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Hospitals contracted with private companies are cutting costs by relying on nurses


The way emergency rooms work has quietly changed over the last decade. No matter the name on the outside of the building, hospitals often contract private companies to run the ER. Most of those companies are owned by private equity investors known for taking on massive debt, cutting expenses and trying to sell for big returns after a few years. And as Blake Farmer of member station WPLN reports, some of the biggest expenses in the ERs are the doctors themselves.

BLAKE FARMER, BYLINE: Pregnant and scared, Natasha Valle went to the only hospital in Clarksville, Tenn., because she was bleeding. It was a miscarriage, but it took three separate trips to the ER, creating three separate bills she's still paying.

NATASHA VALLE: Literally three days in a row.

FARMER: She says not until the third visit did she see a doctor.

VALLE: At the time, I wasn't thinking, oh, I needed to see a doctor. But when you do think about it, it is kind of like, well, dang, why didn't I see a doctor?

FARMER: It's unclear if the repeat ER visits were due to delays in seeing a physician or if that affected her care, but the experience worried her. Seventeen months beforehand, the hospital had outsourced its emergency rooms to American Physician Partners. It's a fast-growing ER staffing company joining the ranks of the largely unknown but dominant firms that run ERs, TeamHealth and Envision. Each is owned by private equity investors. One way they're profiting is by using more nurse practitioners and physician assistants, which are now some of the fastest-growing careers in the country. Typically, they have half the training of a physician and make less than half the salary. This strategy first became evident to me when American Physician Partners held a training in early 2020. ER staffers were brushing up on lifesaving procedures.

UNIDENTIFIED PERSON: Hold my ribs, sir.

FARMER: Wearing purple latex gloves, ER staff handle racks of pork ribs to practice putting in chest tubes for a collapsed lung. And among the doctors were a couple of nurse practitioners like Joshua Allen. He told me his ER in Kentucky had just gone down to having one doctor on duty per shift, along with the nurse practitioner. So they were teaching him some skills that are usually only left to physicians.

JOSHUA ALLEN: I guess we're the first guinea pigs for our ER. Because if we do have a major trauma and multiple victims come in, there's only one doctor there and we're there as well, we need to be prepared to do this procedure.

FARMER: The two-day training also covered intubation to clear an airway and using powerful sedatives. At the time, the ER company's chief medical officer, Dr. Tony Briningstool, said training nurse practitioners and physician assistants on these skills added depth to the staff.

TONY BRININGSTOOL: They're a part of our team, and we want to make sure we're helping them feel confident and help developing their skills.

FARMER: In the last several years, the profitable side of the strategy has become more obvious. Confidential company documents reviewed by NPR and Kaiser Health News show American Physician Partners increased its use of nurse practitioners and physician assistants. APP has numerous cost-saving initiatives underway, the document says, including a shift of staffing between doctors and so-called mid-level practitioners, meaning nurse practitioners and physician assistants. It was pitched as a way to save millions of dollars. In a statement, the company stressed they are supervised by doctors and called it a blended model where everyone can work to their full potential.

This company is hardly alone. One study finds the use of nurse practitioners and physician assistants in the ER has nearly tripled since 2005. It's unclear whether this results in worse care, but it does seem to drive up what patients pay. One study shows patients are more likely to be sent to specialists or for X-rays and other imaging, racking up additional bills all along the way. Dr. Arthur Smolensky is a board-certified ER physician and assistant professor at the University of Tennessee who's been pushing back on private equity in his specialty.

ARTHUR SMOLENSKY: Most of us didn't go into medicine to supervise an army of people that are not as well trained as we are. You know, we want to take care of patients.

FARMER: But with the reliance on nonphysicians, there's now a projected surplus of ER doctors in the coming years, and some are going ahead and leaving on their own.

For NPR News, I'm Blake Farmer in Nashville.

RASCOE: This story was produced in partnership with Kaiser Health News and Nashville Public Radio. Transcript provided by NPR, Copyright NPR.

Blake Farmer