In part 2 of this discussion with emergency physicians Dr. Robert McNamara and Dr. Mitch Li, we learn about the dangers that patients face due to the takeover of private equity in healthcare.
Get the book! https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/
PhysiciansForPatientProtection.org
In part 2 of this discussion with emergency physicians Dr. Robert McNamara and Dr. Mitch Li, we learn about the dangers that patients face due to the takeover of private equity in healthcare.
Get the book! https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/
PhysiciansForPatientProtection.org
Welcome to'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host, Dr. Rebekah Bernard. And I'm joined by my co host and the co author of our book patients at risk the rise of the nurse practitioner and physician assistant in healthcare. Dr. Niran Al-Agba.
Niran Al-Agba MD:Good evening.
Rebekah Bernard MD:Last week, we were joined by two emergency physicians who are experts on the corporate practice of medicine, we're going to jump back into this conversation and I want to start out with Niran because she I know she had a lot of questions that we weren't able to get to at the last episode,
Niran Al-Agba MD:What we left off talking about was this Klauer guy who essentially quit seeing patients who went on to become an administrator. And so I will say this, once they become administrators, they never go back. I suspect it's so much easier than what we do. We don't they don't see gunshot wounds from 16 year olds, they don't watch moms hold their kids hands and die in front of them. So I suspect they crossover and then they forget why they entered this in the first place. What I wanted to ask Dr. McNamara about is you know, you talked about how we just want to see patients that a lot of people don't want to deal with the business. And I guess to me, it's such a not that you're saying that you're saying that's what happens. And it's always been a cop out to me because you know what the business isn't that hard. And I think transparency is involving business. Right? So my patients will ask me how much does this cost. And I can tell them, and I can also tell them when they have Medicare plans or other things. This is the freestanding radiology center where it's 1/5, the cost of an x ray that it is at the hospital, I know those costs, just like I know the cost of drugs. So I mean, I think it's not good enough anymore to just say, let's just take care of patients, you actually need to understand medicine and running a practice. I mean, my grandfather ran a practice out of his house and then moved it down the street. So I mean, these things are possible. And I guess my question is, is this being discussed in the ER groups? I mean, you can own a free standing er in Texas, it's a common thing, a physician can go and open up their er and do the billing. Why are we still stuck?
Robert McNamara MD:Right, so when you look at this, and you follow it, you know that there's pretty clear reasons why we wound up like we did. The leadership told us we couldn't do it, we were the perfect foils. So the people that chose emergency medicine, and still choose emergency medicine are they're not the people that go into plastic surgery, shall we say, they're doing it with a strong sense of social justice, we take care of the homeless, we take care of the uninsured, we can be taken advantage of - that's the nature of the emergency physician. And then we were told, 'these things are so complex' and the leadership, they created this web of mystery around it. But in fact, they're very smart doctors. I mean, emergency medicine residents, 20% are in the top 10% of your class. Most of them are in the top half of the class - it is very competitive, so they know how to get so when you talk to them. And this is a message that Academy has, it's not a difficult business to run. First of all is easier than private practice, right? You don't have to buy an office, you don't have to pay electric bills. You don't have to hire nurses, all you got to do is go in there. Have your charts filled out correctly. RCM company takes that those it split it up. And that was another reason why we became a victim, because it was a simple business model. And there was a lot of profit to be held. So a whole generation, I say that we were sheep, and they had sheep herders like the Klauers of the world to tell us,' Oh, you know, we're taking care of you. This is this is beyond you.' And a lot of docs do realize now that you know they had the wool pulled over their eyes.
Niran Al-Agba MD:Thank you for saying that. Because I guess part of it, I we never get to talk about the fact that the sheep just followed. And I think it's time for it's not going to change until doctors quit being sheep. And what's amazing to me is it is not that hard to run a business. It is not that hard to say 'no' to insurance companies about electronic records. I mean, I'm doing it - still take insurance on paper, they can come and scan my charts that they want to audit, I guess I just think we need to say no more often to the corporations and the large entities and say yes to our patients more often. And I think you can always win when you're doing that. And so I thank you for kind of talking about the sheet because that's how it feels from the outside looking in that we just traded our soul and it's time that we stopped doing it.
Rebekah Bernard MD:Well. Dr. McNamara wrote something really interesting on Facebook. He wrote 'The specialty of Emergency Medicine needs to apologize to the rest of medicine. We or should I say our greedy so called leaders lead the way to corporate takeover.' And you gave the example of Envision and envision is one of the largest CMGs is that right?
Robert McNamara MD:Yes, yeah.
Rebekah Bernard MD:EnVision used to be called EmCare. It was founded by a former president of ACEP Leonard Riggs who made $38 million when he sold that staffing firm to another company. And you mentioned that really nobody at ACEP has really had a negative word to say against the corporate practice of medicine. And then there are all these other CEOs of these organizations, there's a Stephen Schwarzman. He's the CEO of Blackstone, which owns teamhealth, which is a large employer of emergency medicine physicians. And his net worth is$13.2 billion, with a B. So I mean, these people are making so much money, that it's just crazy.
Mitch Li MD:That was $13.2 billion was the net worth in 2018, before the pandemic, so while everybody else was, you know, physicians were losing jobs or getting benefits cut, and patients were going undergoing, you know, horrible financial situations, the net worth ballooned to about twice that $26 billion now.
Rebekah Bernard MD:yeah, you're right! What I see here is 2019 pre pandemic 13.2 billion, and then 2020 19.4 billion. And you said it's even higher at this point. So in other words, making a lot of money off of the COVID pandemic, while they're laying off physicians and nurses left and right.
Niran Al-Agba MD:wow, we're letting this happen. You know, we're continuing to work for organizations we don't trust, we're continuing to work for organizations that prioritize profits over patients. And Mitch, it sounds like you've broken out of that mold. If you're now in your own independent practice, which is great. I think it's the only way to go. How did you do that, like what made you finally decide to give it up, give up corporations being employed,
Mitch Li MD:I'm really stubborn, and you can talk to my family. But I honestly it started back. I graduated from a residency program in Detroit. And so in a similar patient population as Temple and originally that was owned by a private practice group. And I was paying attention to the medicine, I had my head head down looking at the medicine, you have to learn that obviously, in residency, during that time period, the group was sold to teamhealth by two physicians, I don't want to get numbers and inaccurate somewhere between 20 and $40 million by those two physicians or higher actually, most of the physicians in the group, I think, was about 130 thought that they were partners, but they were partners in name only. And so they got an email that basically said,'Congratulations, you're a team health employee.' And again, I was still like really excited about thoracotomy at the time. And I was distracted by that. So I kind of learned this, I heard about the side of my head, I took a job as an associate EMS medical director because I had a lot of educational debt around$350,000. And I thought 'I don't have time to do a fellowship.' So I had an EMS background tactical medicine background in I figured I would do that as a job, learn on the job and start paying back my loans. I mean, long story short, I liked the job, the medical director, there was cool, the mission was great, but it started destroying my soul. And I was you know, as a hospital employee Doc, I felt like they thought that they could control me, I had educational debt that the hospital had repaid with a$50,000 loan that they would forgive $10,000 per year that I worked there. So I don't think they thought that I could escape and they had, you know, they had me by the gonads. So over time actually learned about personal finance. And that would be the number one, you know, piece of advice I would give to any physician is oh, you know, don't don't become house for don't buy, you know, set expectations with your spouse, whatever it is physicians have gone through so many years of feeling like delayed gratification that usually you just bounce right back to the other side, you want to get a big house, a nice car and you know, a yacht or something or just put your kids in private school, right. And that makes you so vulnerable. And I think that's what happened. And I on the other hand, basically just went through and said I gotta figure out how to pay off my loans. So I spoke with a good friend, we had what amounts to like personal finance Journal Club, and I just went deep dive all the time with my coat investor, physician on fire, and Dr. Money matters. So string Patel, he has his own podcast. And that's actually where I first learned about private equity and got - I ran with it. That's actually where I first also heard about direct primary care. And I made though it's all about me, it's all about values and priorities. So I made those my priority. I wanted to spend my money, not on a fancy car, but on freedom. So everything I spent my money on was paying back loans appropriately getting FU money, which is freedom Unlimited, because this is a PG podcast and maxing out retirement funds, and then minimizing my overhead. So I downsized my apartment, and I have been holding on to my 2007 Mazda three as hard as I can. And that basically is what allowed me to escape I left that hospital system I put in my notice I owed $40,000 Because it wasn't prorated after I stayed there a year and a half within three months. And that's a daunting for somebody for the most part. But I was able to refinance that and put a savings out there. And that's really how I escaped you know that and a couple years of rough time of learning how to start a direct care practice is how I escaped but I have to put that into the context of most emergency physicians because I think if we were to look five or 10 years ago, it was the right thing to say to a physician 'don't work for one of these groups. You're wrong to do so you're aiding and abetting a horrible thing and you're a bad person. ' Now we can't do that. Because now if you're in Florida, and you have family there, and you have hundreds of 1000s of dollars in debt, that's your only option. These programs, they've taken over so many hospitals that you can't just tell somebody don't work for him, and they won't, they'll cease to exist. And that's partially by design, we'll get to that later, I'm sure where they flooded the market with corporate residency programs, and started replacing physicians with nurse practitioners and NPPs in general. So we can't quite say that when when we're a hospital based specialty. And this goes for anesthesia as well, like radiology sort of it's it's much more difficult to just open up a private practice. And I'm an example of that, where I have opened up a DPC inspired practice, but I'm not family medicine and not primary care, technically, or depends on how you define that. And so I'm a little bit outside of the mold. And that's not a solution for every single emergency physician. So I'll close that with saying that we do have to have a comprehensive strategy to take back emergency medicine in the hospitals. And that involves largely probably the American Academy of Emergency Medicine Physician Group, which is a subsidiary of AAEM and Dr. McNamara is actually the CMO of that I served on a board for a time until I transitioned to a CMO of the am locum group. But there's that's a lot to unpack, we got to give options for physicians who are experiencing the moral injury and having to work for these CMGs currently.
Rebekah Bernard MD:you're so right, we absolutely need options for doctors. And you know, Dr. McNamara said something at the end of our last podcast where he said that patients have really lost trust because they look at these huge hospital buildings. And it made me think of when I was working for a for profit hospital system. And the administration would have these little like wine, meet and greets in the lobby for when we'd have a new doctor and I was there and there was like a bartender and they were have serving drinks and there was appetizers, and these people walked through the lobby- patients, and then they looked at each other. And the lady said, 'This is why I hate doctors.' And I was like, but'But no, because I'm not like this, this is not who I am.' But that was the impression that they got as they walk through this glamorous, you know, lobby with marble floors. And that was actually really eye opening to me. And I really realized, that's not who I am. That's not my values. That's not my mission. And that's not who I knew patients need. They need caring doctors that are looking out for their best interest, not corporations that are making profits. So I want to get back to the replacement of physicians by non physician practitioners. And let's talk about COVID because we saw that some of these corporate owners are making billions of dollars during COVID. And meanwhile, they're actually making an effort to replace physicians and there was a presentation by person named Krik Jensen. This is a person that is on faculty of ACEP. And they made a presentation on staffing your emergency room during COVID. And what they said was 'your goals were to employ the least expensive resource to accomplish the mission.' And they said that in many emergency rooms up to 25 to 35% of the cases can often be effectively and successfully seen independently by a APPs - Advanced Practice practitioners, which I would call non physician practitioners. And they also suggested hiring family physicians or internist saying that they could see up to 75% or more of the cases that an ER physician sees. And that was an a person that's on faculty with ACEP advocating for replacement of Emergency Physicians. What are your thoughts when you hear that?
Robert McNamara MD:Well, you kind of mentioned before about what has ACEP done about corporate practice? And the answer is absolutely nothing. Unfortunately, now they have the opportunity to do something, I actually rejoined them and put a couple of resolutions forward at the National Council meeting to create what's called transparency and to guarantee emergency physicians due process. I mean, those are the two linchpins of the industry. One is the doctors have no idea what's being billed and paid your name. So they can make as much money as they can, they can send out as high as Bill. And then if you complain about it, they can fire you. If you complain about staffing issues, like 'wait a second, you're giving me too many NPPs to supervise.' Well, we'll just get somebody else to work for you. And did you read your contract? We can get rid of you tomorrow. You complain about the quality of care and the stories that we hear. They're just unbelievable and would really shock the public. Some of them got out, you know, advocating for PPE for patient safety during COVID. I'm dealing with seven different docs right now who've been terminated. And the reasons are crazy ones after the COVID surge happens, they cut staff. Now the voumes are up complained that we don't have enough coverage.'Alright, you're out of here, we'll get somebody else to take place.' So this is these are the facts that are out there. Now, as we said in the last segment, the bottom line is the bottom line for these companies they want to they got to appease the investors. And the most expensive piece of the equation is what they pay the doc so the more you can replace As the expensive doctor was the cheaper provider, the better it is. But as you know, in your book and from physician from patient protection, the sore throat could be devastate it could be epiglottitis, the kid with the flu could have sepsis. So it's, it's the way it is we have our fire departments standing there ready to take care of fire, but the fire doesn't happen every day. But when they do you want professionals to respond. So replacing the the highest level of education, the board certified emergency physician with people that aren't trained in emergency medicine and live on people that aren't even physicians creates a danger to patients. And it's it's right there in the cold corporate slideshow that we want to use the cheapest provider available to get the mission done. And the patients that they don't know that faces walk in, and a lot of times they're deceived. They think you're seeing a doctor, or do you think there's a doctor in charge? And that's not always the case.
Niran Al-Agba MD:And I guess my question is, what about freestanding EDS? I mean, why do these ER Doc's not want to start a freestanding ED, it just if I had that expertise, I think it would be fantastic. Seems like a way to own yourself and to provide emergency care.
Mitch Li MD:If I can, I'll take that and put any standing ER thing I've looked into a little bit. And the bottom line is, I mean, compared to starting, what I have is a practice, which I started for $10,000 or something in total, which I can self finance, I'm able to stop patients from going to the ER that don't need to be because I think what we conflate is the expertise of an emergency physician, and the physical emergency department. So if you go to a freestanding ER, they're not always altruistic, either, it certainly gives power back to the physician, but we're talking about, you know, some of the sometimes and I'm not going to generalize to all of them. But the same use of these out of network bills and making patients think that they're going to effectively an urgent care, but when it's really an ER, they're going to get an ER bill, the freestanding EHRs are used by a lot of the large contract management groups as well. And so there are a few that are completely independent. And I've looked into the structure of them, some of them are started by a company that is sort of a turnkey solution for a freestanding ER. And that company ends up controlling the RCM being the billing and coding for it and takes a stake in the ER. So there's a pyramid in many of these as well. So if I wanted to get a group of five poor ER doctors together with 350,000 or$700,000 in debt, how am I going to finance creating an emergency department to build that? Right? So there might be ways to do it, you know, taking out a loan, having people venture capitalists that are well that have a good mission in mind and are only going to take a small percentage of interest as opposed to taking control over the actual hospital, which was private equity does. When they own a group, they actually, you know, exert control as opposed to just needing to pay off a transparent loan. I think there's ways to do it, but it's it's few and far between.
Robert McNamara MD:Well, I mean, it needs to be said that, you know, we're talking about private equity and whatnot. But in its purest form, physician led emergency practice is one of the greatest forms of medicine out there. I mean, it is, you know, you talk to physicians in physician owned groups who work for themselves, they work for the hospital, they work for the patients, that is a beautiful form of practice. I mean, these are doctors that are dedicated to the patients, and it's a great specialty. I mean, you get to save lives, you get to make a difference. And there's you know, there's a good feeling for taking care of the poor patient, getting the homeless guy a sandwich, doing a nice job on a laceration, saving somebody, thoracotomy, whatever, but you know, endotracheal intubation, so in its purest form, it's a great specialty. We let the economic interest that money changers into the temple. I mean, we allow this for profit motive to really stain the specialty. It's, you know, it's almost a sacred place. Well, look, I love what I - my career has been great. You know, I got a shift tomorrow morning. I worked yesterday, we do great things. And the House of medicine appreciates you, your colleagues, and other specialties have learned to rely on emergency medicine. We've become leaders across the board, Deans, we've become CEOs of hospitals, chief medical officers. So it's unfortunate that we've allowed this to happen because it could be a great specialty.
Rebekah Bernard MD:We really do rely on you. I mean, I'm a family doctor and I trust that when my patient needs emergency services that they're going to get an emergency physician but unfortunately what's happening is in many organizations, it's going away and I want to give you a couple of examples because some people will listen to this and say like they accused you Dr. McNamara back in 1994 of exaggerating and innuendo let me give you some real life examples. So HCA Houston, hospital, Houston health care just recently let go of all of their pediatric emergency physicians. Instead, I have here a screenshot from the Chief Executive Officer Ted Kaliba of HCA Houston saying 'consistent with most emergency departments, HCA Houston Clear Lake will have mid level providers, nurse practitioners and physician assistants, providing care with an emergency room physician' and they mean one that does adult ER and I'm sure has some pediatric training, but is not a certified pediatric emergency physician. And additionally, they would have the pediatric ICU physicians covering all pediatric inpatient beds. So basically just trying to get the most out of the physicians and replacing them. And then the same thing happened in Wisconsin, not in the ER, but in the operating rooms. Wisconsin Hospital replaced all anesthesiologists with CRNAs, which are nurse anesthetists and Dr. McNamara, you were actually quoted in this article that was published in Medscape, in which doctors were saying, 'This is not good. This is really bad for patients, they're not going to have the option of having a physician around if God forbid, there's a negative outcome.' And you really were concerned about that. Right. Dr. McNamara,
Robert McNamara MD:right. I mean, it's what we're talking about, it's somebody making a bottom line decision that the company that did this CRNA thing was envision, right. And as we talked earlier, we metastasize to other specialties. Because you see profit of one specialty, you're going to go on to others, and we kind of unfortunately, set the playing field for them. So I mean, that's that's the whole issue is doctor Training can put up the graphic the hours and hours and hours that we have to endure patient care supervise the amount of contact hours, there's just no comparison, and the patients deserve the best. I mean, the first line of the mission statement of the academy is every patient deserves access to a specialist in emergency medicine defined as board certified doctors. And we're seeing less and less of that, because the the business interest doesn't want it.
Niran Al-Agba MD:And I think we really all need to own a piece of that. So again, the hospitals that do that if I lived in Houston, every patient that I have, would know that is not where we're going because I don't trust what they're going to do. I very rarely send patients to the ER, again, I handle a lot of emergencies. We do all the lacerations. I mean, there's not much I can't do really in the office. And you know, I'll meet people after hours. And there's three reasons to go to the ER, they have a head injury, they can't stop the bleeding or bone sticking out. Everything else can wait till the next morning. And people laugh about that simplification. And of course, I'm a pediatrician, nobody's having heart attacks. But really, if you teach your patients and you you trust them, you develop a relationship, then they know you're looking out for them. I just wouldn't send my patients to Wisconsin, I say Good lord, you're gonna die. If you're operated on in Wisconsin, please don't go there. And that's the conversation I would have. I have that conversation. I just had somebody who wanted to go to I can even say it, you know, Mount Spokane pediatrics, where there are no pediatricians in eastern Washington. And there's a person there who really harmed a little kid and missed a heart defect. And I told my patient, I can't send you there ethically, I won't sleep at night. And she didn't realize there were no pediatricians there. They're all nurse practitioners. They're not even pediatric nurse practitioners, and they call themselves pediatrics. And so we have to stand up and start talking about it. And they think getting that information to our patients is probably the only way and I don't know, as an academician, Dr. McNamara if you're free to sort of say that your patients I know Mitch probably is. So if you could just talk a little bit about that.
Robert McNamara MD:I can tell you I talk to patients about this all the time, we're a tertiary medical center and you want the opportunity to see a physician if at all possible, you know, you kind of raise a theme year, I mean, academic Doc's got to get involved. Like in emergency medicine, I've been trying to convince my colleagues that you have a responsibility to your graduates to create a better community for them to where they go out and practice. And, unfortunately, some have stepped up but the majority are just buried in their own academic world. It's going to haunt them because I think we're going to see a decrease in the appeal of EM to medical students is already happening, and then never say why did my residency fail to fill with those Ivy League graduates? Well, because you'd have to specialty slide to corporate interest. So certainly advocate for that. I think that for instance, I think we ought to can't be an emergency department can call yourself emergency unless there's a doctor present, you know, as well as I do that there are places where there's no doctor, and it says emergency. And what how deceptive is that?
Rebekah Bernard MD:Yeah, we feature the case of Alexus Ochoa, who was brought to emergency room by ambulance expected to see a physician and only a nurse practitioner and not even one with acute care training. She was a family nurse practitioner, treated her there was no physician on site, even though the hospital advertised physicians and unfortunately, the patient died because they she was not properly diagnosed with a pulmonary embolus. And unfortunately, this is happening in hospitals and emergency rooms across the country. And it's not only rural areas, not that I think rural patients deserve any less care than anyone. But they always use that as an excuse. But this was not even a rural hospital where this patient was seen. So patients need to open their eyes they need to ask questions I need to demand physician led care, especially if they're not getting better. In the case of Alexis she was treated for 11 hours and declined the whole time and if her family had known or someone had known They had said, Listen, I want her seen by a physician, you're gonna have to transfer her, you know, maybe we'd be having a different conversation. And that's one of the reasons Miranda and I are speaking out. And we really appreciate both of you talking about this because a lot of doctors are afraid to speak out because they are afraid of losing their job. Now, one of the things that Niran and I wrote in our book, we said that there was a really a conspiracy, of basically corporate takeover of health care and the replacement of physicians. And we were told that we are touting conspiracy theories, and that there's none of this. Well, I've got a really good one that Mitch brought up, Mitch pointed out that there's this organization private equity firm called KKR. And they are a big organization their name it, tell us about it. Mitch, do you have that? Can you share a little more about that?
Mitch Li MD:Sure. So KKR is a large private equity firm, I think it might be the largest one in the world along with Blackstone, I don't have the exact figures on that. They're not small. So the holdings of of the private equity funded emergency medicine groups are a small part of their portfolio. You know, honestly, if it fell off, they might not even notice the next day. But KKR owns envision, which was just a few years ago. And what we didn't really discuss about how KKR or private equity works in general is that these companies are going to flip a business they're going to go in, it's like buying a house and flipping it. So it's making more profitable and get it out of here, there is no like, you know, you can argue argue that the public traded market is somewhat aligned, sometimes with creating long term value, let's create a company that does a good job. And if they do a good job, then the shares will go up, and people make money and everything's good, you know, and that's not always perfect. But that's not even a little bit the case with a private equity company, private equity company, sometimes will hostily take over a company or sometimes it will be sold easily because the owners of the company want to make take make a big payday. But the entire rubric of operations is to cut expenses and increase revenue. However, you can do that quickly, and then show it to another buyer, which could be a health insurance company, it could be the public market and the private equity group, sell it off in pieces, but as something more profitable, so how do you do that in something like a staffing industry, there's not many ways to do that you decrease your your staffing costs, you decrease how much you're paying physicians or you decrease, you change it to a lower training, train model, you know, whatever the market will tolerate, to get the lowest price, and you also increase revenue by out of network billing. And that I mean, that was the main strategy out of network billing, which was used by many groups to negotiate with insurance companies, but making an extreme use of that, and then balance billing patients with surprise bills, and then going after those patients aggressively for them up until actually suing the patients and garnishing wages of poor patients, which is just not what ER doctors went into this for, right, that's another big source of moral injury. So there's legislation that's going to limit this out of network billing. And and that's not it's, it's in place, but it's not completely formed as to how that's going to work. But what's happened is, they've cut off the biggest tool for generating revenue possible in emergency medicine, and for these groups. And so now, the other side of the equation, the the the cost side becomes much more salient. And so you're seeing along with COVID, a really rapid replacement of emergency physicians with NPPs and very aggressive cuts in their own salaries in order to satisfy these investors. So get back to that this sort of conspiracy thing, and I don't think necessarily that the KKR is out there specifically saying the coordinating to do this, but it's very possible they are because again, they exert a lot of control over the business. They don't just they don't have an investment in it. So you know, I just came to this realization as looked up, what else does KKR own? And I think, don't quote me, I think like Nabisco cookies is one of their own, you know, something they don't. So like, I guess who cares, right? A lot of these organizations own J Crew is a big example of one Toys R Us is another example one J Crew when they started when they owned not KKR. But when a private equity company, purchased J Crew, their their clothing started falling apart, they cut corners, and the quality went down. They were profiting or they were exploiting the brand when Michelle Obama wore J Crew, I think on Oprah, and all of a sudden they saw money. So they bought J Crew and they cut corners. The worst that happened was people's clothing got a little worse. So that's not the emergency department where people's lives are at stake. Right? So that's why this is different. Now they do you own Medscape and WebMD.
Rebekah Bernard MD:Yeah, and that's what I thought was so interesting, because there are all these pro NP and Pa articles on Medscape all over the place. In fact, there was a really big one that was called the business case for hiring a nurse practitioner. And the article was all about how it says the NP can bring expertise, increase profits and provide respite for a sole practitioner or a small patient. Practice and that studies show that patient outcomes provided by NPs are comparable to those found with physician care and be here as cost effective and patient satisfaction with NPS is high. And it was all a detail page many pages about why it would be great to hire an NP. And here, this is a company that is owned by this organization. And so you see how the pieces of the puzzle start to fit together?
Mitch Li MD:Yeah, you know, it's then comes the question of, is there a conspiracy, I mean, to me, it's just plain business like it unless they hire really stupid people like KKR, which they don't, they've got the Ivy League, like finance people, they're like, if they're that stupid, that they can't come up with that, then you know, that's why they've got another problem. So when they exert that kind of control, then it is in their interest to help out all the other, you know, investments that they have. And so it makes perfect sense to me that they're going that direction. And when you take WebMD, which everybody knows, don't go to Dr. Google or don't go to WebMD, because you think you're gonna be dying from cancer, or you think you're gonna be dying from a heart attack. Part of that, of course, is just that they have some liability, and they can't tell you not to go to the ER. But I mean, the business model can be basically summed up as scare the crap out of patients, so that they end up for generating unnecessary emergency department visits, that we our heads explode. And we have to express to patients that they didn't need to be here, but then we're kind of pressured into doing unnecessary testing, and they go home and they get it out in network bill, from Envision. It sounds like KKR. While the you know, Medscape is basically touting the business, not the quality, but the business benefits of hiring non physician practitioners. I mean, it's it's not conspiracy that's like it's the plain and clear business model, so
Rebekah Bernard MD:that a lot of patients have no idea and a lot of doctors have no idea. We're only now just starting to open our eyes to this. And thanks to people like Mitch and Robert are sharing this information so that doctors can open their eyes and so that patients can see what's going on and hopefully start to ask more questions and hopefully start to demand changes so that we can ensure quality care physician led care.
Mitch Li MD:I just wanted to put this in context because I right now I see history repeating itself. AAEM was formed in 1993 to fight corporate practice. But we got distracted by fight in fighting with other family doctors, you know, in turf wars. And right now, PPP can fight corporate practice. But obviously, I wouldn't call it infighting because they're not physicians, but we have been aiming the cannons at nurse practitioners. And we know that some of them are complicit. We know that the AANP President is absolutely asking for independent practice, which which is, you know, I think we all agree is absolutely absurd. But many of them wanted to go in to do good thing right? Most Effective nurse practitioners and PAs want to help patients, they don't want any part of this either. When we look at that slide from Envision, everybody on there is upon so the emergency physician is upon the internal medicine doctor in the family doctor that could replace us as upon the NPP is upon even the resident where HCA and envision have started the most residency programs in the country, they're touting that right now. HCA being the largest provider of residency programs. They're pawns. So the point is, we're all being exploited here. And we have to paint that picture for people that even these MPs are NPPs when they're put in an emergency department, over their head, and they might kill a patient or not have the resource of an emergency physician. They're being exploited as well. And so I just want to make sure we drive that thought home.
Rebekah Bernard MD:Thank you so much, Dr. McNamara and Dr. Lee for joining us. If you'd like to learn more about this topic, we encourage you to get our book. It's called patients at risk the rise of the nurse practitioner and physician assistant in healthcare. It's available at Amazon and Barnes and Noble. Please subscribe to our podcast and if you're a physician, please join us at physicians for patient protection.org Thank you so much, and we'll see you on the next podcast.