The Political Games We Must Play
When most of you chose to enter the profession of Emergency Medicine, you probably never imagined the role politics might play in your future. The words politics and politician make the hair rise on the back on many necks. The mere thought of politicians having such a large hand in an industry they fail to thoroughly understand creates quite a controversy. Influence of politics can be seen in many aspects of the practice of Emergency Medicine. Examples we have discussed in previous articles include but are not limited to: documentation and coding regulations, managed care contracting, EMTALA, Medicare payment reductions, and billing compliance regulations. These forces are what I like to call external politics. While I firmly believe these external politics are extremely important for our industry and thus encourage everyone to become involved, I want to focus on the internal politics within the hospital and physician contracts.
In previous articles by Sharon Nicka and myself, we have provided practice management suggestions for increasing revenue streams, improving coding/billing compliance, and working with the many variables that affect our industry. While these variables are all influenced by external politics, internal politics are a key ingredient to keeping and maintaining your emergency medicine practice. Without a good understanding of the many internal politics and expectations, an emergency physician group will often have a short life span at their hospital. Understanding and addressing the politics and expectations at the hospital level is also an important issue in reducing the opportunity for competitors to obtain your contract.
As you know, competition in the emergency department staffing and practice management arena is fierce. Many emergency physician groups are facing continual pressure from local and national staffing companies, other local independent groups, and division among the ranks. Competition bombards administration with promises of higher qualified, lower-priced, more efficient emergency department operation that will produce greater patient satisfaction . Regardless of truth to these promises, the competition has planted the seed with administrative personnel that alternative emergency department staffing is ready and available. This brings the next issue of administrative personnel.
Change of Leadership
The one constant in the hospital administration arena is change. The rate of employee turnover in hospital administration at most hospitals is enormous. One hospital I recently worked with had three different CEO's in eighteen months! This type of turnover increases the complexity with respect to understanding the internal politics of the hospital. The continual change also increases the likelihood that the new CEO may have some relationship with one of your competitors. I have personally witnesses this process and unfortunately it lead to the replacement of a well-established physician group. The most important point to remember is that the development of a personal relationship with the administrative powers can provide your physician group an enormous advantage with respect to your competition.
Four Common Political Battles
After speaking with numerous hospital administrators, most have several expectations of their emergency physician groups. First, most administrators would like for their emergency physician group to operate financially independent without a subsidy of stipend. In a perfect world where most or all patients paid their emergency department bills, this would be possible. The reality, as we discussed in previous articles, is that more and more emergency departments are requiring stipends or subsidies to maintain current staffing levels. When you require a subsidy from the hospital, the hospital tends to have more input into the operational and staffing decisions. Additionally, the subsidy situation can create an opportunity for your competition to underbid bid your contract. I have seen many situations where the hospital decision makers fell for the old bait and switch technique and awarded the contract to the lowest bidder. When this occurs, the new group bids the contract with no subsidy or a reduced subsidy, obtains the contract, and approaches the hospital for additional funding several months into the contract. At this point, the group potentially has leverage because the hospital may fear another emergency department turnover. If your contract ever comes to bid, make certain the decision makers are aware that this tactic is frequently utilized.
Second, the hospital desires good patient care from the emergency physicians. Many administrators want to staff their emergency departments with all board-certified, residency trained emergency physicians; however, variables such as cost and availability prohibit this staffing in many situations. As a result, we have many emergency departments staffed by highly qualified emergency physicians, both boarded and non-boarded in emergency medicine, with additional coverage provided by physician extenders. The infusion of physician extenders has enabled emergency physician groups to add additional staffing to handle the ever-increasing emergency department volumes. The utilization of physician extenders can cause some controversy within the medical staff and community. Take the time to explain to those who don't understand that this staffing model is consistent with emergency departments across the United States.
Third, most hospitals are placing a real emphasis on patient turnaround time. As a result of increasing patient volumes, I have seen patient turnaround time increasing. With volumes increasing and reimbursement decreasing, you must reevaluate your current staffing models to find a solution that is acceptable for your administration and medical staff. The solution will not be easy; however, clearly communicating your issues to administration and other power brokers will assist your physician group. I always advise my clients to ask administration their expectation of patient turnaround time. Once you know this information, you can develop a plan of action that accommodates these expectations or finds a happy middle ground. In my discussions with administrators, I have found that they often have unrealistic expectations regarding turnaround time. The unrealistic expectations tend to stem from lack of information and bad information. Often times they receive turnaround time information on other area hospitals without knowing patient volume, staffing levels, patient acuity, or whether these times include all patients or only patients that are treated and released. Take the opportunity to show national and regional averages and how your physician group stacks up against these averages. In some of my recent discussions, we have found that groups with perceived slow patient turnaround time were actually 60-90 minutes less than other area hospitals. Education and communication are the keys to a common understanding.
Lastly, most hospitals are utilizing one of the many patient satisfaction surveys to measure their emergency department against others in the area and country. Many hospital administrators place a great importance on the results of this survey. Make certain you understand their expectation in this area and to what degree your group will be evaluated on these results. While I realize administrators need evaluators and indicators of satisfaction, I tend to feel that most of these surveys truly benefit only the survey company. If you take the time to analyze the data, you will find that the response to this survey is very low; therefore, most of your patients have not evaluated the emergency department experience. Then you go one step further and realize that the general public has no idea the average emergency department turnaround time in excess of three hours, you tend to have a general public with somewhat unrealistic expectations evaluating the performance of your emergency department. After evaluating patient complaints at the billing office, most complaints tend to be generated by patients that presented without a “prudent layperson” emergency and tend to be uninsured or Medicaid recipients. Patients that are having true emergencies tend to be much more satisfied with their emergency department experience. I would recommend that your physician group work in conjunction with the hospital to find a better mechanism to survey a greater number of patients, evaluate the patient expectations in relation to regional and national averages, and evaluate who are your unhappy customers. The results may surprise you and the administrators.
As with external politics, playing the internal politics correctly is critical for survival. The Emergency Physician groups who develop a close working relationship with the administration, medical staff, and other power brokers tend to have contracts survive the test of time. Invite the administrators and other decision makers down to the emergency department during peak patient volumes so they have a first hand understanding of the issues you deal with on a daily basis. Communicating with and educating these people is your best line of defense to keep your competitors out. Remember that the political games we must play are sometimes the most relevant step in securing our future reimbursement.