Pregnant and scared, Natasha Barre was bleeding in January 2021 and went to Tenova Healthcare Hospital in Clarksville, Tennessee. She didn’t know much about her miscarriage, but it seemed like she had.
He was seen in the emergency room and sent home. She returned when her cramps became unbearable. She then goes home again. Ultimately, three days in a row she had to go to the ER, and after three separate bills were produced, she went to a doctor who looked at her blood tests and confirmed her fears. I met.
“At the time, I wasn’t thinking, ‘Oh, I need to see a doctor,'” recalls Valle. It’s unclear if her return visit was due to a delay in seeing her doctor, but the experience worried her, and she’s still paying her bills.
The hospital declined to discuss Valle’s care, citing patient privacy. But 17 months before her three-day ordeal, Tennova had outsourced her emergency room to her American Physician Partners. American Physician Partners is a medical staffing agency privately owned by her equity investors. APP is hiring fewer doctors in the ER as one of his cost-cutting initiatives to increase profits. Confidential company documents obtained by KHN and NPR.
This staffing strategy is pervasive in hospitals, especially emergency rooms, as they seek to reduce their biggest expense: the labor cost of doctors. While diagnosing and treating patients was once their domain, physicians are increasingly being replaced by nurse-her practitioners and physician assistants, collectively known as “middle-level practitioners.” Pay.
“APP is undertaking a number of cost-reduction initiatives as part of its ongoing commitment to cost optimization,” the document said, including “staffing shifts” among physicians and mid-career practitioners. I’m here.
In a statement to KHN, American Physician Partners said the strategy is a way to ensure that all ERs remain fully placed, and that physicians, nurse practitioners, and physician assistants have “maximum We call it a ‘mixed model’ that allows us to ‘provide possibilities’.
Critics of this strategy argue that attempts to save money result in treatment being administered by people far less trained than doctors, and patients suffering from misdiagnosis, high medical costs, and inadequate care. says it will be easier. And these concerns are reinforced by evidence suggesting that taking doctors out of the ER may not be good for patients.
a working paperThe National Bureau of Economic Research announced Oct.
The researchers found that, on average, treatment with a nurse practitioner increased treatment costs by 7%, hospital length of stay by 11%, and patients’ time in the ER increased from minutes for minor visits to minutes for longer visits. I have found that the case can be extended for several hours. These gaps widened among patients with more serious diagnoses, but could be mitigated somewhat by more experienced nurse practitioners, the study says.
The study also found that ER patients treated by a nurse practitioner were 20% more likely to be readmitted for preventable reasons within 30 days, although the overall risk of readmission was significantly higher. remained small.
Yiqun Chen, an assistant professor of economics at the University of Illinois at Chicago and co-author of the study, said these findings were not an indictment of ER nurses. Instead, she hopes the research will guide how to best place nurse practitioners.
“This is not simply a question of whether we can replace doctors with nurse practitioners,” Chen said. “It depends on how we use them. When we use them as independent providers, it doesn’t seem to be a very good use, especially for … more complicated patients. is.”
Chen’s study mirrors smaller studies, such as the Harvey L. Niemann Institute for Health Policy study, which found that non-physician practitioners in ER were associated. 5.3% more imaging, which may unnecessarily increase patient bills. Separately, a study at his clinic in Hattiesburg, Mississippi, found that mid-career practitioners in primary his care, not in the emergency department, increased patient out-of-pocket costs, while Poor performance on 9 out of 10 indicators of quality of careincluding cancer screening and vaccination coverage.
But Dr. Cameron Goettel, an assistant professor of emergency medicine at Yale University, said the definitive evidence that replacing doctors in the ER with nondoctors harms patients remains elusive. Investments in private equity and use by mid-career practitioners have increased in tandem in ER, and without game-changing research, this pattern is likely to continue.
“Worse patient outcomes haven’t really been shown across the board,” he said.
Deleting ER documents is a ‘simple equation’ for private equity
Private equity firms pool money from wealthy investors to tap into different industries, often cutting spending and looking to transform their businesses in three to seven years. While this business model is a proven way to make money on Wall Street, it has raised concerns in the healthcare industry. In the healthcare industry, there are concerns that the pressure to make big profits will affect life-or-death decisions once reserved for medical professionals.
According to industry tracker PitchBook, nearly $1 trillion in private equity funds has been invested in nearly 8,000 healthcare deals over the past decade. This includes buying into a medical staffing company that many hospitals hire to manage their emergency departments.
TeamHealth, acquired by private equity firm Blackstone in 2016, and Envision Healthcare, acquired by KKR in 2018, dominate the ER staffing industry. It is located in 17 states and is 50% owned by private equity firm BBH Capital Partners.
These staffing agencies are the most aggressive in replacing doctors to cut costs, said Dr. Robert McNamara, founder of the American Academy of Emergency Medicine and chair of Emergency Medicine at Temple University. increase.
“It’s a relatively simple equation,” McNamara said. “Their biggest expense is board-certified emergency physicians, so they want to keep that expense as low as possible.”
Not everyone is negative about the private equity trend in ER staffing. Jennifer Orozco, president of the American Medical Association, which represents physician assistants, said the change to use more non-physician providers was driven by staffing firms’ desire to make more money. Patients, if any, said they were well served by the team. An approach that includes nurse practitioners and physician assistants.
“I see the change, but it’s not about profit at the end of the day,” Orozco said. “It’s about the patient.”
The “change” is almost invisible to the patient. That’s because hospitals rarely promote branding for ER staffing firms, and there’s little official documentation on private equity investments.
Dr. Arthur Smolensky, an emergency medical specialist in Tennessee who seeks to measure the penetration of private equity into the ER, looked at job postings and employment contracts at hospitals in 14 major metropolitan areas and found that 43% of ER patients He said he was found to have been seen in an ER staffed by a non-physician company. owners, almost all of whom are private equity investors.
Smolensky hopes to expand to 55 metropolitan areas later this year and publish his full research. But this study only quantifies what many doctors already know. ER has changed. Depressed by the growing focus on profit and wary of a looming surplus of emergency medical residents with fewer jobs to fill, many experienced physicians single-handedly managed his ER. away, he said.
“Most of us didn’t study medicine to oversee an army of people who weren’t as well-trained as we were,” Smolensky said. “We want to take care of patients.”
“I think we are the first guinea pigs in the 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 repair a collapsed lung.
It was 2020 and American Physician Partners was rebuilding the ER where Allen worked, reducing the shift from two doctors to one. Once Allen places his 10 tubes under the supervision of a doctor, he will be allowed to do it himself.
“I think we’re the first guinea pigs in the ER,” he said. “If there is a big trauma and there are multiple victims, there is only one doctor there. …We have to be prepared.”
Allen is one of many mid-career practitioners finding work in the emergency department. According to the U.S. Bureau of Labor Statistics, nurses and physician assistants are her one of the fastest growing professions across the nation.
Generally, they have a master’s degree and several years of technical schooling, but are significantly less trained than doctors. Many are allowed to diagnose patients and prescribe medications with little or no medical supervision, Limits vary by state.
The Neiman Institute found that the proportion of ER visits in which mid-level practitioners were the primary clinicians was Over 172% increase Another study published in the Journal of Emergency Medicine found that if this trend continues, Equal number of mid-career practitioners and physicians in the ER by 2030.
It’s almost a mystery as to why. federal data Emergency physicians make an average of about $310,000 a year, while nurse practitioners and physician assistants make less than $120,000 a year. In general, a hospital can charge a mid-level practitioner for treatment at 85% of the doctor’s rate, but at less than half that rate.
Private equity can make millions of dollars in gaps.
For example, Envision once encouraged ERs to adopt the “cheapest resource” and treat up to 35% of their patients with mid-level practitioners. 2017 powerpoint presentationThe presentation was scorned on social media and disappeared from Envision’s website.
Envision declined a request for a telephone interview. In a written statement to KHN, spokesperson Aliese Polk said the company did not instruct physician mentors on how to care for patients, and that the presentation did not represent its current views as a “concept guide.” ” said.
American Physician Partners touted a nearly identical staffing strategy for 2021. no surprise methodthreatened company profits by outlawing sudden medical bills. secret sales to lendersthe company estimates it could save about $6 million by shifting more staff from physicians to mid-career practitioners.
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