American Academy of Emergency Medicine

The Moral Arc II

I have been an emergency physician for 20+ years and have worked under a number of models with various groups. I must take exception to the oft-stated position among AAEM leaders that CMGs are somehow more vile than privately run contracts. I offer my personal experiences, admittedly unscientific with an N of 1, but very real. I will not name specific physicians, groups or cities, but they know who they are.

One private group recruited me after they had already been given notice of termination and had me scheduled the very last week they had the contract to staff the ED and never said a single word to me.

Another group strung me along on a 'partnership' track but the founder maintained a 51% controlling interest and overrode the group's recommendation to let me join, without a reason. I quickly realized he intended to retire and did not want to split the profit. As I suspected, he retired and left the group with no succession plan and they were forced to become hospital employees at 35% lower pay. Fortunately, I saw the writing on the wall and had already left.

Yet another group had a fee-for-service model where a flat rate was paid until collections caught up. After a few months, the 'open books' were not reflecting my productivity accurately and I was told there wasn't anything more to be paid. The rest of the group received the largest bonuses ever. Obviously, they were skimming my productivity. I resigned, giving my 90 days notice and even still covering a holiday before leaving. 3 months later, I received a $13,000 bill for tail coverage. If I had simply walked away and quit, they would have had to pay. But because I was honorable, it wasn't covered.

Also, another independent contractor group suddenly decided we needed to be 'on-call' several days per year because other physicians were calling off on weekends and holidays and it was difficult to get coverage. Of course, no incentive was offered to pick up those shifts and there was no compensation for the time we were expected to be available for a last-second call-in. My time away from work is just as valuable as time at work.

Clearly, private groups are often just as unscrupulous as any national CMG. Many of these same small groups sell out their practices to CMGs and pocket handsome profits by a tiny part of the groups' management and leave the rest to fend for themselves. AAEM should fight for fairness for all emergency physicians in all practice settings rather than paint CMGs as EM's bogeyman.

   — Robert J. Benkendorf, MD MMM FACEP FAAEM

I agree completely. Like you, I have seen more than one independent, "democratic" group that was anything but democratic and equitable. Many individual contract holders are as bad or worse than corporate staffing companies. Rest assured that AAEM fights for fair and equitable treatment in the workplace for all emergency physicians — whether they are hospital employees, part of an independent local group, or working for a huge staffing corporation. The basic principles of fairness are the same in each situation.

There is, however, one important difference between an independent physician-owned group and a staffing corporation (contract management group or CMG), and it is fundamental to the business model of each. A purely physician-owned group may be fair and democratic — meaning it is owned equitably by its physician members, with each having an equal share of ownership and control, each having full knowledge of the group's revenue and expenses, each having the protection of peer review and due process within the group, and each being free of post-employment restrictive covenants. A CMG not only usually does not provide these things, it cannot provide all these things because it derives its profit - and riches for its principle shareholders and upper management — by taking money away from emergency physicians far in excess of any value it returns to those physicians or their patients. Thus, while it is true that being entirely physician-owned is no guarantee of democracy and fair treatment in an emergency medicine group, it is also true that a CMG that exists to enrich its management and lay shareholders cannot be democratic or treat its emergency physicians fairly. 

                                             — The Editor

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