Emergency medicine is a constantly changing and evolving medical practice. The business side of emergency medicine is no different. I want to share some insights that have been beneficial to Carrollton Emergency Physicians (CEP), an independent, physician-owned EM practice, hoping that they might prove useful to emergency physicians starting their own practice or to those who would like to learn more about small group practice management.
Explore This IssueACEP Now: Vol 38 – No 03 – March 2019
A little historical perspective is warranted. My journey with emergency medicine started in Atlanta. Having graduated from Emory School of Medicine in 1977, I did a surgical internship at Grady Memorial Hospital, followed by working at the old Crawford Long Hospital (an Emory affiliate) in the emergency department to see if this new specialty of emergency medicine was a fit for me. I liked what I did but realized that being fully trained in emergency medicine was essential. I completed the EM residency at Grady and was chief resident the final year. My wife, whom I met in medical school, had just finished her obstetrics and gynecology residency and had a four-year commitment to the Air Force, which had paid for her medical school expenses. I worked in local emergency departments near her base assignments. During that time, I learned a lot about the medical and business sides of emergency medicine. As my wife’s commitment was ending and we were looking for places to practice, the hospital administrator at my hometown hospital asked if I would consider starting an EM group in Carrollton, Georgia. At the time, all of their emergency coverage was by locums, and none were trained in emergency medicine. When we started looking for a place to live and practice, we created a list of priorities for where we wanted to live. Next on the list was the type of practice we might have and the lifestyle available with two small children. Carrollton was not initially on my list, but the offer of starting a completely new group was intriguing.
Building the Group as Part of the Community
I wanted to start a group that I personally would want to join well after it was started. I was committed to the concept that all the doctors would be EM residency–trained and board-certified. While there are plenty of physicians who are not trained in emergency medicine who practice great emergency medicine, having this consistency and certification was important to the members of the group and also to the medical staff, who had never been exposed to trained emergency physicians. This was also important to the community, which had seen moonlighting doctors from 50 miles away taking care of their loved ones during their most vulnerable times. That factor also convinced me that I wanted all of our physicians to live in the community. They had some flexibility, but I wanted them to be “local” and be seen at the grocery store, schools, and churches. I also asked that they become active in the community in addition to their medical practice. It didn’t matter in what form they were involved, but I thought it was an important factor to increase our credibility in the community. I thought that the more our patients knew us, the less likely they would be to sue us if there was an unexpected outcome. Finally, I wanted to make sure that the spouses were actively involved in the entire process and were thoroughly made aware of the community. The family had to buy into the deal.
The hospital played an enormously important role in this process. The medical staff was very supportive of me setting up whatever type of practice I thought was best; there were no turf wars. Also, the hospital was a community hospital, run by a board of local community leaders with a stable administration and a solid financial footprint. I purposefully told all candidates about the importance of the hospital’s stability in their practice, as well as having a stable contract. Your ED contract is only as good as the working relationship between the ED group, administration, and board. This concept was frequently new to many interviewees.
I told our administration that I hoped to have all residency-trained physicians in five years; this was actually accomplished in three. Everyone in this new group had to buy into the general concepts of the group structure and dynamics for the plan to work. This was Carrollton Emergency Physicians’ practice, not mine.
The next question was, can this type of democratic, independent EM group serve one hospital system, prosper, have contract stability, and provide long-term careers for our physicians?
Because all the physicians took ownership of the process and the hospital was enormously stable and successful, this concept worked quite well.
Dedication Leads to Success
Because all the physicians took ownership of the process and the hospital was enormously stable and successful, this concept worked quite well. We currently have 24 physicians, all residency-trained and board-certified/eligible, who are all partners and equal shareholders. The group is completely democratic, with the most junior partner making the same salary and working the same shifts as the most senior partners. Administrative costs for the partners managing the group are capped at 4 percent of gross revenues. This year, the group will see about 100,000 patients with the aid of 15 advanced practice providers.
Since the group was started in 1985, we have had only one partner leave the group, and that was because his wife’s family, who lived nearby, moved. We only used locums once, 15 years ago, when the hospital asked that we immediately take over ED coverage for a smaller hospital it acquired. Within a year, they had all been replaced with residency-trained emergency physicians. Additionally, we have enjoyed a limited malpractice history. We have had very few claims because the physicians are good and known by our community. This has resulted in lower premiums.
Transitions are important. I recently retired from my clinical practice and administrative duties. The current leadership actively practices emergency medicine, and the group supports them. They are being creative and thoughtful as they handle the ever-increasing challenges of medicine. They implement important changes after the group votes while maintaining the core principles of the group.
The process can work. It works because the physicians come to work every day, making the process happen. They all believe that it is an honor and privilege to provide care for their community. I think that all the components (hospital, administration, community, and how the EM group is established) are important.
Dr. Fitzgerald is former CFO, past president, and founder of Carrollton Emergency Physicians in Carrollton, Georgia.