Pregnant and scared, Natasha Valle went to Tennova Healthcare in Clarksville, Tennessee, in January 2021 with bleeding. She doesn’t know much about miscarriage, but this seems to be one.
In the emergency room, she was examined then sent home, she said. She came back when her contractions became intense. Then back home. She ended up having to go to the emergency room three times in three consecutive days, generating three separate bills, before she saw a doctor, who reviewed her blood count and confirmed her fears.
Related: ER doctors call private equity HR practices illegal and seek to ban them
Valle recalls: “I didn’t think, ‘Oh, I need to see a doctor.’ “But when you think about it, it’s like, ‘Wow – dang – why didn’t I see the doctor?'”. And she’s still paying the bills.
The hospital declined to discuss Valle’s care, citing patient privacy. But 17 months before her three-day challenge, Tennova leased her emergency rooms to American Physician Partners, a medical staffing firm owned by private equity investors. APP employs fewer doctors in its emergency rooms as one of its cost-saving initiatives to increase income, according to a confidential company document obtained by KHN and NPR.
This staffing strategy has overwhelmed hospitals, and especially emergency rooms, seeking to reduce their flagship cost: physician labor. While diagnosing and treating patients was once their domain, doctors are increasingly being replaced by nurses and physician assistants, collectively known as “mid-level physicians” who can perform many of the same tasks and generate the same amount of revenue for less than half the cost. wage.
“The APP has multiple cost-saving initiatives underway as part of the Company’s ongoing focus on cost optimization,” the document says, including “staff shifts.” between doctors and mid-level practitioners.
In a statement to KHN, American Physician Partners said the strategy is one way to ensure all ERs remain fully staffed, calling it a “hybrid model” that allows doctors, nurses and Physician assistants “provide care to their fullest potential”.
Critics of the strategy argue that finding ways to save money leads to treatment being done by someone far less trained than a doctor, leaving patients vulnerable to misdiagnoses, medical bills. higher and inadequate care. And these fears are bolstered by evidence that leaving doctors out of the emergency room may not be good for patients.
A working paper, published in October by the National Bureau of Economic Research, analyzed approximately 1.1 million visits to 44 ERs in the Veterans Affairs Health Administration, where nurses can treat patients without a doctor’s supervision.
The researchers found that a nurse’s treatment increased the cost of care by an average of 7 percent and the length of hospital stay by 11 percent, extending patients’ time in the emergency room by a few minutes. small visits and hours for longer visits. These gaps widen in patients with more serious diagnoses, the study says, but could be reduced somewhat by more experienced nurses.
The study also found that nurse-treated ER patients were 20% more likely to be re-hospitalized for a preventable reason within 30 days, although the overall risk of re-hospitalization remained very high. small.
Yiqun Chen, an assistant professor of economics at the University of Illinois-Chicago and a co-author of the study, said the findings are not indictment for nurses in the emergency room. Instead, she said, she hopes the research will guide how best to deploy nurse practitioners: to treat simpler patients or those without a doctor.
“It’s not just a simple question of whether we can replace doctors with nurses,” Chen said. “It depends on how we use them. If we only use them as independent providers, especially… for relatively complex patients, that doesn’t seem like a good use.”
Chen’s study echoes smaller studies, such as one from the Harvey L. Neiman Health Policy Institute that found that non-physician practitioners in the ER were associated with a 5.3% increase in image size. photos, which can unnecessarily increase the patient’s bill. Separately, a study at the Hattiesburg Clinic in Mississippi found that mid-level practitioners in primary care — not in the emergency department — increased patient out-of-pocket costs while also leading to to poorer performance on 9 out of 10 quality-of-care indicators, including cancer screening and vaccination rates.
There is still no clear evidence that replacing ER doctors with non-physicians has a negative impact on disease, said Dr. Cameron Gettel, assistant professor of emergency medicine at Yale. core. Private equity investment and the use of mid-level practitioners have increased in the ER, and in the absence of game-changing research, this pattern is likely to continue, Gettel said.
“Worse patient outcomes have not really been shown on a large scale,” he said. “And I think until that’s shown, they’re going to continue to play an increasingly large role.”
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