Should Physicians Unionize?

Dustin MelchiorArticles

Leon Adelman, MD, MBA, FACEP
Co-Founder & CEP Ivy Clinicians
Author, Emergency Medicine
Workforce Newsletter
Clinical Emergency Physician, Wyoming

Only about one-quarter of attending emergency physicians are practice-owners. For many employed emergency physicians, working condition improvement is desperately needed. Emergency medicine has become the specialty with the highest burnout rate and lowest levels of job satisfaction.

Improving working conditions is generally more difficult for employees than for practice owners. Some would say, just kick out the non-physician-owned groups and bring in a better EM practice. The problem with that solution is that emergency physicians don’t determine who staffs a hospital’s emergency department. The hospital CEO makes that decision.

Employed emergency physicians who are dissatisfied with their working conditions and do not want to change jobs have the legal right to bargain collectively with their employer. In other words, EPs have the right to unionize.

Source: Author’s analysis of AMA 2020 Physician Practice Bench

For community EDs, what are the most likely outcomes from emergency physicians bargaining
collectively with their employer and the hospital?

  1. The hospital CEO would get mad. Unionized employees have legal protections to publicize poor working conditions. No hospital CEO wants their emergency physicians to talk with the press about boarding, staffing, or quality concerns.
  2. The hospital would terminate the staffing company’s contract. Emergency physicians unionizing against a subcontractor would mean the end of that contract.
  3. The hospital would choose a physician-owned group to staff the ED. Legitimate practice owners cannot unionize. If the physicians remain employees rather than becoming owners, the union can also remain.

Bottom line: collective bargaining through unionization is the most effective method for employed community emergency physicians to change their contract-holder from a CMG to a physician-owned group.

For recent examples, check out Ascension St. John and the Greater Detroit Association of Emergency Physicians:

President Pearls

Dustin MelchiorArticles

NSA and Payment Leaks

Robert Chavez, MD, President, IEPC
Providence Little Company of Mary Medical Center Torrance

Here are my pearls for this month:

NSA – No Surprise Act
NSA IDR Criteria to be disseminated to your RCM company or the CFO of your group. When submitting IDR claims, always keep in mind the 6 criteria being considered by the IDRE. These are the following:

  1. QPA in the same geographic region, increased for inflation. (From 2019).
  2. Level of training, provider experience, and quality and outcomes of the provider
    (Think MIPS).
  3. Market share of the provider or facility.
  4. The patient acuity or complexity of the case.
  5. The teaching status, case mix, and scope of services.
  6. Demonstration of good faith efforts or lack thereof made by the provider or plan
    to be in network, previous network rates for the last 4 years.

Payer Leaks
All private groups should make it a point to review EOBs (Explanation of Benefits) at least once or twice a year to avoid any payment leaks. It can be surprising how often incorrect payments are made even with in-network payers. Take a moment to make sure your RCM partner calculates this as a percentage of Medicare for all payers, in-network and out-of-network. With this, it will allow you to do a much faster apples to apples comparison. If you find a leak, namely, you are being paid less than your contract calls for or an out-of-network payer is paying you less for your services, then have your RCM company reach out to the payor directly and do a deep dive to see how far back the leak goes chronologically. this can sometimes lead to a nice “catch up” check from your in-network insurance carriers. Finally, you can potentially use this information during the IDR process to demonstrate potential decreases in pay by the insurance carrier affecting your Qualified Payment Amount (QPA).

2024 IEPC Speaker Series

Articles

Free to All Friends of IEPC!

Time & Date: 9:00 AM – 9:30 AM PT on the fourth Monday of each month. Membership in IEPC is not required to attend. Advance registration for the meeting is required. After registering, you will receive a confirmation email containing information on how to join the call! To receive a registration link, email admin@iepc.org.

Dr. Leon AdelmanShould Physicians Unionize?August 26, 2024
Dr. Robert FrolichsteinAAEM UpdatesSeptember 23, 2024
Christina Lampman,
Steve Freedman, and
Deanna Christofferson,
of The Doctors Company
Malpractice UpdatesOctober 28, 2024
Dr. Andrew SeleznickLegal Updates for
Emergency Physicians
November 11, 2024

Congratulations Dr. Ariella Lee

Articles

Roneet Lev, MD, FACEP
Executive Director, IEPC

Dr. Roneet Lev and newborn Ariella with Governor Gray Davis

Ariella Lee joined IEPC when she was in high school at 14 years old. There was reluctance to hire a young kid as an assistant to a large organization of doctors, but the IEPC board decided to take a chance. Ariella put on a suit and pumps and impressed the doctors with her ability to organize meetings and lunches. She went on to analyze the annual IEPC survey and create a list of California hospitals and ED directors. Ariella was a natural for the role of Administrative Director when IEPC’s original director stepped down. Ariella grew with IEPC through high school and college. Her IEPC experience was included in her medical school application.

Keren Lee, MD LT MC USN, Ariella Lee, MD LT MC USN

In May 2024, Ariella graduated from the Uniformed Services University Medical School and matched into the Anesthesia residency program at Balboa Naval Medical Center in San Diego.

In the picture, she is in her Navy whites uniform with her sister Keren Lee, who also attended USU Medical School and hooded Ariella during her medical school graduation.

I, Ariella’s mother, am of course proud of my daughter, and am sharing this news with our IEPC physicians, who are also proud of her and thankful for her service to our country and IEPC.

Student Loan Forgiveness

Articles

Andrew Fenton, MD | Vice President, IEPC
Napa Valley Emergency Medical Group

I recall in medical school receiving a financial lecture about student loans. I attended George Washington University, which was, and is, one of the most expensive medical schools. Though I realized I would be taking on a significant amount of loans and debt, I also believed that my eventual physician salary would allow me to pay off my loans and not too long after residency. How scary could any federal program with the name “Sallie Mae” be anyways?

Twenty-five years have passed, yet I still was saddled with over six figures of medical school tuition debt. Life unfolds and after residency, I married, bought a house, and started a family. Paying off low-interest student loans became less of a priority as mortgage payments, house remodels, tuitions, and retirement investments took precedence.

I was resigned to the realization that medical school debt payments would be a part of my adult life and follow me near the entirety of my career. That is when I read about changes to the Public Service Loan Forgiveness (PSLF) program that offered a glimmer of hope.

The U.S. Department of Education changed the PSLF program about one year ago, which allowed California physicians to participate in the program. Previously, the physician had to be an employee of a non-profit entity that provided public service. Because of California’s prohibition on physician employment by hospitals, we were therefore ineligible. The Department changed the definitions so that members of the hospital’s medical staff and those who contract with the hospital to provide medical services would now be eligible.
To quality, physicians would need to receive confirmation of their status by the hospital, will have worked full-time for 10 years, would need to have made 10 years of monthly payments (at least 120), and be current on their payments. The application was fairly straight forward, but I was required to consolidate my loans within a new “direct government” loan. Here is what I learned from the process.

The process starts at the website: https://studentaid.gov/pslf. From there, I created a log-in and was able to find my hospital, and its Employer Identification Number (available online) and confirm they were eligible as a non-profit hospital. I completed the application and (this is important) inserted my hospital as my “Employer.” Do not insert your ED group or your personal corporation in this section. I then had to obtain the signature of my hospital’s medical staf office director who confirmed my full-time status as a member of the medical staff for >10 years and submitted my application.

The website worked surprisingly efficiently and was able to identify my outstanding previously consolidated Stafford loan and a loan I took out to cover costs between medical school and residency. I was then required to consolidate my loans into new loans directly through the Department of Education. This was all done online, was fairly simple, and resulted in the exact same low interest rate. This new loan was approved quickly, and I waited, hoping and praying that my previous decades of loan payments would be considered “qualifying patments.”

A couple months passed, but I recently received that cherished letter that stated, “Congratulations! You have successfully met the requirements of the Public Service Loan Forgiveness (PSFL) program and all of your loans have been forgiven. Thank you for your public service!

The PSFL program application deadline was recently extended, but the program may not be around forever, and I encourage all my colleagues who are eligible to apply. Good luck!

Emergency Medicine Benchmarking Alliance – EDBA

Articles

James Augustine, MD | Director
Vice President | Emergency Medicine Benchmarking Alliance

Welcome to The Emergency Department Benchmarking Alliance!

The Emergency Department Benchmarking Alliance (EDBA) was created in 1994 for those ED leaders interested in the application of management and service best practices. The Alliance was founded at that time to investigate issues of growing patient volumes and high acuity patients, with unscheduled health needs that were not served in other settings. It has grown into a group of Emergency Department leaders that are dedicated to a high-quality mission; whether their background is pysician, nursing, or administrative. The EDBA is now composed of about 1,500 EDs that saw 45 million patients in 2023.

The vision statement of the EDBA is simple: the Identification, development, and implementation of future best practices in Emergency Medicine.


Attributes of Alliance Members

The Emergency Department is a site of intense service challenges, unpredictable care loads and expectations, and cost challenges. In the healthcare service industry, ED leaders and providers are obligated to a continuous process of quality improvement and patient safety. To mantain this level of service, it is essential to apply the best service concepts in the industry. So EDBA members share materials through an annual survey and active Listserv that promulgates information related to quality medical care, patient satisfaction, staff engagement, medical education, and community service.

The Alliance has ongoing participation by high quality EDs of all volumes and service populations, which collaborate in non-competitive efforts to improve the industry. By fostering community, sharing, support, and mutual advice for people with operational responsibilities in emergency services using a Listserv with 1,400 active members.

Membership in the EDBA is geographic diverse, with members that have recognized expertise in ED operations. The sense of ownership is shared among all disciplines and professionals that provide leadership in an Emergency Department. The attendance of the ED team of physicians, nurses, and administrators cannot be replicated in other groups.

The Alliance makes effective use of the process of “industrial tourism,” and each member has benefited by the firect and non-threatening observation of other ED operations. Alliance members are wired to major events happening throughout the country in emergency practice matters. Ongoing participation of Alliance EDs permits information exchange at a variety of levels, not available through the literature or at offsite meetings. This is an organization that coordinates operations research and health services studies intended to identify best practices.

The EDBA Annual Data Survey

The most critical function of the EDBA is an annual data collection. Since 2004, the Alliance has surveyed its members to collect ED performance data. The data survey represents a broad base of hospital-based EDs, with a separate data report for hospital-affiliated freestanding EDs of EDBA members. The data survey is done rapidly, and includes a full analysis of ED performance for the year, and incorporates the assessment of the latest CDC Emergency Department Survey within the National Hospital Ambulatory Medical Care Survey.

The Alliance has effectively moved the market. The EDBA provides the data to major agencies that are critical to the emergency practice — CMS, the ENA, ACEP, the AHA, The Joint Commission, and a variety of state regulatory bodies. The Alliance has the body of knowledge and data to communicate with general media and other groups that have an interest in ED operations.

The Benchmarking Alliance has conducted annual conferences since 1996 for outside audiences. These conferences feature national speakers on topics relating to Emergency Department “Innovations.” The EDBA conducts the ED Definitions and Performance Measures Summit every 4 years to develop and update the metrics that are needed to manage our industry. This Summit is attended by all major organizations in the industry.

The EDBA seeks regular participation from colleagues engaged in the work of making the ED function at higher levels for patients, medical staffs, hospitals, and communities. This was the most important during the critical early stages of the pandemic.

The Alliance was founded by and remains dedicated to Emergency Department leaders seeking solutions to local service issues. The President of the Alliance is Nick Jouriles, MD. For information on the EDBA, contact Mike Gibbons, the Executive Director, at (855)-622-6674, or visit the website at www.edbenchmarking.org.

The 2023 EDBA Data Report was shared with IEPC members on June 24, 2024.

  • Volumes collapsed 2020, but ED volume was up from 2022, and across all ED’s is at or above 2019 levels. ED leaders believe the volume increase will continue.
  • Outstanding ED work during the pandemic saved hospitals and medical staffs.
  • Acuity of ED patients continues to increase.
  • The data indicates improved ED flow, although many hospitals still have crippling “Boarding.”
  • Mental health cases and ED violence up significantly.
  • Walkways may have Decreased.
  • Diagnostic testing (especially CT scans) is Increasing.

The Volume Expectations are Portrayed in the Graph above.

IEPC Members: IEPC Membership includes EDBA membership. Any IEPC member who wants to access the EDBA website or Listserv conversation, please contact September Liller, Membership Manager, at september@edbenchmarking.com.

President Pearls

Articles

Robert Chavez, MD
President, IEPC

Providence Little Company of Mary Medical Center Torrance

Here is my pearl for this month:

  1. On June 28, 2024: MIPS Final Score preview became available. Final payment adjustments will not be available until the middle of August.
  2. You can access this information by signing in to QPP website to check final score for year 2023. (Paid in 2025).
  3. Be sure to review your final scores from 2022 and 2021, as well as payment adjustments for your score are available.
  4. Once you have the final scores with payment adjustments, have your RCM company review previous years EOBs regarding Medicare reimbursement to see you were paid correctly with Medicare. If not, send a call or send an enquiry letter to Medicare or visit the FAQs on the QPP website to ask for an explanation for the incorrect payment.
  5. Here is an example, a score of 100 in 2022 paid +8.5% in 2024.
  6. Depending on your physician turnover rate, your total reimbursement for increased score will decrease due to this turnover. Namely, a doctor leaves the group but was part of the 2022 reporting year. In 2024, this theoretical doctor will not see any patients on behalf of the group, therefore no increase will be realized.
  7. All of this is up in the air in 2024 given the bonus pool was done away with at the end of 2022.

2024 IEPC Speaker Series

Articles

Free to All Friends of IEPC!

Time & Date: 9:00 AM – 9:30 AM PT on the fourth Monday of each month. Membership in IEPC is not required to attend. Advance registration for the meeting is required. After registering, you will receive a confirmation email containing information on how to join the call! To receive a registration link, email admin@iepc.org.

Jim AugustineED DataJune 24, 2024
Lisa MauerEMBCJuly 22, 2024
Leon AdelmanIvy Clinicians and EM WorkforceAugust 26, 2024
Robert FrolichsteinAAEM UpdatesSeptember 23, 2024
Christina Lapman,
Steve Freedman,
and Deanna Christofferson
Malpractice UpdatesOctober 28, 2024
Andrew SeleznickLegal Updates
for Emergency Physicians
November 11, 2024