and the use of mid-career physicians have risen in lockstep in the ER, Gettel said, and in the absence of game-changing research, the pattern will likely continue.
“Worse patient outcomes have not really been demonstrated across the board,” he said. “And I think until it’s shown, then it’s going to be a growing task.”
For private equity firms, leaving ER equity is a ‘simple equation’.
Private equity firms buy money from wealthy investors in various industries, often spending heavily and looking for businesses to flip over three to seven years. While this business model has proven currency on Wall Street, it raises health concerns, 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 nearly 8,000 health care businesses over the past decade, according to industry hunter PitchBook, including buying medical staffing companies that hire many hospitals to manage their emergency departments.
Two firms dominate the ER staffing industry: TeamHealth, purchased by private equity firm Blackstone in 2016, and Envision Healthcare, purchased by KKR in 2018. American Medical Giant’s affiliates are trying to undercut these staffs, a rapidly expanding company that runs at least in ERs. 17 states and 50% owned by private equity firm BBH Capital Partners.
These cohorts have been among the most active in replacing physicians to cut costs, said Dr. Robert McNamara, founder of the 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 emergency room physician. So they want to keep that expense as low as possible.”
Not everyone sees the trend of private equity in a negative ER light. Jennifer Orozco, president of the Academy of Medical Associates, which represents physician assistants, said that even if the shift — to more nonphysician providers — is driven by staffing firms’ desire to make more money, patients are still best served by teams. an approach that includes nurse practitioners and physician assistants.
“Even though I see a shift, it’s not about profit at the end of the day,” Orozco said. “He is sick.”
The “transition” is largely invisible to patients because hospitals rarely promote brand names from ER staffing firms and there is little public funding available for private equity investments.
Dr. Arthur Smolensky, a Tennessee emergency medicine specialist trying to measure the intrusion of private equity into ERs, said his review of hospital work and contract labor in 14 major metropolitan areas found that 43% of ER patients were seen in ERs by nonphysician-based companies. They are almost all owners who invest in private equity.
Smolensky hopes to publish his full study, to increase 55 meters, later this year. But this research just changed what many doctors already know: The ER. Demoralized by the increased focus on profit, and to avoid an unnecessary surplus of emergency medicine residencies because there are fewer jobs to fill, many experienced physicians are leaving the ER on their own, he said.
“Most of us are not into medicine as an army of people who are not as trained as we are,” Smolensky said. “We want to take care of patients.”
‘I guess we are the first guinea pigs in our ER’
Joshua Allen, a nurse practitioner at a small hospital in Kentucky, used a rubber band snake through a rack of pork ribs to fix a chest tube inserted into a collapsed lung.
It was 2020, and American Medical Associates had built the ER where Allen was, reducing shifts from two doctors to one doctor; he said. After placing 10 tubes under the care of a doctor, he was allowed to do it by himself.
“I guess we’re our first guinea pigs in the ER,” he said. “If we have a major trauma and many victims come in, there’s only one doctor there. … We have to be prepared.”
Allen is one of many Midwestern doctors working in emergency departments. Nurse practitioners and physician assistants are among the fastest growing occupations in the nation, according to the US Bureau of Labor Statistics.
They usually have master’s degrees and receive several years of specialized training, but they practice significantly less than doctors. Many patients are allowed to be ill and prescribe medicine with little or no medical care, although limitations vary by state.
The Neiman Institute found that the participation of ER visits in which the average level of a primary care physician increased more than 172% between 2005 and 2020, another study, in the Journal of Emergency Medicine, reported that if the trends remain the same number. mediated by doctors and nurses in ERs since 2003.
There is little mystery as to why. Federal emergency medicine doctors are paid about $310,000 per year on average, while nurse practitioners and physician assistants earn less than $120,000. In general, hospitals can get care from an average doctor at 85% of a doctor’s rate, while paying them less than half as much.
Private equity can make millions in the gap.
For example, Envision once encouraged ERs to use “precious resource minutes” and to 35% of patients with mid-care physicians, according to a 2017 PowerPoint presentation posted online by the company. The presentation drew mockery on social media and soon disappeared from Envision’s website.
Envision declined a phone interview request. In a letter to KHN, spokeswoman Aliese Polk said the association does not direct its medical leaders to care for patients and called the presentation a “concept guide” that does not represent the current opinion.
The American Medical Association has largely agreed to the same plan in 2021 in response to the No Oppression Act, which threatened the company’s profits, surprising medical billers. In its confidential pitch to creditors, the company estimated it could cut nearly $6 million by drawing more fees from doctors to mid-careers.
KHN (Kaiser Health News) is an editorially independent, national program of the Kaiser family foundation.
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