Emergency physicians experience burnout at three times the rate of the average doctor. A common refrain underlying this is that corporatization by so-called contract management groups (CMGs) interferes with the physician-patient relationship and erodes the specialty. Acerbic posts in the 24,000-strong Facebook group EMDocs, for example, identify CMGs as sources of ungodly wickedness.
The magnitude of emergency physician ire is often justified. Headwinds face the specialty. Reimbursement is falling due to the No Surprises Act and government cuts. Emergency department (ED) crowding and boarding are worsening. Some hospitals and physician groups have undertaken strategies contrary to the best interests of physicians and patients. This includes slashing wages and benefits, instituting contractual non-competes, and overbilling patients, then suing them when they can't pay. Physicians feel burnout from this lack of control, unfair work environment, and falling pay.
While real, some of the wrath is misdirected. For full disclosure we are physician leaders in a company most would call a CMG. Before your head explodes, please read on.
First, what exactly is a CMG? By all accounts, a CMG is a large group. But how large: five, 50, or 500 contracts? And what about physician number -- is 50 physicians at three sites a CMG? How about ownership? Is a large, non-profit academic group a CMG? Many academic groups manage community ED contracts, employ hundreds of physicians and advanced practice providers (APPs), and are almost never owned by physicians. What about a single majority physician owner managing five contracts with 50 physicians? Does involvement with external funding sources (e.g., private equity) define a CMG? The point: CMG is a poorly defined term.
If "CMG" is not a meaningful boogeyman for what's wrong with healthcare, what questions should emergency physicians be asking about their group? The answer: Physicians should ask questions about strategy.
Who leads your group and determines strategy: physicians or non-physicians?
In our experience, physician-led organizations engage less in strategies harmful to physicians and patients, such as out-of-network billing, lawsuits against patients, non-compete clauses, absent due process, and sudden contractual changes.
You should ask if physicians are owners or if the group is owned by another entity. Ownership and control by arms-length investors and non-clinical leaders can reduce quality by indiscriminately cutting investments in education, risk management, and safety.
How does your group treat physicians?
Are physicians treated equitably in wage and shift preference? Special "deals" have historically led to underpayment of women and underrepresented minorities, and have been prominent in academic departments. Additionally, is there due process when clinical issues or other conflicts arise? Does the group have non-compete clauses for clinical work? Groups that have standardized processes and avoid non-competes are more physician friendly.
Does your group pay fairly and what is the financial health of the group?
Compensation should be assessed in totality, including hourly clinical pay, productivity bonuses, retirement, health/malpractice/disability insurance, parental leave benefits, and continuing medical education (CME). What percentage of physician fees support back-office functions or fund a "Dean's tax" in an academic center?
Is financial performance transparent and communicated to frontline physicians? Does your group have an appropriately cautious and disciplined financial strategy? Or does it conduct business affairs with only the bottom line in mind by negotiating high risk-high reward contracts and putting themselves at risk when economic circumstances change?
How does your group address quality?
Does the group actively use evidence-based clinical tools that adhere to the latest literature or is quality of care not emphasized or funded, leaving resources underused? How does the group mitigate risk to patients (and by extension its physicians)? In high-risk clinical situations, is there real-time structured support for physicians by their peers? What feedback do physicians receive when addressing quality or patient experience -- is positive feedback given or is negative feedback the norm? Is negative feedback constructive or punitive? The literature shows that audit and feedback programs are very effective in enhancing quality.
How does your group handle patient issues after the acute care visit?
When patients can't pay, do they get sued? Or are there more patient-centered tactics to handle payment issues? After discharge, does the group contact patients to assess recovery, care issues, and follow-up?
How does your group utilize advanced practice providers?
How is advanced practice provider (APP) quality addressed? Do APPs work side-by-side with physicians in a team or in silos without real-time communication? Are APPs formally trained to standards established by physicians? When clinical schedules require modification, are physician schedules altered differently compared to APPs?
Framed this way, three themes emerge. First, the term CMG does not have a clear definition. We propose defining a CMG simply as a group that manages multiple contracts. For structural specificity, one can add descriptors of profit-status, ownership, specialty, multi-state presence, and academic status.
Second, vast differences exist in how groups manage physicians and approach patient care, staffing, and billing. In our experience, no group does everything perfectly, but some use many more positive strategies than others.
Third, accurate, public information about group strategy and finances is almost never available. Information on unofficial websites or social media is often incomplete, distorted, or frankly false. The best way to understand a group's strategy is to meet directly with the leadership and the physicians actively working there. Engage, ask questions, and hold them accountable for inconsistencies.
Ultimately, judging physician groups as a monolithic category based solely on structure (i.e., CMG or otherwise) is bound to be misleading. Groups should be judged by their strategy, performance, and how they treat their physicians and patients.
Jesse M. Pines, MD, MBA, MSCE, is chief of clinical innovation at US Acute Care Solutions and a professor of emergency medicine at Drexel University and a clinical professor at George Washington University. Amer Aldeen, MD, is chief medical officer at US Acute Care Solutions.