Explore This IssueACEP Now: Vol 36 – No 02 – February 2017
Disclosure: Dr. Klauer was formerly employed by EMP from 1999 to 2014. He has no current financial or other relationship with EMP and has no current or former relationship with USACS.
Summa Emergency Associates Weighs In
KK: Tell us about the background and history of your group.
JW: Our group is private and independent, owned and run by the physicians. We’ve been around for 40 years or so, and we have run the residency program at Summa Health System since 1980.
KK: How challenging was that for you to begin a training program in emergency medicine, knowing that Akron General was already in place just down the road?
JW: Both are very good programs. Both have won international awards, do well recruiting each year, and put out a very good product, well-trained residents. We have residents go all over the country every year. We have 10 residents a year; it’s a three-year program.
KK: The program has a great reputation and provides great training. What really happened, from your perspective, with this transition?
JW: Basically, our most recent contract [with Summa Health System] was a three-year contract started in 2013. At that time, there was an RFP because Summa wanted one group for six emergency departments. One has since closed, so now it’s five emergency departments. It was us and many other groups vying for that contract. We won the contract in 2013 and picked up three other emergency departments within the system.
KK: Was this negotiation in 2016 different?
JW: We had dealt with similar administrations for multiple years. Some members of the new team have been here for one to three years. The negotiations didn’t get started, unfortunately, until mid to late November. We saw the first contract on Nov. 26. It was about an 80-page contract. The biggest issue was that it was never about quality, timeliness of service, or meeting any metrics. We do fantastic on the metrics. The residency does very well on the medical education side. When we won the RFP three years ago, we picked up three new emergency departments within Summa. All three are underperforming either financially and/or by volume.
Two weeks before we took over the Wadsworth contract, the hospital decided to get rid of inpatient beds; it took out 36 percent of the volume within that ER. The groups that were in there before us had asked for stipends or assistance. We did those contracts for three years and lost between $8 million and $9 million. It cost us more to staff them, bill them, and malpractice them than we were receiving in revenue. There was nothing to cut from our end. We offset the losses with other departments that we run.
Five senior residents this year wanted to stay with the group. All five had to sign with competitors because I could not offer them the type of package needed for them to pay back the $350,000 in medical student loans.
KK: So the math is simple. You can’t compensate people and pay your bills if they’re more than you can bring in in revenue.
JW: Correct. I’ve been head of our group for 15 years, and even before I was president of the group, we never had any financial assistance from the hospital, but those in residency roles got graduate medical education money. In our counterproposal to Summa, we didn’t even ask for financial assistance. We said, “Can we get out of two of these three ERs? Can we close them? Can we make them urgent cares?”
KK: Was there anything extraordinary beyond meeting your losses with the stipend you were looking for?
JW: No. Initially, we didn’t even want a stipend, but when it was discussed, it was actually significantly less than what we were losing. Basically, our group, doctors, and corporation were giving [Summa] a stipend the last three years, and my doctors were taking less.
KK: In effect, you were subsidizing the hospital. Did you decide to withdraw, or did they terminate your contract?
JW: The contract was over Dec. 31 at 11:59 p.m. I had requested face-to-face meetings with emails saying, “Guys, let’s get together and get this worked out.” We got the contract on Nov. 26 or 28. Our first and only face-to-face meeting was Dec. 26. We thought the attorneys could get this worked out. We continued to talk, and our last conversations were Dec. 31 at about 4 p.m. I had submitted a term sheet on what I thought could work out. Summa offered us a three-year contract that decreased our residency funding and offered no financial assistance for the underperforming EDs. We countered with a 15-year contract and made adjustments to the residency funding. I figured we would negotiate that somewhere between the three years they offered and the 15 [the offer was rejected on Dec. 14, with Summa offering a 60-day extension). Eventually, I offered a five-year contract with a revenue assurance the first year. That was rejected on that Saturday [Dec. 31].
KK: Did the contract expire, or did Summa or SEA terminate the agreement?
JW: The contract was going to expire at midnight; it just expired.
KK: It sounds like they may have had a backup plan in place?
JW: Well, they had actually talked to US Acute Care Solutions on Dec. 24 before we had our face-to-face meeting on Dec. 26.
KK: I have heard that your group has been offered employment opportunities with USACS. Is that true?
JW: I want to clarify. We did not walk away from any patient care. We took care of all the patients the way we were supposed to, completed the workups that we had already started, and we did appropriate turnover and checkouts for the physicians coming on. Some of our physicians were offered contracts by US Acute Care Solutions. Some of the contract language is vague and more of a short-term offer than long-term. We are a group that believes in the independent practice of medicine without a lot of the corporate involvement.
KK: I assume none of them have taken the offers.
JW: We had one part-time physician who is now working for the new group, but the other 65 are not.
KK: Well, I admire your solidarity, that’s for certain. Some people have been critical on both sides about the transition of the training program. Tell me, from your perspective, what transition plan you had in place to protect the residents.
JW: That was one of our biggest concerns. The residents [250 residents] within Summa Health System wrote a letter to us, and the Residents Council wrote a letter to the board of directors with a vote of no confidence in the hospital leadership. Our biggest concern was the continued education of our residents. Our residency director and core faculty were willing to continue to educate the residents and even provide a weekly conference without getting paid until a transition was laid out. That was never taken up.
KK: We’ve heard that you sent the residents home to take a month off. Can you speak to that decision?
JW: No. The residents are back in the department. Our concern was with the staffing levels and the credentials of the new physicians (never shown to either us or our residency director). The residents (only those on an ED rotation) did not work for two or three days. They were put on administrative elective, basically a study month for their in-service exam. They have since gone back to their normal routine.
KK: Who told them to come back to work?
JW: They were pressured by [two members of Summa Health System’s senior leadership]. They were told that they could potentially lose their jobs if they didn’t come back into work.
KK: Did you have concerns that there was any undue influence over the negotiation process by those who might have had a conflict of interest?
JW: Absolutely that was one of our biggest concerns. The initial hospital contract team was the COO, who was new to her position within the last year or two. The biggest concern was the CMO of the hospital, who is the wife of the USACS CEO. She was directly involved with contract negotiations.
KK: So from your perspective, she was involved with the negotiation? It’s not just that she works there?
JW: No, no, no. She was directly on the hospital’s contract negotiations team. The first conversation we had about the contract took place in November, and included me and the [Summa Health System] CMO and COO, about two to three weeks before we got the contract [Nov. 26]. We turned in our counterproposal on Dec. 12. They reviewed it on Dec. 14, and she was directly involved with that meeting.
US Acute Care Solutions Weighs In
KK: How long have you been with USACS?
DS: I’ve been with US Acute Care and its former self, EMP, since 1995.
KK: We’re talking about the transition of the emergency department services at Summa Health from Summa Emergency Associates to USACS on Dec. 31, 2016. I wanted to have a conversation with you to make sure that we heard directly from US Acute Care about exactly what has happened from your perspective. Can you provide some background about USACS?
DS: USACS is a coalition of physician-owned emergency groups (EMP and eight other independent physician-owned emergency groups) and is now the largest physician-owned emergency medicine group in the country.
KK: I think people may not be aware that you’re located right in Akron-Canton, Ohio, and have had business relationships with Summa before. Could you speak to your history with Summa? It didn’t just start Dec. 31.
DS: Correct. We have staffed three of the five Summa facilities in the past. We staffed two of them for over a decade prior to them becoming part of Summa, and one was a new build, freestanding, that we started staffing when they built it. We staffed them up until about three years ago when the system put out an RFP and consolidated all five sites into one ER contract [awarded to SEA].
KK: Getting into some of the controversial topics, did the hospital contract with you prior to the end of their agreement with SEA? Some have raised the question of whether or not Summa had already contracted with USACS.
DS: No. Let me give you the timeline. Their contract, from what I understand, was never terminated. Their contract expired at midnight on New Year’s Eve, and it sounds like they had been negotiating with the hospital for some time. There was never an RFP or any sense that we were going to be involved in a transition or that there would be a turnover of this group. We fully expected that SEA would renew. Until we got a call on Dec. 24, we knew nothing about this.
KK: Do you think you were contacted as a potential backup plan?
DS: Yes, we were contacted, and I’m told at least one other if not two other national groups were contacted for exactly that reason. They felt they needed a backup plan because they were being told that the doctors were going to walk out at midnight.
KK: But no one was contracted with Summa before the expiration of their contract. Is that correct?
DS: Their contract expired on the 31st. They first reached out to us on the 24th. On the 27th, they said, “We would like a proposal for how you would take over on the 31st if you can,” and they sent that proposal to two other national groups.
KK: From your perspective, do you think they were still negotiating in good faith with SEA at that point?
DS: Absolutely. From what it said in the papers, there were offers to SEA as late as the afternoon of New Year’s Eve. What was reported in the paper last week was that they were offered a five-year contract or an extension to continue to negotiate, and SEA refused both and walked out at midnight. On the 29th, Summa told us, “If we have to do this, we’re going to do it with you.” They told us verbally they would work with USACS if they still couldn’t negotiate, but they were still negotiating. It wasn’t until the 31st that they said, “SEA has refused our offer of extension, and has refused the contract terms that we’ve given to them. You guys need to start tonight.”
KK: How would you respond to the criticism that you, as a large group, came in and displaced one of the few remaining independent groups in the area?
DS: We would have wanted to do it differently. We encouraged the hospital to continue to try to get an extension for the sake of the residency and the rapidity of the transition and the disruption that could cause, fully knowing that doing so might have led to SEA working it out. I really don’t see us as having displaced them. I see us filling a void. They left, and there was no one there if we didn’t go in.
KK: What resources or expertise does your group have to run or support a residency training program?
DS: We either run or are involved in supporting nine other residency programs across the country. We have a lot of resources in the way of faculty and teaching physicians, and we are bringing all of those resources to bear to support and to continue this really tremendous training program at Akron, which has a great reputation and a great history.
KK: Some have raised issues about patient safety, electronic medical record (EMR) proficiency by the physicians, even the physicians being non-residency trained and/or board-certified in emergency medicine. Can you clarify?
DS: You can’t get credentialed to be on staff at Summa in the emergency department if you’re not a board-certified emergency physician; all of our physicians who have worked there and are on staff are board-certified in emergency medicine. There was a rumor out there at some point about an internal medicine–trained doctor. That’s untrue.
KK: What about patient safety issues that might have been created because of the transition?
DS: There were no patient safety issues. We had all of the shifts covered, and we have qualified physicians. Some of the low-acuity patients experienced slightly longer waits because the physicians weren’t as facile with the EMR, but there were no patient safety issues. Within two days, all of the wait times were back to baseline.
KK: Did you ever have to use a different documentation system other than the EMR system that was in place?
DS: The first two days, the hospital used their downtime procedures, which do involve the physician documentation being on paper. The nurses were using the EMR for some of their charting, but they did use their downtime procedures for the first approximately 40 hours. They didn’t have enough trainers to do the transition that quickly, but within 40 hours, we were back on the EMR. This was the hospital’s plan for the transition.
KK: There’s been a lot of conversation and discussion about the optics of conflict-of-interest with friends or family members who may or may not have been involved with some of the negotiations. Any thoughts or comments?
DS: We all know in medicine that there are conflicts of interest at times. The issue in my mind is how they are dealt with. In this case, the conflict had been disclosed in the past and was well-known. The person that we’re talking about, [the wife of the USACS CEO], has been on the board of [Summa] hospital in the past, and she’s the CMO currently. That conflict had been disclosed. She was recused from any part of this decision making. In fact, there was no decision. As we said, we didn’t get notified until the 24th, so the idea that this was some type of a plan just simply isn’t true. She was recused from the negotiations and any part of that conversation. Clearly, the hospital knew that this was an issue that would be brought up, and they handled it as any large organization handles potential conflicts. I don’t have any concerns about it.
KK: Are you fully staffed, and what does your staffing plan look like?
DS: We have fully staffed all of the shifts. We have a group of partners with us who travel. We’re using them. We have a lot of volunteers from our partners across the country, and we’re actively hiring. We also are actively staffing the residency program. Scott Felton is the interim program director. We have Chris Lloyd as the associate program director. We have the rest of the 10 core faculty named, some of whom are interim; we continue to look for permanent core faculty.
There have also been some comments about how this group was displaced and doesn’t have jobs. They are great doctors, so we’ve obviously reached out to them multiple ways, multiple times, and would love for them to stay with Summa and continue to provide great care to the community, which they care about. I want to make sure that it’s not portrayed that we aren’t interested in them coming back. We would love to have them as part of our team.
Summa Health System Weighs In
“It was Summa’s intention to complete a long-term contract with our former emergency services provider. When presented with multiple offers of extension to reach an agreement over a holiday weekend, our former group declined. This forced Summa into a position to execute a contingency plan involving US Acute Care Solutions. USACS stepped in to serve our five emergency departments, and our EM residency, under extraordinary circumstances and has performed admirably.”—Valerie Gibson, Summa Health chief operating officer
The ACEP Board of Directors Weighs In
Understanding the importance of this issue to our members and our specialty, the ACEP Board of Directors met on Jan. 19, 2017, and discussed this topic extensively. We are committed to protecting the interests of our specialty, patients, members, residents, and training programs. Your input as we develop supportive resources is welcome. We will to continue to communicate with you on this and other important issues.