Unity, Purpose, and Passion: Influencing the Future of the EM Workforce

January 31, 2022

Message from Dr. Angela Cai, EMRA President

EMRA has been hard at work ensuring that your voice, as the future of our specialty, drives solutions to the emergency medicine workforce in response to the multi-organizational workforce study. We would like to continue the dialogue by sharing what we've learned, what you've told us, and where EMRA stands. This is a living document being shaped by you. Share your thoughts through this workforce survey or via email at president@emra.org. For even greater impact, become an EMRA leader or submit Representative Council resolutions (due Feb 11).  

The projection of a 9,000 EM physician surplus by 2030 has created a lot of angst and fear among all of us. But projections are just that - projections. As additional research continues, EMRA remains focused on solutions to design our futures.   

Table of Contents

Supply

Residency Program Growth and Training Standards

Demand

Nonphysician Providers

Rural

Expanding the Scope of Emergency Medicine

Corporate Practice of Emergency Medicine

Supply

Residency Program Growth and Training Standards

EMRA’s Stance:

  • EMRA is participating in a multi-organizational effort to propose recommendations to the ACGME for increasing residency standards. These recommendations must center on training quality rather than arbitrary training obstacles without educational merit.
  • EMRA continues to support both 3 and 4 year training programs and individual resident decisions to choose their training format.
  • EMRA supports a broad definition of required resident scholarly activity, as this affords residents the opportunity to complete a project that is meaningful to their individual careers and best contributes to the advancement of our specialty as a whole.

Background:
Over the last 6 years (2014-2020), the number of emergency medicine (EM) residency training positions and programs has grown rapidly making EM one of the fastest growing specialties. The number of training programs has increased by 15%. The number of training positions has grown even more, by 30%, which is a result of both new program growth and existing programs expanding their complement. Compared to prior years, the proportion of programs sponsored by for-profit institutions during this period has increased from 4% to 37%. All programs are sponsored by hospitals or educational consortiums. No current programs are sponsored by physician staffing groups.1 Hospitals that created Graduate Medical Education (GME) programs after 2015, known as “GME-naive,” have a strong incentive to increase the number of residents at their site within 5 years of starting because the Centers for Medicare and Medicaid Services (CMS) calculates their training cap after the fifth year.2

Residency programs are accredited by the Accreditation Council for Graduate Medical Education (ACGME) Emergency Medicine Review Committee based on compliance with minimum standards. Accreditation of ACGME programs is a voluntary process. ACGME policy states, “It is not the intent or purpose of the ACGME to establish numbers of physicians in any specialty.”3

 

Demand

Nonphysician Providers

EMRA’s Stance:

  • Patients want and deserve emergency medical care that is provided and led by physicians. 
  • EMRA has believed for decades that the only pathway to the independent practice of emergency medicine in the 21st century is completion of an ACGME/AOA accredited residency training program and ABEM/AOBEM board certification.
  • EMRA partners with ACEP in their advocacy against non-physician provider independent practice, including at the ACEP state chapter level and through the AMA Scope of Practice Partnership. 
  • EMRA supports post-graduate training of nonphysician providers to ensure that patients receive the highest quality care. Nonphysician provider post-graduate training is not equivalent to residency training and should not interfere with resident education.

 

Background:  

In 2012, the Affordable Care Act awarded up to $200 million to educate and train nurse practitioners. Since then, the number of nurse practitioners practicing in the United States has nearly doubled from 154,000 to over 290,000 as of March 2020. EM has seen a similar explosion of care being delivered by nonphysician providers (NPPs, i.e. nurse practitioners and physician assistants), with an estimated 15% of all patient encounters in emergency departments (EDs) being seen by a NPP in 2015 and is projected to grow to 20% by 2030.4,5 The projected increase in proportion of visits seen by NPPs is notable given the projected oversupply of emergency physicians by 2030.     

What factors contribute to the increased utilization of NPPs? First, NPPs are substantially cheaper to employ, while allowing hospitals and staffing groups to bill patients at the same rate and thus generate a higher profit. Second, there is a strong push for independent practice for NPPs, especially for nurse practitioners. To date, Full Practice Authority (FPA) legislation has now been passed in 23 states, granting nurse practitioners the full practicing rights of a physician after as little as 18 months of online classes and 500 clinical hours required for NP licensure.6 In many other states, NPs are able to practice with minimal physician oversight. A recent analysis by a team of nurse researchers concluded that due to extensive variability across the academic preparation, licensure and certification of NPs in EDs, NPs should not perform independent, unsupervised care in the ED regardless of state law or hospital regulations in order to protect patient safety.7 Despite these concerns, with tremendous lobbying effort by the American Association of Nurse Practitioners and strong financial backing from other supporters of FPA within health care, the FPA movement has advanced significantly over the last decade. Expanding NPP scope of practice affects patients across all specialties which is why EMRA supports ACEP’s alliance with the AMA Scope of Practice Partnership to coalesce efforts across the house of medicine.  

Rural

EMRA’s Stance:

  • EMRA advocates for increased elective opportunities for rural exposure in residency.
  • EMRA believes that every emergency patient deserves to see an emergency physician; however, given current economic and workforce constraints, rural patients are often evaluated by nonphysician providers without physician supervision. EMRA believes emergency physicians should direct care for these patients by setting training standards for nonphysician providers and supervising rural care onsite as much as possible with telemedicine as an adjunct. 

Background: 

Providing adequate access to emergency care to rural communities has been an ongoing challenge. Although 1 in 5 Americans live in a rural area, only 8% of all emergency physicians practiced in rural communities as of 2020 - and that number is shrinking.8 In fact, over the last 4 years, 96% of EM graduates chose to practice in urban areas. The rural emergency physician workforce is also aging with many now in mid-career or closing in on retirement. 

 In addition to a maldistribution of emergency physicians, rural hospitals are facing other significant challenges that make practicing rural EM uniquely challenging. These factors include the following: 

  • Hospital Closures and Financial Strain: Due to a combination of low patient volumes, especially in frontier departments, and a lower income and often uninsured payer mix, many rural facilities operate at a negative margin and require state and federal assistance to remain open.9,10 However, this assistance is often not enough and over 136 rural hospitals have closed over the last decade, with another 21% of rural hospitals at high risk of closing even pre-pandemic.11 The COVID-19 pandemic has now accelerated the rate of hospital closures with a record number of 73 hospitals closing over 2021.12
  • Limited Resources: Practicing EM in a rural community also poses challenges for those with limited exposure to delivering care in an under-resourced setting. Because many services are often not directly available or require transfer, emergency physicians often have to make crucial decisions without access to this potentially care-altering information. If the patient is critically ill or specialty services are not available in the hospital, one of the most important decisions is when to admit versus when to transfer - many times the transferring hospital will be an hour or more away. This requires managing critically ill patients for longer periods of time, the ability to step into the role of a variety of subspecialists, and a mastery of a wide breadth of procedural skills.
  • Lack of Exposure to Rural Emergency Medicine: The majority of EM residents train in tertiary care centers with 24/7 access to subspecialty care, with only a small subset of these programs requiring a rural rotation.13 Thus, most emergency physicians will graduate residency without ever being exposed to rural EM. Other challenges that exist to exposing residents to rural EM include ensuring appropriate supervision, adequate patient volume, and acuity at selected rural sites, as well as longitudinal education experiences. Rotating at rural sites may cause both financial strain to the resident and may pose a strain on the resident’s family and relationships as well.    
  • Lack of Incentives: Incentives to recruit emergency physicians to rural areas, such as loan repayment programs and sign on bonuses, are not widely available. 

Several solutions have been proposed to help improve access to emergency care for rural communities including the expansion of telemedicine, post-graduate training in EM for NPPs, as well as reimbursement reforms. 

Expanding the Scope of Emergency Medicine

EMRA’s stance:

  • EMRA recognizes that most trainees want to work in the hospital-based emergency department. We also know that emergency medicine is changing with patient and workforce needs. Expanding the specialty’s scope allows emergency physicians to have options for variety in practice which promotes career longevity. EMRA is committed to looking ahead at the future to ensure that residency curricula appropriately prepare trainees for their practice environment of choice. 
  • EMRA supports telemedicine training opportunities, interstate licensure compacts, and reimbursement policies that promote current practice of and future innovations in telemedicine.

Background: 

There are many opportunities for innovation in EM practice. While many trainees value the traditional model of providing acute unscheduled care in a hospital-based emergency room, emergency physicians are interested in non-traditional practices to fill gaps in the health care system and provide a diversity of practice, which can promote career satisfaction.14 Patients are also interested in new delivery models such as telemedicine.15 All told, there are many reasons to expect that EM will not be practiced in the same way in 20 years, and we must prepare trainees for future models.16 In addition to providing opportunities, this scope expansion can provide new job opportunities in the face of projected workforce shortages. Other specialties have evolved by expanding their practice such as the expansion of anesthesia into pain management.  

 

Corporate Practice of Emergency Medicine

EMRA’s stance:

  • EMRA believes patient care and medical education must be evidence-based.
  • EMRA advocates for emergency physicians to have fair employment environments, including due process, billing transparency, and honoring of employment contracts
  • EMRA is concerned that corporate investors in emergency medicine practice and training create conflicts of interest and incentives that infringe upon physician and patient well-being. While all business models have a profit motive, the incentives are more powerful when outside stakeholders are invested.
  • EMRA supports objective research on the potential impact of corporate affiliated emergency residencies and the resulting hiring and training outcomes.

Background: 

The Corporate Practice of Medicine doctrine (CPOM) is the term used for the general principle that limits the practice of medicine to licensed physicians and prohibits corporations from practicing medicine or directly employing a physician. Most, but not all, states have laws prohibiting the corporate practice of medicine. These laws can limit or prohibit non-physicians from owning, investing in, or otherwise controlling medical practices. Exceptions to CPOM are common and include professional corporations formed by physicians, hospitals, and health maintenance organizations (HMOs). Corporate generally refers to public shareholders, venture capital, private equity, insurance companies, and health systems.18

These laws are particularly pertinent when discussing physician practice management companies (PPMC), sometimes referred to as contract management groups (CMGs), which are corporate entities that contract with multiple hospitals to provide ED physician staffing. The PPMC often handles billing, scheduling, liability insurance, and other important (but often cumbersome) administrative tasks in exchange for overhead fees collected from the physician’s reimbursement. It can also provide educational support, leadership training, and other advancement opportunities for physicians, but it cannot directly employ physicians or provide clinical care.19 PPMCs have a wide variety of governance (e.g. democratic, partnership) and ownership structures that range in various combinations of physician owners, corporate owners, and corporate investors. 

Despite the existence of this doctrine, corporate interests have had increasing involvement in health care. In 2016, the percentage of physicians who do not have ownership in their practice across all specialties topped 50% for the first time. Physicians across all specialties including EM have questioned the role of corporate actors infringing on autonomous clinical practice and medical education.20 Consolidation in health care across insurers, hospitals, and physician groups continues to increase the role of corporate actors in EM. Since their emergence in EM in the 1970s, PPMCs in 2013 contracted with over half of the EDs in the US.21

Fundamentally, the concern with corporate actors in medicine is the conflict of interest between financial performance versus the patient care, educational, and research missions of EM practice and training. While all health care businesses must generate profit, certain corporate structures may incentivize business decisions at odds with physician or patient well-being. For example, the economics of private equity control might incentivize riskier, more aggressive strategies that are especially concerning given the lack of transparency in health care relative to other industries where private equity invests.22 While there is no objective data on the impact of private equity or other corporate investors in EM, their role in poor patient outcomes and increased spending in the nursing home industry has led the public and Congress to scrutinize their presence in health care overall.23 Further complicating the understanding of corporate actors in EM is the wide variation in ownership and governance structures that utilize corporate investment.     

Resources:

Jarou, Dimeo, et al. pending publication, study conducted at the request of EMRA Representative Council Spring 2019 in collaboration with ACEP

2 https://www.chcf.org/publication/expanding-graduate-medical-education-gme-naive-hospitals/#related-links-and-downloads

https://www.acgme.org/globalassets/PDFs/ab_ACGMEPoliciesProcedures.pdf

4 https://www.annemergmed.com/article/S0196-0644(21)00439-X/fulltext#secsectitle0030

Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners : Occupational Outlook Handbook.” U.S. Bureau of Labor Statistics, U.S. Bureau of Labor Statistics, 1 Sept. 2020, www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse- practitioners.htm

6 https://www.sciencedirect.com/science/article/abs/pii/S2155825622000102

7 https://doi.org/10.1016/S2155-8256(22)00010-2

8 https://doi.org/10.1016/j.annemergmed.2020.06.039

9 Ellison, A. (n.d.). Why Rural Hospital closures hit a record high in 2020. Becker's Hospital Review. Retrieved January 17, 2022, from https://www.beckershospitalreview.com/finance/why-rural-hospital-closures-hit-a-record-high-in-2020.html 

10 Kelly, M. (2020). The crisis in rural America. Annals of Emergency Medicine, 76(3). https://doi.org/10.1016/j.annemergmed.2020.07.010

11 Rural Emergency Medicine Section // Download the Rural Task Force Summary (acep.org)

12 Ellison, A. (n.d.). State-by-state breakdown of 73 hospital closures. Becker's Hospital Review. Retrieved January 17, 2022, from https://www.beckershospitalreview.com/finance/state-by-state-breakdown-of-73-hospital-closures.html 

13 Talley BE, Ann Moore S, Camargo CA Jr, Rogers J, Ginde AA. Availability and potential effect of rural rotations in emergency medicine residency programs. Acad Emerg Med. 2011 Mar;18(3):297-300. doi: 10.1111/j.1553-2712.2010.00987.x. PMID: 21401792.

14 Cydulka RK, Korte R. Career satisfaction in emergency medicine: the ABEM Longitudinal Study of Emergency Physicians. Ann Emerg Med. 2008 Jun;51(6):714-722.e1. doi: 10.1016/j.annemergmed.2008.01.005. Epub 2008 Apr 8. PMID: 18395936.

15 Patients, doctors like telehealth. Here’s what should come next. | American Medical Association (ama-assn.org)

16 Administration and Operations Committee EMRA

17 Status of the Anesthesia Workforce in 2011: Evolution During the Last Decade and Future Outlook

18 Issue brief: Corporate practice of medicine (ama-assn.org)

19 Corporate Practice EMRA

20 2018 Annual Meeting Policy D-383.979, “Corporate Investors.”; ACEP Council 2020; EMRA Spring 2019; AMA Policy H-310.904, “Graduate Medical Education and the Corporate Practice of Medicine”

21 Envision Healthcare Corp 2013 Annual Report 10-K (sec.report)

22 Howell Ways & Means Testimony 03252021 v5 (house.gov)

23 jun21_medpac_report_to_congress_sec.pdf

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