PeaceHealth Oregon has decided to use the Atlanta-based company ApolloMD to staff its emergency departments in Lane County, ending a decades-long contract with Eugene Emergency Physicians. The decision led the group to hold a no-confidence vote in PeaceHealth leadership, which the hospital’s medical staff supported overwhelmingly.
In a statement, PeaceHealth said it selected ApolloMD based on “Lane County’s future emergency medicine needs and the type of resource required to meet increasingly high patient volumes and medical complexity.”
Margaret Pattison is the emergency department medical director at PeaceHealth RiverBend in Springfield and a member of Eugene Emergency Physicians. She joins us to talk about the decision and how the group is responding.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. For more than 30 years, PeaceHealth has staffed its emergency departments at its Lane County hospitals with a local group called Eugene Emergency Physicians. But that partnership is ending. PeaceHealth Oregon has decided to use the Atlanta-based company ApolloMD to staff its ERs in Lane County going forward. The decision led the hospital’s medical staff to overwhelmingly support a no-confidence vote in PeaceHealth management. Margaret Pattison is the medical director of the emergency department at PeaceHealth RiverBend in Springfield and a member of Eugene Emergency Physicians. She joins us now. It’s great to have you on the show.
Margaret Pattison: Thank you for having me.
Miller: Can you describe what your relationship, what Eugene Emergency Physicians’ relationship has been like with PeaceHealth over the decades?
Pattison: So we are a small democratic group. We hold the contract to staff the physician services, so we have physicians and PAs to cover the emergency department. We’ve been in practice for 35 years, originally at the old University District Sacred Heart Hospital is where it started. Our physicians covered that hospital. It was at their request of PeaceHealth that they form their own group.
Our contract is renewed every three years. It hasn’t been contentious in the past, and when RiverBend opened they continued that contract and covered RiverBend. And then in 2018, PeaceHealth asked us to also cover the emergency department in Cottage Grove, which we do now as well.
Miller: In general, can you give us a sense for the small number of common ways that hospitals around the country staff their emergency departments? This might come as a surprise to many listeners.
Pattison: I think it is. I think if you’re a patient and you come into the hospital, you assume that the person there works for the hospital, and most of the time or frequently they do not. So emergency physicians, they can be staffed as, they can be employed by the hospital, so they can be a regular employee. You don’t have as much control over your practice, so the hospital decides how many people are working at once, but you’re an employee, so you have protections as an employee and you get your benefits and your health insurance.
We’re a small democratic group, which means we hold a contract with the hospital, and all the physicians are partners in our group. So we own our own practice essentially, but we only provide services at this hospital. This is, amongst emergency physicians, tends to be the preferred employment model. We have more control over our practice. We can stand up for things that we think are important, and we can provide better working conditions which helps us retain and recruit physicians.
So it’s super important to us to have balance and provide quality care for patients. We make sure we provide health insurance, disability insurance. We actually have a sabbatical program, trying to prevent burnout just because it is so common in emergency medicine. And that gives us a huge recruiting advantage. We’re usually completely full. We almost never have to advertise. We can recruit top graduates, which is a benefit to us and a benefit to the hospital.
The third model and what’s kind of causing the controversy is the corporate medical model. So these are large nationwide staffing firms, they may be physician owned. The majority have investors in them, and many are private equity investors. And in this type of model, they obtain hospital contracts, but they’re also making a profit off that contract. So that money that they’re bringing in is going to either people that own the business or investors in the business, and this creates a lot of concerns. There’s research showing that some of these private equity contracts have resulted in an increase in mortality.
As a physician, you have less control over your job, less ability to speak up. Many of these companies employ physicians as independent contractors, so you have no benefits other than malpractice, and you also have very little protection in your job. So you don’t have to be fired, they can just not give you shifts anymore if you speak up or say something that somebody doesn’t want to hear, and that creates a lot of concern for the practice environment.
Miller: PeaceHealth was not able to provide somebody to be on our show today, but they did refer us to a recent interview that KLCC recently aired with James McGovern, the system’s chief hospital officer. This is part of what he said on KLCC’s show Oregon on the Record:
James McGovern: What we felt we needed in a partner going forward was a strong ability to do process improvement, to look at the way that people flow through the emergency departments and help us do it better and faster. ApolloMD has that very well structured process improvement in the organization. They have experience with emergency departments across the country that see over 150,000 patients a year. We are seeing about 80,000 right now. They have multiple EDs that are in the same range and same size as RiverBend, so they’ve got that baked-in, well-structured performance improvement. They have experience with highly complex, large volume EDs. They have the ability not just to design the process flow, but then to implement it and make sure that it sticks.
Miller: So the two big points there that he’s making is in terms of their decision to go with ApolloMD as opposed to your group is ApolloMD’s experience with larger hospitals with greater scale, and their ability to improve the processes and implement improvements in the processes at an emergency department. What’s your response?
Pattison: So, in terms of process improvement, I mean, I agree process improvement is important, engineering is important. How we move patients through is, especially in such a tight space, it matters to our department. We’ve had consultants come through and provide input in the past. I believe in it, I actually went back to school and got an MBA, learning about process improvement, project management, and we as a group have taken that and brought it to the hospital and led the process improvement work.
We’ve done projects to move patients into rooms faster, to decrease our turnaround times. We moved a provider into the triage area to get tests started earlier. We brought a program to move patients into rooms and examine them quickly and get things started early in their visit so that we could move patients through faster. I don’t know the details of ApolloMD. They so far haven’t really shown us what they’re going to bring beyond what we’ve brought so far.
In terms of hospital size, most of us trained in really large hospitals. I mean, I trained in a hospital that’s much larger than RiverBend, so do most of my partners.
So we do have experience working in large hospitals, moving a lot of patients. ApolloMD does have a large hospital in Georgia that they staff that sees a much larger volume than RiverBend, but the physical space is also much larger. And that’s a very different question, moving a large number of patients through a large space is a very different model than moving a large number of patients through a very small space, which is what we’re tasked with in our hospital. So what do they bring that we don’t already have now, and so far they haven’t really been able to show us what this company’s bringing that we don’t already have access to.
Miller: Let me play you one more short clip from that James McGovern interview from KLCC. This is more about what they are actually hoping they will get or be able to provide with ApolloMD:
McGovern: I know there’s some concerns out there that we’re going to have a bunch of PAs and we’re not going to have doctors, we’re going to have residents. The ratios, the number of physicians in the department are going to stay the same. We control that. We will have high quality of care in our emergency department. We will have access to care. On top of that, we’re going to have lower wait times.
Miller: What do you think it would take to get lower wait times for high quality care with the same number of physicians, the same ratio of physicians to physician assistants, all for the same price that the hospital has been paying your group, because in another part of that interview, McGovern said that this is not about saving money?
Pattison: That’s a whole bunch of questions there. So in terms of how do we get wait times down, I think we have to look at some of the systemic issues that are plaguing our emergency department. Switching the physicians isn’t gonna change those things. So, the ED is kind of like a canary in the coal mine. I mean, if you’ve, if you’ve watched The Pitt or you’ve been to an ER, it’s crowded, there’s long wait times, and this is a sign of a national problem. The financial pressures on hospitals are going up, labor costs, supply costs are going up, revenue is going down.
The Big, Beautiful Bill is going to make that worse. Their hospitals are expecting a significant decline in reimbursement. Many of the hospitals in Oregon are underwater, they’re losing money, facing bankruptcy. We’ve already seen that in Eugene with the closure of the University District Hospital and that’s shifting a lot of patients, they were seeing about 100 patients a day, and that shifted over to RiverBend and McKenzie Willamette.
And so, the hospitals are crowded. There’s not increasing finances, more money coming in to build more hospital beds. Oregon already has one of the lowest per capita number of hospital beds in the nation, so the hospitals are full. There’s more patients that need beds than there is room for. They can’t get patients out because there aren’t long-term care facilities.
We can’t transfer or divert patients cause the other hospitals are full too. And when that happens, all those patients back up into the emergency department. And there isn’t space and there isn’t room there. And that’s a problem of the healthcare system, it’s not a problem that changing emergency physicians or bringing in a different management company is gonna fix. There’s a shortage of nursing staff in Oregon, there’s a state-mandated nursing ratio of 4-1 for nurse to patient ratio in the ED. And then there’s a lack of space, and this backs up. Then as the emergency department patient comes in, we have EMTALA laws, we have to see everyone that comes in. We can’t stop people from coming in, and it ends up with long wait times.
In terms of the quality of care, as a group, there were 41 of us. We all had concerns about this transition and individually pretty much all decided that we didn’t want to continue to work for this type of staffing model. We agreed that none of us were going to work for ApolloMD for 90 days. We don’t want to prohibit anyone, everyone came to their own decision. At this point, I don’t know of anybody who will continue to work here after that.
And that brings out a huge number of safety concerns. I mean, normally we’re adding two physicians a year and there’s very little turnover. Now we’re talking about turning over everyone in the span of one day. We’re a stroke stemmer, a chest pain center, a trauma center. There’s a very high volume in a very small place of which everybody has to work together. You have to work as a team across specialties to move patients through, and that’s bringing up a lot of concerns about the quality of care.
Obviously, I worked there. I know a lot about the details. I have a personal interest because it’s my job. But at the same point in time in this transition, I also live here. My family moved here because I’m here. This is my community, probably will still continue to live here after that. And so, having family members that are sick, that they’re elderly, my dad was just in RiverBend, got a pacemaker put in. To me, this type of transition is scary, and it’s something that I worry about as a community member.
How are we gonna provide emergency services with this amount of turnover of physicians? There is a shortage of emergency physicians across the nation and in Oregon. There are lots of open positions and open jobs. This decision has not been only unpopular with the medical staff, but also with the emergency medicine community. This is national news within, I mean, there’s only so many of us and we have social media, so this is national news within emergency medicine.
Miller: Margaret Pattison, thank you. Thank you so much for joining us. I appreciate your time. That’s Margaret Pattison, RiverBend Emergency Department medical director and emergency medicine physician.
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