The Centers for Disease Control and Prevention cites nearly 130 million visits to U.S. emergency rooms (ERs) in 2010. Statistically, that is around 43 visits per 100 people annually. As often the first and sometimes the last defense against medical crisis, emergency departments (EDs) are the melting pots of their communities, seeing all walks of society and adapting to technological, cultural, economic and legislative change.
Hospital EDs perform a vital and complex role for the communities they serve, and for the last 38 years, Mid-Atlantic Medical Associates, P.A. (MEMA) has played a pivotal role in emergency medicine in Charlotte and the surrounding region.
Founded in 1976, MEMA is an independent, physician-owned emergency medicine practice that provides emergency and acute medical care through its longstanding relationships with several area hospitals.
With corporate leadership including a chief operating officer, chief financial officer and a professional recruiter, and governed by an elected board of directors, MEMA currently consists of 48 physicians who are board-certified/board-eligible in emergency medicine and pediatric emergency medicine, with several physicians double-boarded. MEMA also has 24 advanced practice providers, including both physician assistants and nurse practitioners.
Partners in Health Care
MEMA President and CEO Timothy Lietz, M.D., FACEP, explains the practice’s origins.
“We’ve been at Presby [Presbyterian Hospital] 38 years,” Lietz says. “We were the first emergency department group to staff that hospital. Before that, the emergency department was staffed by community physicians who would take turns.
“MEMA was originally a group of doctors who did the majority of shifts. Then they were hired by the hospital and eventually they became an independent group of emergency medicine specialized staff that provided the service to the hospital.”
Lietz joined MEMA in 1994 to staff the then newly opened Presbyterian Matthews hospital and was medical director there for 17 years.
Since 1976, MEMA has provided the 24/7 staffing for the Novant Health Presbyterian Medical Center (formerly Presbyterian Hospital Charlotte) ED and currently also provides 24/7 ED staffing for Novant Health Matthews Medical Center and Novant Health Huntersville Medical Center.
The ED of the new Novant Mint Hill Medical Center, slated for completion in 2017, will also be staffed by MEMA when it opens.
Lietz describes the practice’s relationship with the hospitals they staff as a strong partnership involving common goals.
“We walk hand in hand with Novant Health in their goal of a remarkable patient experience,” Lietz says. “It’s our vision as well. We’re dedicated and committed to it. We had staffed other hospitals in the area but when their vision became different from ours, we went separate ways.
“Our goal is a patient-centered experience where we provide the best, highest quality emergency care. Physicians aren’t the only factor in accomplishing that. The hospital, the nursing staff, the administration and the tools available to us are all factors in making that happen.”
MEMA’s close relationship with partner hospitals is reflected in their joint work. All three Novant Health Medical Centers are certified stroke centers and accredited chest pain centers and Novant Health Presbyterian was the first hospital in the Charlotte area to open a dedicated Pediatric Emergency Department in 2003. The department was expanded in 2011 and is staffed by MEMA physicians that are board-certified in pediatric emergency medicine.
MEMA physicians are also involved in key hospital committees such as the Medical Executive Committee, Emergency Services Council and the ED Hospital Steering Committee, among others. “Innovation is collaborative between us and the hospital,” says Lietz.
One such innovation implemented last year was the Safe Sign Out Project. “One of the times most vulnerable to mistakes is when patients are turned over at the end of a shift,” Lietz explains. “If a patient is in the middle of a work up and is waiting on results from an X-ray or a CT scan, things can be miscommunicated or not properly followed up.
“To prevent these issues, we decided to institute a formal process to ensure that all information was provided to the oncoming physician. In this way, the physician taking over care of the patient has the patient’s anticipated diagnosis, pending tests and a tentative action plan. It enhances patient care at our partner hospitals and makes our practice safer.”
Commitment to Leading
The relationship between MEMA and its partner hospitals is bucking a trend. Lietz notes that MEMA is the last independent emergency group in Charlotte. “When I first came to Charlotte in 1994 there were three or four private practice emergency groups that staffed area EDs,” he explains. “Now some of the hospitals use national contract groups to provide their physician services.”
Integration, where hospitals buy private practices and physicians become employees of the hospitals, is also a long-term trend in Charlotte and nationwide. “Maintaining our independent practice status is a challenge,” says Lietz, “but we believe it is the best way for MEMA to remain a high quality practice.
“Our independent, physician-owned status allows us to hire physicians who eventually become owners of the practice and who are committed to making the practice a success,” he says. “We hire people who want to be in the Charlotte area and establish a long-term career here. National contract groups often have doctors who will work here for a few years and then move onto other regions.
“We try to develop a core group of physicians at each one of our hospitals who will spend their careers there. That way we get to know the medical staff and hospital administration and become integrated into the medical community of the Charlotte area.
“What makes us stand out is that our physicians are committed to our group, they’re committed to their hospital and they’re committed to their community.”
Leadership also makes MEMA physicians stand out. Of their current physician members, 19 are former chief residents; 11 are former attending physicians from teaching hospitals; three are past presidents of the North Carolina College of Emergency Physicians; two are current councilors of the North Carolina College of Emergency Physicians; two are current board members of the North Carolina College of Emergency Physicians; one is a current representative to the American College of Emergency Physicians, Reimbursement Committee; and Lietz currently holds the prestigious position of a member of the North Carolina Medical Board.
“It’s important for us to hire leaders in emergency medicine,” he says. “We hire people who are leaders among their peers as medical students and residents so that during their career with us they become leaders within emergency medicine in our state.”
The Charlotte community appears to also think that MEMA physicians stand out. In 2007, a MEMA doctor was named Presbyterian Healthcare Physician of the Year. In the 2013 Charlotte Business Journal list of Top ER Doctors, three of the five doctors named were MEMA members and in the 2014 Charlotte Magazine Top Emergency Doctors, five of the eight top doctors were MEMA physicians, including Lietz.
Lietz says he chose emergency medicine because he likes the high volume and high intensity of the specialty. “Every day, every shift is a new adventure,” he says. “We’re diagnosticians. We see a patient fresh. We see a set of vital signs and their chief complaint and we make a diagnosis. Other than that, it’s about trauma care, stabilization and resuscitation. Everything under the sun comes into the emergency department and we take care of it all.”
With life and death stakes as a regular part of a work day, you might think emergency medicine doctors would become emotionally detached from the crisis situations they routinely encounter and efficiently handle, but when asked about a memorable work experience, Lietz has trouble beginning—still emotionally impacted by the case years ago.
“About five years ago, I took care of an 18-year-old girl. She’d had a stroke. She was 18 years old.,” Lietz emphasizes. “She was in the emergency department all day—critical care, life support—all that stuff the whole time. We thought she was going to die.” Lietz pauses briefly to compose himself.
“About four years later, a young woman comes up to me in the ER and asks me if I remember her and tells me that I took care of her when she had a stroke. Today she works in our ER as an administration person.”
Real World Medicine
While the very nature of emergency medicine is a difficult one fraught with inherent challenges, emergency medicine today faces complex issues that can significantly impact its practice.
“Our practice mirrors what goes on in the real world,” affirms MEMA Chief Operating Officer Michael W. Icenhour. “When I started with MEMA 15 years, ago our Medicaid population was 16 percent. Now I’d estimate it to be around 25 percent.
“After the economic downturn, we saw a difference in our payer mix. Medicaid went up, self-pay went up and commercial (insurance provided by employers) went down. Our ER physicians treat patients based on acuity only, not on whether they have or don’t have insurance. But if 25 percent of our patient population is self-pay, that’s a huge issue for us from a business standpoint.”
The Congressional Budget Office estimates that through the implementation of the Patient Protection and Affordable Care Act of 2010 (PPACA) an additional 32 million Americans will have health insurance by 2019.
To date, Lietz and Icenhour say they have not seen an improvement in coverage. “The North Carolina Republican-controlled general assembly has elected not to expand Medicaid in the state so there’s a gap of people between those who can get subsidies to pay for their health insurance and those who are eligible for Medicaid,” explains Icenhour. “Those in the gap are our self-pay patients.”
“A huge challenge is taking care of all the folks who don’t have the resources to get health care,” Lietz adds. “Part of the practice of emergency medicine is taking care of the people who can’t get health care anywhere else but there’s a misconception out there.
“People don’t use hospital emergency departments as primary care because they need routine care for their diabetes or hypertension. They show up for an acute part of that illness. So a diabetic will show up in the emergency department because their sugars are out of control or in the case of hypertension, because their blood pressure is sky high. We take care of the acute phases of a chronic illness but we don’t function like a primary care physician.”
The cost of caring for the uninsured, which is absorbed by EDs, has serious financial consequences. According to the American College of Emergency Physicians (ACEP), the annual number of ED visits has increased by 23 percent from 1997 to 2007. Contemporaneously, 535 hospitals closed, 381 EDs folded operations, and available inpatient beds shrank by 134,000, exacerbating a nationwide problem of ED crowding.
“It’s a complex problem,” says Icenhour. “Even if everybody gets insurance, we don’t have enough primary care physicians to take care of all these people. I was talking to my primary care physician about this and he said he can’t find any internists to hire. They’re not out there, so people who can’t get in to see a primary care physician will still have to come our way until the crisis in primary care physicians is resolved.”
In fact, the ACEP points out, “In sum the PPACA, by increasing insurance coverage to individuals who in the past had none, and by not addressing the PCP [primary care physician] shortage, will exacerbate the problem of ED overcrowding by an influx of 13 million newly publicly insured patients.”
“For the Affordable Care Act to really work it’s going to take a culture change,” says Lietz. “It’s not just about how we pay for health care. People are going to have to change the way they think about getting their health care.
“They can choose to maintain their health instead of just using the emergency department for an acute medical crisis. That could change the role of EDs in health care, but unfortunately people are still going to have heart attacks and strokes and get into car accidents. They’re still going to need us and we’ll be here to help them.”