Ask Sue Cejka, managing partner, Grant Cooper & Associates, what’s at stake in hospitals’ relationship with the physicians who staff their emergency departments and she doesn’t mince words.
“The emergency department is the hospital’s Achilles heel; it’s where there is the highest patient dissatisfaction. If you come into the ED and leave without being seen, you’re not coming back for elective surgery.”
So compensation strategies for ED physicians must reward quality, efficiency, and patient satisfaction above all, right? Not so much…
Different Strokes for Different Folks
Almost all emergency department physicians work for either a hospital (occasionally more than one) or for increasingly large private practice groups. A group may employ physicians directly or contract with them as independent practitioners; a few “democratic practice” groups, made up entirely of partners, usually employ themselves within a corporation and then split any profits at the end of the year. In any case, it is the group, rather than the physician, that signs an exclusive contract with hospitals to provide emergency medicine services.
Regardless of which entity is paying, the most common way to pay for emergency medicine services currently is by the hour. This definitely rewards them for showing up.
There is a trend, however, toward employers of both kinds paying ED physicians a straight salary. If it’s an academic medical center, the salary is sometimes lower and being paid in part by the affiliated medical school or clinic. Either way, however, many see this practice as unfair, because a fast-moving physician makes the same amount as a slower one.
This is why some hospitals and more private practices pay either bonuses or some portion of the overall compensation package, say 10%-25%, on the basis of productivity. According to Jeffrey Bettinger, MD, FACEP, a spokesperson for the American College of Emergency Physicians, this is typically measured by work RVUs or numbers of patients seen.
Some hospitals that have tried tying basic pay to a productivity formula, says Bettinger, have found that it leads to cherry-picking of patients and other practices harmful to the chemistry of the group.
At the other end of the scale is what is sometimes called the “eat what you kill” approach, in which the physicians bill and collect for their own services; if they belong to a private practice, often the group will handle these administrative chores (or hire a firm to do so) in return for a percentage of the collections.
Fee for service, says one emergency physician who is paid this way, is getting harder to find but remains extremely popular. “The harder I work, the more I get paid.”
But isn’t there a built-in incentive to, well, rush? “There’s an incentive for me to see more patients but it balances out, because the more I do for a given patient, the more money I get.” Of course, “if there’s a slow shift, we go home.”
There definitely is an incentive to rush when ED physicians are paid strictly by the head, an approach that also punishes physicians when business is slack. On the other hand, as Cejka points out, it certainly eliminates the problem of patients who are put on gurneys and just left in the hall.
There’s no agreement on how common this payment method is.
What to Measure?
There is growing agreement, however, that probably the only way to enhance efficiency and quality in the nation’s emergency departments is to put some portion of the physicians’ pay at risk. The question is, what measures, other than productivity, could or should be used.
Bettinger says that he doesn’t know of any hospitals “where quality has been incorporated in some meaningful formula in the compensation structure.” The only exception is with some groups that can’t generate enough fee-for-service revenue and so “get some sort of subsidy from the hospital to augment the physicians’ compensation.
“Some of these hospitals build quality benchmarks into their subsidy payments, using the six or seven Physician Quality Reporting Initiative measures that apply to emergency medicine, such as time to administering aspirin after a patient presents with chest pain.”
Kaiser Permanente, for one, has long taken patient satisfaction into account when figuring bonuses for their emergency physicians, who are otherwise salaried just like housekeepers and engineers.
If Cejka had her way, ED physicians would be paid by the hour but have the opportunity as a group to earn a 20% bonus based on three factors: patient satisfaction scores, wait times, and numbers of patients who leave without been seen.
“This would give physicians some control over at least part of what they earn, allow the most efficient ones to apply some healthy peer pressure on the rest, and, at the same time, accomplish an important hospital goal: improving patient satisfaction. These are also the three easiest things to measure.”
And are a lot of hospitals and private practices using this strategy? Not so much…