Editor’s Opinion: Contract Conundrums


The news of the sudden breakup between Summa Health and its longtime emergency department physicians sent shockwaves through the emergency medicine community. While there are many things we won’t know about what happened, we do know that the change occurred suddenly, that there were several conflicts of interest within the Summa/USACS partnership (which presented opportunities for personal gain by interested parties), that there were several overwhelming “no confidence” votes in the Summa leadership, and that Summa Health leaders have refused to provide interviews to any media outlets.

What can emergency physicians learn from this series of events?

First, we need to realize that none of our jobs is secure and that our livelihoods are constantly in some degree of jeopardy. Regardless of how long we have been working at a hospital, leadership at the facility will change, patients will complain because they don’t get what they want, and there will inevitably be conflicts with staff. Each of those events puts our jobs at risk. The contracts that we sign make it relatively easy for hospitals to immediately terminate our employment. Many contracts force us to waive due process. Others force us to agree to immediate termination for vague occurrences such as if the “hospital requests that [the physician]no longer be scheduled.” If we are immediately terminated, we are put at a significant financial disadvantage. Whereas a typical employee can leave one job and begin working at another job the following day, with emergency physicians, it isn’t so easy. Hospital credentialing typically takes months to complete. During that time frame, physicians are unable to provide medical services and therefore have no income. Just as diversification is an important tenet to investing, diversification of employment is essential to mitigating employment financial risks. Have licenses in more than one state – even if one is inactive. DO NOT agree to exclusivity clauses in contracts. ALWAYS be on staff at more than one hospital and with more than one group. Protect yourself.


Second, emergency medicine is changing. Patients used to have lifetime commitments to one physician who knew them personally. Insurance has now fragmented patient care so that many patients change physicians on a yearly basis to maintain insurance coverage. Similarly, emergency physicians used to be committed to providing care at one hospital or with one group. Now hospital contracts change hands when increased revenues and decreased costs are dangled as carrots in front of administrators. Whether we like it or not, our professional lives are increasingly being affected by bean counters and others seeking to make a profit – many of whom have had little if any experience caring for patients. While our overarching goal in emergency medicine is to provide the best possible care to our patients, we are increasingly being pressured to also avoid overutilization of testing, see at least 2.0 patients per hour, and attain a ranking of 90th percentile or greater on our patient satisfaction scores (which is statistically possible for only 10% of physicians in the United States). Unless we provide excellent medical care while also pleasing bean counters, we risk becoming a liability instead of remaining an asset. See bullet point #1 above. Adaptation is important, but we need to seriously question how that adaptation affects proper medical care, and, in the Summa case, medical training.

Third, the contraction of emergency medicine groups in this country should be a concern to all of us. An oligopsony is a market situation in which a small number of powerful buyers has gained control of a specific market and can therefore dictate market terms to the sellers. Consider how the relatively few online music outlets are able to dictate terms to musicians. If the musicians do not agree to those terms, the online music outlets do not offer the artist’s work and the artists are put at a significant business disadvantage. While hospitals are ultimately the “buyers” of emergency physician services, most hospitals partner with contract management groups (CMGs) to staff their emergency departments – meaning that we are technically selling our services to CMGs. As larger CMGs continue purchasing smaller groups and driving other groups out of business, an oligopsony is developing. Larger groups then create staffing situations and contract terms that are increasingly against physicians’ interests. See bullet point #1 above. When one large staffing company partners with most hospitals in one geographic area, physicians who wish to practice emergency medicine in that area are forced to agree to the staffing company’s demands. While this isn’t intended to disparage large CMGs that still have our backs, we need to seriously consider how market forces may adversely affect emergency physician interests and emergency medical care in the future. How will we protect our specialty and our patients?

Click here to read more from the Deal Breakers: The Summa Story series.



SENIOR EDITOR DR. SULLIVAN, an emergency physician and clinical assistant professor at Midwestern University in Illinois, is EPM’s resident legal expert. As a health law attorney, Dr. Sullivan represents medical providers and has published many articles on legal issues in medicine. He is a past president of the Illinois College of Emergency Physicians and a past chair and current member of the American College of Emergency Physicians’ Medical Legal Committee. He can be reached at his legal web site http://sullivanlegal.us.


  1. Robert McNamara, MD, MAAEM on

    Great piece Dr. Sullivan. The specialty is burning down around us. We possess the #1 ranking in burnout surveys. Large swaths of the specialty are in the hands of lay corporations who cater to administrators in order to keep the profit stream intact. We feel the brunt of this in our daily practice as outlined in bullet #2. The EM physician leaders who were supposed to look out for us instead cashed in and sold the future of EM. All EM physicians should be concerned by this oligopsony as we represent the #1 expense for the CMGs.

  2. They have one goal. Flood market with sufficient labor to gain power in negotiation. CMG controlled residencies are the death of our specialty. Leadership is bought and paid for.

    I’m forced to be an IC and even have difficulty controlling my liability. Becoming increasingly difficult to even be a leader in the ED. Too much noise and you are gone. I can’t advocate for myself or colleagues. I can’t direct employed PAs. Envision and HCA have succeeded in using my license to fund their profit streams. I’m a button clicker and a billing widget.

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