Parties in Summa Health staffing dispute agree on little

Leaders from Summa Health System and Summa Emergency Associates, the independent physician group that staffed the system's emergency departments until this month, agree on this: Contract negotiations, which ultimately broke down days before the deadline, could have started sooner.

Both say they entered negotiations in early November fully expecting to have SEA clinicians staffing all five of Summa's emergency departments in 2017 and years to come.

Beyond that, the two agree on little about how negotiations played out.

Upon reaching a stalemate in the last week of December, Summa solicited proposals from other companies that could, within days, have enough doctors available at midnight on New Year's — an unnecessary move, said Dr. Jeff Wright, SEA president and ER physician. But Summa leaders say it was their only option.

Officials at US Acute Care Solutions (USACS) — which has been staffing the EDs since SEA's contract expired Dec. 31 — thought Summa and the SEA group that has provided emergency services there for decades would reach an agreement.

Dr. Thomas Malone, Summa president and CEO, said it was a tough decision. Realizing they were at an impasse, he brought on USACS at the last minute to staff Summa's Barberton, Akron, Wadsworth-Rittman, Green and Medina emergency departments.

"I don't think they thought we could do it," Malone said. "It was horribly disruptive to the organization, unbelievably disruptive to the ED staff, to the patients the first couple of days because they had longer waits. But because of the hard work of the staff, mostly the nurses, the credentialing staff (and) IT, we were able to pull that off, and every day it's been better."

The wait times have returned to normal, and patient volumes have remained steady, said Valerie Gibson, chief operating officer of Summa and president of Summa Health System hospitals.

But that hasn't appeased concerned practitioners and patients.

Summa leaders, its board and many of the system's department chairs support the decision and stand on one side of what has become a very public and contentious debate. Facing them is a sea of unhappy community members, fed-up physicians — hundreds of whom have signed a no-confidence letter — and other groups weighing in.

In late November, Summa sent SEA its initial proposed contract: a three-year deal without financial assistance, similar to what SEA had operated under before.

Wright returned it with additions two weeks later. He said he wanted a 15-year contract to help with recruitment and retention, as well as financial assistance to help SEA make up for financial losses sustained while staffing some less busy Summa emergency departments.

Although Wright said SEA had been talking to Summa for a year or two about the financial struggles in those EDs, no form of stipend was in the initial contract. His counteroffer was to not staff two of the financially underperforming departments.

Summa leaders realized the two were very far apart. A 15-year contract is outside the industry standard of three years, said Ben Sutton, Summa's senior vice president for strategy and performance management. And any stipends Summa includes in contracts are assessed by a third party for fair-market value, a process Sutton said SEA didn't initially offer.

Summa offered an extension of the contract so they could get on the same page. Wright, thinking they'd certainly be able to work it out, declined the offer. He saw his requested changes as wording and legal issues that the attorneys could hammer out.

Summa leaders didn't think it was that simple. Sutton said, they were asking for things "so far outside of the norm that there was no way that we could even contemplate doing some of the things that they asked."

Summa offered four extensions, all of which SEA turned down, Gibson said. Wright doesn't know an exact number, but acknowledges declining multiple extensions.

He said it didn't seem like Summa officials were "putting the effort forward to get a contract finalized."

Malone said he's never been in an environment where people didn't extend a contract, especially if they'd had it for as long as SEA did — about 40 years, according to Wright.

Although the short time frame worried Wright, he was more concerned that during any extensions, Summa would find another group to take over the contract. "It was a lack of trust," Wright said.

Many have raised questions about the involvement of Dr. Vivian von Gruenigen, Summa's chief medical officer, in the negotiations. Her husband is CEO of the group tapped to replace SEA. Summa officials say they ensured that anyone with conflicts of interests, including von Gruenigen, was excluded from the selection process for the new company.

In the crunch of the final week, SEA and Summa officials share different versions of the verbal and written offers from each. But ultimately, they could not bridge the gap, and USACS was put in place.

The fallout from doctors, community members and beyond was swift.

About 215 attending staff members signed a letter of no-confidence in Malone and another such letter with a couple hundred signatures came from medical residents, said Dr. Hitesh Makkar, vice president of medical staff at Summa.

An anonymous survey circulating has garnered 350 to 400 votes of no-confidence, said Makkar, a partner and physician with Respiratory, Critical Care, Sleep Associates (RCSA), whose contract with Summa also was not renewed.

This decision, though made last summer, is under public scrutiny following the ED contract negotiation breakdown. Summa maintains that these were separate decisions.

Summa moved to an exclusive contract with its employed group but would include others who align with the system, Malone said.

Dr. Charles Fuenning, another partner with RCSA, said the move indicates that Summa officials wish to move to a wholly employed physician model and don't appear to be interested in collaborating with independent physicians.

Malone disputes this, saying they'll work with any independent group that wants to work with Summa and join its affordable care organization.

Fuenning and Makkar are investors in Western Reserve Hospital, which is co-owned by Summa Health and Western Reserve Hospital Partners, who are in an ongoing legal battle.

Malone said the ED decision was an unfortunate and separate situation, but now independent docs who are shareholders at Western Reserve "are trying to make it more disruptive than it needs to be."

Makkar and Fuenning both say they did not bring attention to their contract issue following the ED decision and say the contract disputes are separate from their involvement with Western Reserve.

Malone said the SEA residency program director canceled upcoming interviews for medical students interested in next year's residency. He said they "maliciously" attempted to impact the residency. "I've never seen this kind of behavior from physicians before," Malone said.

Wright doesn't know who canceled the interviews, but said it would have "probably been someone in the residency office, which would have been one of our physicians."

Wright said SEA physicians had no way of knowing whether medical students traveling there would have anyone to meet with.

Summa's board and department chairs have issued letters of support for the administration's decision.

Summa and USACS say the EDs have been fully staffed since midnight on New Year's and the wait times are back to normal, while Wright says he's heard otherwise from former colleagues.

Gibson emphasizes that the decision was a contract dispute and had nothing to do with quality of care. SEA physicians were high-level, board-certified doctors that Summa would love to have back — provided they come through USACS, which has been reaching out to physicians.

Dr. David Scott, USACS chief administrative officer, said they're in negotiations to hire some docs back.

Summa is working with physicians to make sure they understand the decision and feel engaged in the system's vision, Sutton said.

"We made the right decision," Malone said. "As I've gone through this again and again, no matter how much press we get on it, the board is confident in the new group and we're not turning back."

Dr. Eric Espinal, Summa's chief of cardiothoracic surgery, said that with this much of an upset, it's clear that communication should have been better. At the end of the day, the Summa administration and the physicians want the same thing, he said.

"We want a financially viable institution, we want our nurses and the families who depend on all of these employees to be happy and enjoy coming to work, and we want our patients to be confident that they're well taken care of," Espinal said.

"Parties in Summa dispute agree on little" originally appeared in Crain's Cleveland Business.