The emergency medicine specialty holds a crucial role as the nation's healthcare safety net. This responsibility presents a unique set of clinical and financial obstacles for emergency medicine physicians, which are magnified by trends such as an aging Medicaid population and payers' narrowing provider networks.
Becker's Hospital Review asked emergency physicians and other leaders in the field to comment on the greatest issues facing emergency medicine today and what they feel is misunderstood about the specialty.
Editor's note: Responses have been lightly edited for style and clarity.
Alex Rosenau, DO
Chief of the Division of Emergency Care, Department of Emergency and Hospital Medicine at Allentown, Pa.-based Lehigh Valley Health Network; Past President of the American College of Emergency Physicians
"Hospital networks understand the central role of emergency departments to access, population healthcare and financial success. … Emergency medicine has emerged from its status as a place of last resort and is the hub of the system. The ED is the essential healthcare safety net, having evolved into a rapid diagnostic and decision center. However, increasing facility, imaging and laboratory test charges have brought conflict and misunderstanding to the true costs of emergency physician care. News reports often conflate all charges (not only diagnosis of disease, but also subsequent hospitalization and surgery costs) labelling them 'ED costs.' Insurance industry practices have confused and concerned patients and employers while casting blame on emergency physicians. Solving the out-of-network fair payment conundrum for patients and their healthcare providers must be a priority."
Rebecca Parker, MD
Chief Medical Affairs Officer for Nashville, Tenn.-based Envision Physicians Services; Past President of the American College of Emergency Physicians
"It's important to realize emergency physicians and emergency medicine are safety nets. We're the ones who are there 24-7, 365 days a year. We're the ones that see half Medicaid patients and two-thirds self-pay patients. We are providing the underlying care, and emergency physicians are mission-driven in that way. I picked the specialty to take care of all kinds of patients. The reality is we are always there, and we see everyone. No other specialty does that, and I am proud of that."
John Holstein
Director of Client Development at Zotec Partners
"Emergency physicians are master diagnosticians, educated and trained to evaluate and treat the clinical presentation of their patients, many times with no perspective nor past medical history. Since inception of the specialty as strong patient advocates, they also know and understand the appropriate "next-step" along the care continuum for their patients. This is an exceptional skillset, especially as our healthcare landscape is constantly in flux as sites of service continue to shift to outpatient settings. Emergency physicians on a daily basis encounter the entire spectrum of human accident, illness and/or infirmity, treating every patient regardless of their ability to pay 24-7, 365 days a year.
"The emergency medicine specialty has embraced moving into value-based care having already developed an alternative payment model, currently pending with HHS. This new model will evidence the specialty's commitment to extending the care continuum beyond the acute care visit and its utilization of innovative process and technological solutions. It will also address both the specialty's core and persistent mission of patient advocacy, as well as its concern about healthcare cost today."
Vidor Friedman, MD
President of the American College of Emergency Physicians
"Certainly, this effort on the federal and state level around 'surprise bills' is a significant issue for us. I think there is a lot of misconceptions about why those happen. The fact of the matter is, most emergency physicians want to be in-network with most payers. I think the reverse is also true, as well. But right now, insurers can have a higher deductible for out-of-network care than in-network care. Most patients who are insured don't necessarily understand that. It creates a rather perverse incentive for insurance companies to have narrow networks, particularly for emergency care. We think that in an emergency situation, the deductible should be equal because patients don't have time to ascertain who or which hospitals are in- or out-of-network. They shouldn't be trying to make that decision in an emergency. A lot of the quote 'surprise bills' out there are really about this issue, the deductible."
Dean Wilkerson, JD, MBA, CAE
Executive Director of the American College of Emergency Physicians
"We have a growing elderly population in America utilizing Medicare. We also have a large and growing Medicaid population of poorer Americans. Both groups are disproportionate users of emergency care. Medicare and Medicaid do not pay the true cost of delivering emergency care. For budgetary and political reasons, including the need to cover the uninsured, there will be significant healthcare reform in the next few years that could expand coverage under these programs. That will present a challenge for emergency medicine, since we have an obligation under EMTALA."
Chris Giesa, DO
President of the American College of Osteopathic Emergency Physicians
"The most pressing issue that I face in my own practice and share with many ACOEP colleagues is how to best serve mental health patients in the ED. In recent years, there has been a significant increase in mental health patients in the ED. We are adept at screening mental health patients and diagnosing mental illness. We know when they need to be referred to a crisis center for further evaluation by a psychiatrist, but the challenge lies with those patients who do not need crisis intervention and can be discharged from the ED. One challenge surrounds those patients who are not already in treatment and need to be connected without patient psychiatric care. It is very difficult to get these patients set up without patient services. The local clinics are frequently full and cannot take new patients for months.
"A similar challenge is with those patients who are already in a treatment center but have delayed access to mental healthcare providers. Many patients will say, 'I have an appointment, but it's not until next month. They can't see me sooner. I don't know what to do.' As physicians, we are conflicted. Do we just sent them home and tell them to call in the morning and try to get an earlier appointment knowing that the possibility is slim to none? Many of the physicians that I practice with will default to sending patients to the crisis center. It may be a safer option, but it not always appropriate. A significant increase in mental health services is greatly required if we are to best serve our patients."
David McKenzie, CAE
Reimbursement Director for the American College of Emergency Physicians
"In the emergency medicine reimbursement area, the most important issues today — and over the next 18 months — are resolving out-of-network balance billing payment issues; the reconsideration of emergency department evaluation and management code valuation; and the current efforts to streamline chart documentation to lessen the administrative burden on providers.
CMS has identified the ED E/M codes as being potentially misvalued, and those five codes have recently been considered in the Relative Value Scale Update Committee process with a recommendation given to CMS for consideration. Those codes account for about 85 percent of ED revenue, so a shift up or down in value will have a tremendous impact on the financial viability of the specialty. CMS and the CPT Editorial Panel have also been considering changes to the documentation guidelines, which are used to select and audit the level of service reported based on chart documentation of the encounter. CMS has recognized that documentation is time-consuming and causing physician burnout. Any changes must be a meaningful balance between performance and documentation of activities that reflect the time and resources used in the patient encounter and the commensurate fair payment."
Michael Gerardi, MD
Director, Pediatric Emergency Medicine and Faculty in Emergency Medicine at Morristown (N.J.) Medical Center; Past President of ACEP
"We're incredibly successful for being a relatively new specialty. People continue to 'speak with their feet,' as we say. They're showing up to EDs in increasing numbers because they want prompt, accurate and efficient care. We are misunderstood, though, because people think many of these visits are for non-emergencies. This has led to what I call a 'moral injury' leading to stress for our physicians and nurses. Moral injury starts with our specialty being devalued and undervalued, resulting in payers trying to figure out ways to not pay us. We practice with an unfunded mandate, EMTALA — the act that truly defines who we are. We take care of anyone at any time, regardless of their ability to pay. But that doesn't mean emergency medicine should be devalued. Our country must find a way to fund our medical safety net. In America, people view healthcare as a right, but fund it as a privilege."
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