Workforce: Tough Times or Opportunity

What a year! Not even half over and 2020 will be remembered by many for the rest of their lives for various events. Some of the most notable are SARS-nCoV-2 (Coronavirus) and the disease it caused (COVID-19), the public outrage of the horrific killing of a handcuffed man by a police officer in Minneapolis and the public outrage, the lockdown (shelter-in-place) that government officials ordered for the people they represent, the resulting skyrocketing of unemployment and never before rise in unemployment filings within a 6 week period and the resulting damage to the population, the failure of numerous small businesses as a result of the lockdown, the spending of taxpayers’ money at levels never seen before…. I could go on about people dying alone, cancellation of graduations, prohibition of family members being with dying loved ones, a small percentage of hospitals being inundated by COVID-19 while the majority of hospitals’ emergency departments seeing 30, 40, 50% or more decline in patient volumes and cancellations of many other hospital services. An economy that was booming that was brought to its knees. A stock market that dove and then came back all within 3 months.

A healthcare industry that had record revenues that suddenly was laying off staff and closing clinics, canceling elective cases, and asking for financial handouts. A time when doctors, who most believe would never worry about a shortage in demand for their services, experienced a decline in the demand for their services. Emergency physician (EP) pioneers that started freestanding emergency centers (FECs) and those who work for them have been affected. I understand that many have closed. It is thought that this may be from insurance company failure to properly reimburse, large groups not wanting FECs to be successful as they take business from traditional emergency departments (EDs) that are perceived by many as not as “nice” or desirable as the FECs, and lack of support from legislators, etc. I mention the FECs as it frustrating that EPs who try to be entrepreneurs and do something that increases choice for the public and EPs and that “forced” hospitals to do better, are failing. The FECs were a beacon of hope that EPs may be able to take back their specialty. I could go on, but I won’t, I will try to focus on the possible silver lining here.

Positives

One of the refreshing things that resulted from the pandemic was the outpouring of overt appreciation for EPs, nurses, other first responders, and healthcare workers who run to the sick instead of running away from them. The appreciation of the many grocery store employees, postal carriers, Amazon employees, truckers and others who enabled most to still get their necessities and have minimal disruptions compared to what might have been.

Beneficiaries of the Crisis

The boom in the internet and other related services that enabled people to virtually stay in touch, continue to work (from home), virtually attend classes, virtually visit friends and family and the boom in telemedicine. There are many other things that I and others could add to this list but that is for another time. I will try to focus on workforce issue as they pertain to us, emergency physicians, and related topics. So, let’s begin…

Reaction of EPs

Many emergency physicians have experienced consequences from the recent events. Many have reached out to me to learn more about telemedicine and telehealth. As Chair of the Telehealth Section for ACEP, I have come accustom to fielding various inquiries about the topic. After hearing what many had to say, I realized that things were worse than I thought. Many emergency physicians were worried about their job and financial security. Many who had signed up as employees of, or independent contractors for, large contract management groups (CMGs), who may have justified doing so because they felt it gave them more job security, learned that this was not the case. Many were negatively affected. Some were furloughed (nice way of saying “fired” but maybe we may ask you to come back if it will benefit the company), hours were cut or their offer to work were withdrawn (residents graduating). I get it. The CMGs are in the business to make money and cannot survive if they consistently lose money. But that is the point of mentioning it, to make sure there is no mistake as to what is most important to the CMGs. It is them, not you.

I could go on about CMGs, but I will try to limit the discussion here.

More Good News

Even though times may seem uncertain and our income has been affected, the future is bright. In fact, interruption, disruption, challenges, and hard times often lead to some of the best innovations and advancements. I believe this is no different. This is a great opportunity for capable people to do great things. And emergency physicians are capable. Emergency physicians are a special breed. We do a job that many do not want to do and could not do even if they wanted to. We also adapt well. As a profession, we are the safety net, we are often the patient’s best advocate, and we are on duty 24/7/365.

Telemedicine

Even before COVID-19, I emphasized the importance for all emergency physicians to familiarize themselves about telehealth. It is the future and has been for the past few years. It had already started to become more and more used before the pandemic but was supercharged by COVID-19. The shutdown and isolation knocked out much of its competition, made it a necessity in many cases and highlighted many of its advantages to the public and especially physicians, who were often the slowest to accept the implementation of telemedicine before COVID-19.

Opportunity for Entrepreneurs

For those of you who have an entrepreneurial spirit, there are many opportunities to use telemedicine to deliver quality care to patients. Remember, telemedicine is not a new form or specialty of medicine, it is simply the vehicle we deliver it. One day, people will no longer call it telemedicine but simply call it medicine. How many banks say they do “tele-banking”? None. They allow you to bank from your computer or phone, but it is banking, not-tele-banking. Telemedicine is simply medicine. Tele-EM is simply emergency medicine. The opportunities are endless: concierge medicine, contracts with businesses, schools, prisons, nursing homes, etc. Your imagination can lead you to new opportunities that others still haven’t capitalized on.

After seeing the opportunity to change healthcare for the better and the challenges many fellow EPs are facing, I decided to look into starting a telehealth company that can provide an opportunity for fellow EPs to be able to be part of something that is enjoyable, provides a great service to patients, may be a “game changer” in the industry and allow them an opportunity to actually obtain equity so they can truly have “ownership” as opposed to being permanent “renters” like so many of us are when working for CMGs. Nothing wrong with people choosing what is best for them. This gives people more choice.

Non-entrepreneurs

“Where to work” and “what group to work with.” For those of you who do not want the extra work and responsibility of being an entrepreneur, or do not have the desire, there should be plenty of options and perks. The key is to choose wisely. This too is an opportunity. Make sure you interview the perspective employer. Is it a good fit? Will you be working in an arrangement you want? Will you like your co-workers? Is the compensation arrangement what you want? Will you be a partner? Will you be an equity partner? By hitting these points, one can feel more of a sense of belonging that is important to one’s happiness at work. I list many of these under “Some suggestions for anyone to consider before agreeing to a new, or continue an existing, contract.”

Freedom/Flexibility

The beauty is, in some ways, you have many more options and flexibility in telehealth. Think about it. You probably work where you work because it is near where you want to live. With telehealth, you can live almost anywhere that has broadband and provide your skilled services to people almost anywhere in the world! So, you can live where you want. Heck, you may never have to work a night shift, or day shift, if you do not want to depend on the time zone where the patients are.

Security

When you have more options and are able to work at numerous “facilities” or locations, one has greater “job security.” One is able to have employment and should things change, work more at other facilities literally without changing locations, ie, still work from their home office, dining room table, bedroom, etc.

Efficiency

Tele-physicians who work out of their home no longer have to commute and incur the lost time and aggravation associated with it. Few if any ED jobs pay for travel time. So, a 12-hour shift may actually take 13-14 hours of your time but only pays 12 hours of it.

Control your practice/specialty/life

This is an opportunity for you, the emergency physician, to take back our specialty. While many CMGs have taken over much of the control of our specialty, the Tele-EM space is still wide open. The CMGs do not control it. I challenge you, the EPs out there to seize the opportunity. You are the reason why people come to the ED, you are the one with the medical knowledge, you are the emergency specialist, you are the one with the medical license, you are the one that the bill has to be billed under by name or license number; you have the power. Do not sell yourself short or let others convince you otherwise. Take ownership and control of the specialty again. Once you do, be responsible and protect our specialty and the patients we see. Do not allow others to unduly influence what is right or best for our patients or the people who care for patients. Let the free market, or you (if you want to charge less), determine what your charge is. It also allows you to have more control over your life. If you are not dependent on one place (location) as is often the case with traditional EDs where EPs work, then it is harder to be pressured to do things, less painful to make changes, ie, spouse who wants to live in a certain city, children in school system with friends, etc. that limit your ability to negotiate more effectively. Things that some unscrupulous employers/CMGs take advantage of.

Economic Well Being

This may be a drawback in many cases of telemedicine particularly if one is not savvy and does not understand the complete picture. Often, telemedicine is considered a money loser but allows cost savings for payers (insurers, patients, or employers). Finding the right fit and getting fairly reimbursed may be a challenge as many will try to pay you the minimum they can get away with if you let them.

Future

From the people I have spoken with, it appears that ED volumes were initially hit hard but are starting to recover from the decline. Although not back to normal, I am told they are now only down about 30% on average. I expect ED volumes to continue to increase but do not expect them to ever return to levels that would have been if there was never COVID-19 and the fear and panic associated with it. I would guess that a 15-20% reduction from pre-COVID-19 is reasonable in the next 6-12 months. I anticipate that some people will never use the ED as they had before and opt to do telemedicine because of its convenience, cost, and superiority in some cases. The future is not in expensive, bricks and mortar EDs but more in delivering EM care outside of the ED. I encourage every emergency physician to join the Telehealth Section. It only costs $40 a year but the information that you may learn could be incredible. Telehealth will affect emergency and acute unscheduled care as well as most every form of medicine; it is a small investment. In full disclosure, as stated before, I am the Chair of the Telehealth Section.

Whether regarding telehealth or traditional emergency medicine, I have some suggestions for anyone to consider before agreeing to a new, or continue an existing, contract.

1. Read it, study it, and understand it. Too often people assume it is a good contract or told it is a “standard contract” or “good contract,” so they sign it. Without fully understanding a contract or understanding that contracts are negotiable, people make the mistake and sign them. Rarely will a CMG or group voluntarily divulge this to you because they often write the contract (or have lawyers do it for them) that are in their favor. They are unlikely to give you something of value if they do not have to.
2. Have a trusted and knowledgeable person review it for you that understands the specialty you are in and the job you are seeking. Someone who is familiar with contracts and who can pick up on certain language or notice certain things that are missing. If you think you know what you are doing, ask yourself how many contracts have you written, how familiar are you with law, specifically business law and then ask yourself how many contracts do you think the CMG or group has done with other physicians?
3. Know your “worth.” Understand what the going rate for someone like you is. Find this yourself, do not take the employer or opposing side’s word for it, do your research. Not just an physician but someone with your training, board certification, experience, capability of speed, acuity and value that you bring in quantifiable terms. Remember, many CMGs or employers put emphasis on how much you can make them. Be realistic but do not be embarrassed to stick up for yourself. Be polite and professional but do not be afraid to demand (if necessary) what you are worth or to walk away if they do not agree to your terms.
4. Know the market, research what going rate is for physicians with your qualifications are in that particular location, at other locations nearby, with that acuity and volume, and at the coverage levels that they have. There are many ways to disguise bad jobs so make sure you know all the variables.
5. Take your time. It is great to be able to agree right away but most good contracts take longer. Ask for a copy and a few days to review it. Then you can apply #1 to it. Come up with the changes, additions, and deletions you want.
6. Be reasonable. You may not get everything you want so know what are the things that you must have, the things that would be great to have and the things that would be nice but not worth not reaching an agreement over.
7. If it seems too good to be true… Then you probably are missing some important information. You may want to consider #2 again.
8. How receptive the other side is to you changing the contract? Adding in things? Removing certain things? Do they have an issue with you having a few days to look over the contract? How flexible are they and willing are they to work with you to get the contract into something you want? If they are not willing to work with you, that may be a sign of problems ahead. In addition, if that is the case, the terms will often not be favorable to you. Common things to consider: Pay and the pay formula; sign on; retention bonus; other bonuses; pay for extra time to complete charts, attend meetings, non-clinical activities; minimal guarantee to physician; requirements beyond clinical; productivity; revenue sharing; number of shifts; length of shifts; coverage (physician vs providers); responsible party for the providers and how many you are responsible for during any given shift, who determines the hiring, training or termination of the providers; what shift breakdown will you have to work; are shifts flexible-penalty to trade; med malpractice terms: limits, occurrence or claims made, who pays for it, who has final say to settle or not? Are you paid for your time in event of malpractice claim involving provider? Is there a copay? Does malpractice cover other things? What rights do you have on medical staff? Same as all other physicians on medical staff or less as an ED physician; severance pay if terminated before certain period; voting rights in group and company, etc. There are many others. My point is there is so much more than an hourly amount. Unless you ask, you may not know or may not be given the things that are valuable to you.
9. Know what you want. Know what your walk away is. There are worse things than not reaching an agreement. That is agreeing on something that you will regret. There is only one you and there are many potential jobs out there. Everyone has their own value system and assigns the value of any give factor is or how important it is to them. Find the job that will make you most happy.

I hope you find this article informative and useful when considering your options and negotiating your contract. This article is for informational purposes and not intended for to serve as advice (legal, professional, or other). I wish you the best and hope you will enjoy your profession, be able to care for patients in a safe and enjoyable environment, provide great care and be paid a fair amount for your specialized and valuable services. If you have any questions or would like to know more, you may contact me at ed@shaheenconsulting.com.

Etch Shaheen, MD
Chair of the Telehealth Section, Founder of DrHouseCallMD.com and
Author of IN THE DARK & Make Healthcare Great Again