Dave Packo on the EM Workforce

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altGreg Henry sat down with EMP co-founder David Packo to discuss staffing models, Press Ganey and other workforce quagmires.  

Greg Henry sat down with EMP co-founder David Packo to discuss staffing models, Press Ganey and other workforce quagmires.  


Greg Henry: We’re going to take the gloves off and talk about the controversy of staffing. Henry’s Law: Too many nurses, not enough techs. PAs can probably do 98 percent of what I can do. And we don’t know exactly where this thing is going. So enlighten me. Tell me what’s going to happen.

David Packo:  Well, I wish I had a crystal ball. I don’t know what’s going to happen. Obviously, a lot of change is going to occur in the next five to ten years. I was at a hospital back in the 90s where they stopped hiring LPNs and hired only RNs. And it never made sense to me. I always thought: Why not hire the people that can do the easiest job at the easiest level?

Henry:  That was always insanity to me too. Now places are bragging that “We’re an all-RN department.” If you went to the assembly lines in Detroit, they don’t hire mechanical engineers to put the nuts on the bolts. They get the appropriate person for the appropriate job. And I think you hit the nail on the head here, that we used to have people who did real work. Now they want to think.


Packo:  Right. As a practicing physician, my favorite person is the all-do-it tech. Right?

Henry:  Yes.

Packo:  The tech can do everything. They can help scribe. They can help do the medical record. And they can help empty bed pans. They can get labs. I don’t need everybody else.

Henry:  They can get the patient in, get them completely undressed, have the suture tray set up, have the eye instruments there and the slit lamp. That’s what saves me time. If I’m going to move through it, let’s get to it.


Packo:  Okay. So we’re done.

Henry:  Well, we’re not done yet. In a lot of states, the nursing unions have a mandated staffing ratio that says: “Four patients, one RN.” And that doesn’t reflect the intensity of the care. You and I both know, we live on small potatoes. Maybe ten percent of our patients require drip medications. And those are the ones that are going to be admitted anyway. As soon as a drip is hung, you’re in a different group. I understand having RNs for that group. Does the average sprained ankle need RN intervention? That’s the question.

Packo:  Absolutely not. And I’m not sure they need me and you. Right?

Henry:  Well, that’s exactly right. And this is very frightening. I’m okay. I mean, my house is paid off. My kids have been through college. But this is going to be the discussion of our era. Now we’re living in a country which is going broke.

Packo: Well, it’s not going broke because of us though, right?

Henry:  Excuse me. We’re small, but every time a resident orders two more CT scans, you’re not just the piano player in the whore house of medicine. You’re one of the whores.  

Packo:  Yeah. But how expensive is that CT scan? It’s cheap, right? I mean, they’ve already bought it.

Henry:  Well, now wait a second. Not quite right.

Packo: The cost, not the charge.

Henry:  I agree with you. I’m a cost guy, not a charge guy. Understand that down the road, there’s very good data that we increase the number of cancers.

Packo:  Right, absolutely. I agree with you that from the aspect of too much radiation. But our problem is not the cost of labs, the cost of CTs, the cost of X-rays. Medicine’s problem, the United States’ problem is not emergency medicine; it’s not the cost of the tests that we’re doing. Even if we over-order tests three, four-fold, that’s not where the problem lies.

Henry:  Well, I understand that. And you and I are advocates of emergency medicine. But what we shouldn’t do is pretend that we’re not a part of the process. For example, when grandma comes in and she should have been allowed to die in the nursing home and we decide to run the code and now she gets a $50,000 hospital bill before she dies 24 hours later; we’re a part of that.

Packo:  Right. Yes. It’s true. A lot of money is spent at the end of life. And we know there is plenty of savings to be had. I do question unfortunately our politicians’ knowledge and ability to figure out where those savings should come from. I don’t think we’re the biggest part of it. But yes, there’s definitely money to be had where we are and where we sit and what we do.

Henry:  Alright. Let’s move on to another area of workforce. You have an excellent company that supplies doctors. Are we now at the point where you’re going to be laying down policies that say: “We’ll have one doc on a shift and the next person has to be a PA”? Are we to that level yet?

Packo:  We have definitely changed as a company. Dominic and I came out of residency and our motto was: “We’re only going to hire emergency medicine, residency trained, board certified physicians.” Which is still our motto. And we’ve always pushed: “Look, we want to see every patient.” But we are definitely moving away from that to the point that mid-level providers, physician assistants, nurse practitioners are going to have a much bigger part in what we do. Because they almost have to. Because you can’t afford to have a board certified, residency trained physician. You don’t have the staffing for it. And you don’t have the ability to afford it; to have it all over the place. So yes, we’re going to definitely have more and more mid-level provider provision of care.

Henry:  And I think that the American public is looking to us. They want the care supervised. We’re getting paid to supervise, and what I’m afraid is happening around the country is a lot of people are getting that hundred percent fee. We’re not going in and redoing the case. And you notice that the Secretary of Health and the Attorney General have both been sending out all these messages and signals that they’re looking for crooks. Now, we’re like small time crooks. I never stole anything big. But what they’re saying is: “If you’re going to be charging, sending in a provider number with your signature on it, you better have supervised that care.” How are you guys going to enforce supervision? And here’s the most important question: What cases are you going to insist that your doctors see?

Packo:  It’ll probably be case-by-case. We’ll come up with a list, like everybody else has. But we do try to get our docs involved in as many cases as possible. We do require our docs to put their head in, to do a little bit of history, to do a little physical.

Henry:  On every case?

Packo:  We ask for more. And if they don’t, then we’ll charge at 85 percent – at least for the governmental payers. But we do ask for our docs to get in there and see every patient. You know, part of the problem is that 90 to 98 percent of the cases can be taken care of pretty easily, pretty quickly with less knowledge than we have. The problem is figuring out that two to ten percent.

Henry:  Let’s talk about training. Here at ACEP, CORD meets, as do all these various societies that have to do with training. What are they invested in? Maintaining their jobs as
trainers? Turning out scientifically-oriented doctors? Is anybody turning out the product that you want, that knows how to work with PAs, nurse practitioners, organized healthcare networks? What are we going to do to turn out a product for this century?

Packo:  It definitely depends on the residency. And they obviously go up and down. So, quite frankly, the community residencies to me probably do a better job of that. I don’t want to get the academics upset at me, but the fact is the community residencies are a little bit more in tune to what’s going on in the real world at the community hospital; which is a lot of what we see and what we do. The academics are great. And some of the academic places are fantastic too and they can bring that aspect in. And some of the community places aren’t great. But some are very good at training people for today’s healthcare environment.

Henry:  I think there’s a difference between practice management, running an ER, working in an ER, and understanding all the science. I mean, if I push a button on Jerry Hoffman’s head, sensitivity and specificity indices come out. No hospital administrator gives a crap about that. They care about two or three things. The most important one is: How many complaint letters did they get? There’s no question that two of the greatest geniuses in America are Misters Press and Ganey. They took the most wafer-thin soup of statistical reliability and sold it to every administrator. They are salesmen par excellence. They taught these people that this really mattered. In the overall world, have they been damaging to the care we give in the emergency department? Because now, administrators are basing their bonuses on this. They’re deciding which emergency docs they’re going to take out and whip mercilessly. Has it been good or bad?

Packo:  Well, you know, you can argue about how they measure, what they measure, what they do and the statistics they use. I think the concept of what they do was right on from the very beginning. Dominic Bagnoli, my partner, and I can still remember one of our first cold calls we made to a hospital. His point was: Look, if I go in to get my air filter – if I take my car in because it’s not working right – the mechanic doesn’t say: “You dummy, your air filter’s dirty. You should have changed it three months ago.” Customer service in our field has been not the best over time. I think customer service – treating everybody like your mother, your father, your sibling, your kids – is the number one goal from my standpoint. If you do that, you get so far down the path of providing good care that it’s really a bonus. So I think Press Ganey and customer/patient is paramount.

Henry:  It has a place.

Packo:  Not really for measurement, unfortunately. Just for care. EMP’s physicians do get paid based on their Press Ganey scores. They don’t all love it. I don’t love it. But I don’t know a better way to operate where we provide patient satisfaction as a key component of patient care.

Henry:  Alright. You run a company. You supply doctors. You are joint holders of contracts, or you have a relationship with the contract. What’s the future of contracted medicine in America? Where’s it going to be in ten years? Is the Phoenix going to rise again?

Packo:  That’s a great question. I don’t know the answer. I know that we’ve seen hospitals buy primary care practices and not necessarily fare so well. My guess is if they try to run the ACO model and they try to run the emergency department, they’re not going to be as good as EMP (or any CMG here at ACEP) could be at doing it. I mean, this is all we do, right? We better be good at it or we should be doing something else.

Henry:  Well, the claim is: Whenever a hospital takes over a physician practice, productivity drops 25 percent. All of a sudden, the guy who used to stay in his office another hour clearing out the patients, now at 4:30 says: “Start sending them to the emergency department.” So it’s been a boon for us in many ways.

Packo:  Yes. Until we don’t get paid.

Henry:  So the hospital pretty much understands that there’s a decrease in productivity. But there’s such a huge increase in their control of the place. This is always a problem.

Packo:  Well, I think you’ll see a lot of groups move to the ACO model, where we’re doing emergency medicine, we’re doing observation, we’re doing hospitalist and we’re doing after-care. You asked about the contract; it’s not going to be just for the ED contract any more. It’s going to be for the whole front end. We won’t be doing the cardiac surgery and the orthopedic surgery, but we’ll be doing a lot of that front end from start to finish.

Henry: Whether you know it or not, Dave’s family’s in the pickle business and he’s certainly given us some tangy and spicy answers today. So signing off, this is Greg Henry from the American College of Emergency Physicians Scientific Assembly. Thanks Dave.

Packo:  Thank you, Sir.


Greg Henry, MD Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP. 

David Packo, MD Co-founder and president of Emergency Medicine Physicians (EMP) www.emp.com 

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