It was the day after Christmas, 2016, when the president and chief executive officer of the Summa Health System finally met with his emergency physicians, the Summa Emergency Associates (SEA). Their contract was due to expire on New Year’s Day. The hospital system had worked with the independent group for 4 decades, and its physicians had staffted some or all of its emergency departments (EDs) in the greater Akron area, in northeastern Ohio. But in late 2016, the hospital had let negotiations lag. With less than a week remaining in the contract, the face-to-face meeting had become necessary.

The gathering lasted less than an hour. The president of SEA, Jeffrey Wright, MD, left the meeting feeling like the hospital would accept 1 of the 3 proposals his group had offered. But nothing materialized. The next day, the hospital administrator sent out an e-mail saying he would entertain deals from other groups. And in a drama that made for front-page headlines from the end of 2016 through January 2017 in Akron, the 11th-hour contract negotiations failed just before midnight on New Year’s Eve. SEA physicians were pushed out, and another group moved in. The hospital system said the midnight handover—which would surely have qualified as one of the most bizarre sign-outs in the history of emergency medicine—went smoothly. However, the subsequent aspects of the transition were not as painless, ultimately costing Summa accreditation for its emergency medicine residency program.

“There were really no winners in this whole thing, just losers,” Dr. Wright said of the affair. “Especially for the patients and the medical residents. There’s been total chaos and disarray with the residents.”

The developments in Ohio just before and after the beginning of 2017 offer a powerful reminder that the landscape of medical care in the United States, including that of emergency medicine, is changing rapidly as it plunges into an era of consolidation and the uncertainty that can follow. Understanding how a small but respected regional group of emergency physicians found themselves out of work seemingly in an instant may offer some perspective on these shifting tides.

How did a 40-year relationship between a hospital and a trusted emergency physicians group unravel so quickly? Financial problems may be at the root. Dr. Wright described the 6 EDs that SEA had staffed in recent years, noting that 2 of them had low volume (roughly 20 patients per day) and one had a poor payer mix. For SEA, staffing the 3 underperforming EDs with board-certified emergency physicians proved challenging. Summa ended up closing one of its EDs, leaving 2 viable campuses and 3 struggling ones.

“Every month, all 3 of those contracts were losing money,” Dr. Wright said. “So we began talking to the hospital system about alternatives.” Perhaps they could be staffed differently, converted to urgent care clinics, or keep shorter hours? These were some of the suggestions put forward by SEA as the contract renewal date approached.

Contract talks, however, didn’t begin until November 2016, with a midmonth telephone discussion between Dr. Wright and Summa officials. During that telephone call, Dr. Wright said, Summa said it wanted to cut resident education and core faculty positions. Dr. Wright, meanwhile, explained that the emergency physicians needed financial assistance because of the 3 underperforming EDs. When Summa finally offered a contract on November 28, it didn’t reflect nay of the physicians’ concerns.

“The initial contract was worse than the one we had signed 3 years before,” Dr. Wright said. It offered no financial assurance and decreased the graduate medical education (GME) funds the emergency physician group had been receiving by 20%. The 3-year deal also was far shorter than what the SEA desired.

By this time, there was just a month and a few days remaining in SEA’s existing contract with Summa. The hospital system gave SEA 2 weeks to review its contract offer and return it. At this point, Dr. Wright became mildly concerned. He’d negotiated with the hospital for the past 12 years as president of SEA, and in recent months some of the system’s administration had turned over. He also noted with concern the involvement of Vivian von Gruenigen, MD, Summa’s chief medical officer, in the negotiations. Her husband, Dominic J. Bagnoli, Jr, MD, served as chief executive officer of US Acute Care Solutions (USACS), a competitor to SEA.

Still, Dr. Wright said, he worked with his physicians to craft a counterproposal. A key feature of this agreement was a 15-year length, which SEA believed it needed to recruit and retain physicians in the area. The group had lost as much as $9 million because of the 3 underperforming Summa hospitals, Dr. Wright said. Given the quality of SEA’s physicians, their long history with Summa, and their medical education contributions, Dr. Wright still thought that his group had the inside track when they made their counteroffer on December 12.

At this point, Dr. Wright said, the hospital reviewed the contract, and on December 16 Summa requested a 60-day extension. Dr. Wright viewed this as excessive, given that the initial contract negotiations had only formally begun with a contract offer 33 days before the end of the year. He was also concerned the delay was requested to give Summa time to bring a new group of emergency physicians into the hospital.

Lacking an extension, Dr. Wright finally had his first, and only, face-to-face meeting with Tom Malone, MD, MBA, Summa’s president and chief executive officer. During that meeting, Dr. Wright said he offered 3 different contracts; 5 years with 5 years of revenue assistance, 7 years with 3 years of assistance, and 10 years with 2 years of financial assistance. “I thought we had a verbal agreement,” he said. “We thought we were walking out of there with one of those deals. But the next day, the hospital administrator sent out an e-mail saying they were entertaining deals from other groups.”

Even as Dr. Wright and SEA officials conducted conference calls on the 28th and 29th of December with Summa, the hospital system was also negotiating with USACS. As discussions continued into New Year’s Eve, the Akron community began to grapple with the possibility of an abrupt shift in emergency care. It was no small matter to swap emergency physician groups at midnight because the 5 campuses experience a total of approximately 170,000 visits annually.

As New Year’s Eve approached, Dr. Wright offered the hospital a 7-day extension. The hospital countered with proposed 14-day extension. Neither side budged. Then SEA made its final offer: a 5-year contract with 1 year of revenue assistance. By then, the 2 sides had agreed on the GME money and core faculty issues. But it didn’t matter. “Two hours after I sent that offer, I was called by the chief executive officer to reject the offer, and he told me he was moving forward with the new group,” Dr. Wright said.

New Year’s Eve turned surreal in the Akron EDs. The normal SEA physicians had reported as usual for their shifts earlier that day, and then around 11 pm that night a brand new group of physicians arrived. Some of the SEA physicians stayed past midnight to ensure continuity and to avoid total chaos in the EDs. “We never walked out on the patients,” Dr. Wright said. “We made sure they were seen and had appropriate workups.”

Summa Health System did not agree to be interviewed by Annals for this story. Instead, a statement by Valerie Gibson, RN, MSA, Summa Health’s chief operating officer was provided: “It was Summa’s intention to complete a long-term contract with our former emergency services provider. When presented with multiple offers of extension to reach an agreement over a holiday weekend, our former group declined. This forced Summa into a position to execute a contingency plan involving US Acute Care Solutions. USACS stepped in to serve our five emergency departments, and our EM residency, under extraordinary circumstances and has performed admirably.”

But we can glean some of the hospital’s viewpoint from Dr. Bagnoli, the chief executive of USACS, who said he got his first call from Malone on December 24. This was 2 days before Malone had his face-to-face meeting with Dr. Wright. Dr. Bagnoli characterized the Christmas Eve discussion as a “phone call of exploration,” and said Malone thought the 2 sides were still pretty far apart. “I basically told him that his best solution was to work out an extension with his current group,” Dr. Bagnoli said. “If that’s impossible, and it can’t be done, then there are probably only 3 or 4 groups that could help him on a week’s notice. We were one of them.”

After the December 26 meeting between SEA and Summa, the hospital system issued a request for proposals on December 27 and sought responses by the 29th. Despite the remarkably short window, USACS and at least one other physician group responded. Even at that point, Dr. Bagnoli said he thought that SEA and Summa would work out their differences. “I’ve never, in 25 years of business, seen a group walk away from an extension like this,” he said.

Still, he made arrangements for physicians to be ready to go on New Year’s Eve just in case, quickly submitting physician applications to obtain credentials. Malone finally called him at 5 pm on New Year’s Eve to tell him the final offer and extension had been rejected. “A lot of the docs who said they would be there if we needed them probably thought they would get a call saying ‘You’re not needed,’” Dr. Bagnoli said. “But when they were called and told to be at their designated hospital, they showed up like the cavalry.”

Not everything went smoothly, however. The Akron Beacon Journal printed several articles in the immediate aftermath of the handover about problems related to longer-than-normal wait times and patients leaving without being treated. Morale in the ED also apparently suffered, perhaps nowhere more so than among the medical residents, whose mentors had suddenly been axed from both their employment and their teaching responsibilities. On Sunday, January 1, the House Staff Council, which represents the 230 medical residents at the Summa system, announced that they had voted no confidence in Malone.

For Sharhabeel Jwayyed, MD, the director of the emergency medicine registry, it was an especially bitter time. Only recently, on October 6, 2016, the Summa Health System’s weekly newsletter had praised Dr. Jwayyed as a winner of the prestigious 2016 Accreditation Council for Graduate Medical Education (ACGME) Parker J. Palmer Courage to Teach award. Now, 2 months later, he was out of a job.

“Our program, with 30 emergency medicine residents, was doing great,” he said. “It was really a beacon of excellence. And after this, the residency basically exploded.”

Concerned about the safety of the residents on an ED rotation, and the lack of a core faculty, Dr. Jwayyed devised an administrative elective that would allow the residents to spend a month out of the turbulent Summa EDs to study for their in-service examination. But after 2 days, Dr. Jwayyed said, they were “pressured and coerced” by Summa officials to go back to the ED, apparently because USACS could not scramble enough departmental coverage on such short notice. As of early February, he said, most of the new core faculty still live outside of Akron, and he has heard concerns from his former residents about USACS attending physicians leaving their residents unsupervised for 2 to 3 hours after a shift.

The plight of the residents led the American College of Emergency Physicians to issue a statement on January 6 that said, in part, “We are deeply concerned about the continuity and stability of training for the emergency medicine residents working in the Summa Health System following the abrupt shift in contracted emergency physician services from Summa Emergency Associates to U.S. Acute Care Solutions. Hospitals and health systems change staffing contracts routinely, but what is not routine at Summa Health is the abruptness of the change. Typically, it takes 90 to 120 days for a transition to be completed, to allow for adjustments to personnel, schedules and infrastructure. We are concerned about what plans Summa Health has to ensure smooth transition for the residency program and the residents directly involved.”

Dr. Bagnoli said in early February that criticism of the residency program after January 1 has been unfair. Summa Health System is paying for the core faculty and fulfilling its obligations under the ACGME, he said. “They are 100 percent committed to residency education,” he said. “We’ve been painted as the group that doesn’t care about residency, when frankly we came in and provided the support to save it. We have every intention to keep it as one of the great residencies.”

Amidst these increasingly public concerns, an unplanned ACGME sight visit took place and on February 8, Summa Chief Operating Officer Valerie Gibson revealed in a memo to employees that the residency program had been placed on immediate probation by the ACGME. As it stands, the Summa emergency medicine residency program, one of the oldest in the country, could lose its accreditation on July 1. “Needless to say, we are extremely disappointed by the decision, we respectfully disagree with the decision and we will appeal the decision within the next 30 days as allowed,” Gibson wrote. “Our program will remain in continued accreditation during the appeal process.” If the appeal is denied, the 21st- and 22nd-year residents will need to find new residency positions elsewhere starting in July. Their ability to find new hospitals will depend on whether Summa Hospital permits each resident’s federal funding to follow them to their new job. If not, programs willing to accept them may not have the financial ability to do so.

During an interview with Annals , the USACS chief executive, Dr. Bagnoli, also dismissed the notion that his wife, Vivian von Gruenigen, had improperly interfered with contract negotiations between Malone and him. Yes, he and Dr. von Gruenigen have been married for 25 years, Dr. Bagnoli said. But 2 independent reviews of 6 months of e-mails and text messages found nothing to suggest there was a conflict of interest—although at least one of those investigations has itself come under scrutiny for its own conflicts of interest. Moreover, Dr. Bagnoli said Dr. von Gruenigen recused herself during all parts of the decisionmaking between USACS and Summa.

Dr. Bagnoli recalled that on Christmas Eve his wife came home and told him that Malone would be calling him that day about the EDs. She’d been part of a meeting on the ED contract with SEA that morning. After that, however, when Dr. Bagnoli said he started to talk to her about the matter again, Dr. von Gruenigen replied, “I can’t talk to you about this. I can’t be involved.”

And, Dr. Bagnoli insisted, she didn’t, and she wasn’t.