Emergency Room (ER) doctors are gradually being replaced by physician assistants and nurse practitioners. The Neiman Institute reported that between 2005 and 2020 the number of ER visits with midlevel practitioners in attendance increased by 172%.
Midlevel practitioners are performing many duties previously carried out by doctors and specialists but for almost half the pay. According to the U.S. Bureau of Labor Statistics, physician assistants and nurse practitioners are now the most sought-after occupations in the U.S.
The forces behind this trend are private investment companies bent on cost-cutting and relying on promoting midlevel practitioners to accomplish that end. Powerful and persuasive professional opinions both positive and negative are expressed on all sides.
Federal data confirms that ER doctors receive about $310,000 annually as opposed to physician assistants and nurse practitioners who earn under $120,000. Therefore, the temptation will be to continue cost-cutting.
Private Equity Companies
Private Equity Companies receive money from investors to gain entry into various industries. Although this has proven to be successful on Wall Street, there are concerns about this business model in health care.
According to tracking by PitchBook, approximately $1 trillion of private equity has accounted for about 8,000 healthcare investments during the past decade. That includes funding medical staffing companies that are hired by hospitals to manage their ERs.
The Glass is Half Empty
And yet the administrators at the American Academy of Physician Associates do not have a negative view. Jennifer Orozco, President of the academy said that even if it is the cost factor driving the staffing companies, she believes that patients will still receive proper care from physician assistants and nurse practitioners.
The founder of the American Academy of Emergency Medicine, Robert McNamara, M.D. agrees that the staffing companies are perhaps the most aggressive in cost cutting by using midlevel staffing.
Dr. McNamara accepts the concept that staffing companies are going to cut their highest expense and it is obviously high salaried emergency physicians.
American Physician Partners
American Physician Partners (APP) is a medical staffing company owned by private investors. According to Moody’s APP generates about $651 million in annual revenue. APP is an excellent example of using midlevel practitioners rather than doctors to staff the ERs under their control.
KHN and NPR obtained a confidential document confirming that one of APP’s cost-cutting measures is to employ fewer doctors for the ERs in its portfolio. The document claims APP’s continual focus on optimizing cost includes shifting the balance of staff between doctors and its midlevel practitioners.
The explanation APP offered to KHN suggests that their strategy ensures that all ERs are always fully staffed. The company refers to this strategy as a “blended model” stating that it allows doctors, physician assistants, and nurse practitioners to meet their full potential.
On the contrary, critics say this strategy results in treatment by staff with less training than doctors. Therefore, patients are at risk of higher medical bills, misdiagnoses, and less than adequate care.
Until such time as more substantial results are obtained, conflicting opinions will continue. One such opinion is presented by Cameron Gettel emergency medicine professor at Yale University. Professor Gettel notes that private equity investment as well as the number of midlevel practitioners rose equally in the ER. Professor Gettel also notes that until research can confirm otherwise, this pattern will no doubt continue.
The Emergency Medical Treatment and Labor Act (EMTALA)
EMTALA guarantees a level of medical care to patients in ERs that accept Medicare or Medicaid. In 2018 WebMD and Georgia Health News by way of the Freedom of Information Act, requested a list of EMTALA violations in the U.S. from 2008 to 2018. The most frequently reported violation was the failure to conduct adequate screening exams.
The ER is changing due to an increased focus on profits coupled with a surplus of ER residents and fewer available jobs. Experienced doctors are leaving the ER.
