SB: We have 15 million visits that are seen in our democratic section. If you take a cross section of the groups that define themselves as democratic practices, which are within that section, 15 million visits is not a small number, and there are plenty out there that are just independent and don’t come to the section meetings. So it’s a much larger number than one would expect.

WF: I think it raises a question, not from the point of view of practitioners of emergency medicine but from the point of view of payers and executives in hospital systems and other people that are interested in the triple aim. I think that what they want to know is whether or not democratic group structures actually add value to the quality of care on behalf of patients and population. I think that’s becoming the market test and also the government challenge coming at us from both employers and payers and people that run the federal programs. The important question is whether or not the democratic practice model is clearly the best way to deliver care on behalf of populations or if it’s really a boutique kind of activity that can only happen in increasingly rare circumstances.

By and large in groups, even the ones that have one person, one vote, my experience has been that the work is never equal and the level of commitment to accountability and responsibility is never equal. —Lynn Massingale, MD, FACEP

LM: I think this will be on point to what Wes just said. My analogy: A friend of mine runs a large, large, large chain of nursing homes. I was talking to him the other day, and he was telling me about how his average length of stay was going down dramatically and how his census was going up and yet his total occupancy was going down. I thought about all three of those data points. Those are metrics that in the past no one would have ever associated with a nursing home except occupancy percentage. No one talked about length of stay in a nursing home in the past. What’s happening with payment reform, with demonstration projects, with others putting somebody at risk, somebody who chooses to be at risk, working with an [accountable care organization] or other entity, etc., focusing on the admission and the 90-day post-acute after the admission, the simple fact is that people are trying to get patients in and out of nursing homes quickly, not just parking them there indefinitely. They’re aggressively managing the therapy they receive. It’s an example of an industry that’s being absolutely transformed, not willingly but transformed by force, outside forces, into a whole new set of behaviors that they have no control of. They have no control of the forces that are acting on them. They’re simply reacting to those forces and those forces being the assumption of risk by some entity, like an ACO. Increasingly, I think all of us in emergency medicine, and our colleagues in hospital medicine, are feeling those same pressures. When you think about the IT commitment and the organizational change that has to take place to make the group ready to accept risk, or be part of risk and reward, it’s just so hard to do that if you’re spending almost all your work time on clinical care. Somebody has to spend a fair amount of time on the administrative piece and a fair amount of money on the administrative piece. I know when we first started, one of the doctors in my group said, “Look, I appreciate the fact that you want to spend time on the business stuff, but it doesn’t really mean a damn thing to me, and I don’t think I should have to pay anything for the time you spend administratively.” Most groups feel like that. There are big groups, there are democratic groups that do have people who spend a lot of administrative time, so I’m not saying it’s all or none. But it’s very hard for a group to do that if, in fact, there’s an expectation that everyone has an equal vote, everyone’s going to do equal work, everyone’s going to write a check for capital expenditure for IT, etc. It’s just gotten so complicated. The good news is everyone on this call spends all day, every day with a group of people who are really, really smart. In my case, most of them are smarter than me, or all of them are smarter than me, but we all spend time around smart people. It’s not that doctors in emergency medicine are not capable of doing that. Our experience is more and more they don’t want to do that. The ones who want to do that can find a place to do that in any group, either in a small group or midsize group or a big, a democratic group or a group like ours. If you want to do that work, you can find it, but if you don’t want to do that work, which is what we find more and more is the case, then you have to figure out where you want to be. And for me, the most important question for a doctor, any doctor, isn’t, is it a democratic group or not, but is it a group that’s going to win? Is it a group that’s going to survive? That’s number one. And is it a group that’s going to win in a rapidly changing health care environment that requires all of us to be and do things that we were not and could not do yesterday or last week? That to me is the better question. Not is TeamHealth a democratic group or not because we aren’t. The question is, are we going to win or not? The question is, is CEP going to win or not? The question is, is the Akron General group going to win or not? And if you are, if that group has the chops and the commitment to win in that changing environment, then I think good doctors can find a great place in any of those organizations.