ACEP President Shares His Vision for EM's Future With 2011 Council
By David C. Seaberg, MD, FACEP
ACEP President
Address during the 2011 Annual Meeting of the ACEP Council in San Francisco, CA.
Listen to Dr. Seaberg's address
The best way to predict the future is to create it. Though often repeated, this sentiment is just as relevant today as it was when economist Peter Drucker first wrote it many years ago. The question I pose to all of you is -- what future will we create for emergency medicine?
As your new president, I am honored and thankful for the support of the Council as we continue to fight for our specialty, to ensure a bright future for all emergency physicians. There is no other group I would want next to me in our battle, than my emergency medicine colleagues. The Councillors in this room represent the very best our specialty has to offer. Yet, the next three years of healthcare reform will likely affect the next 30 years of our practice. It will touch all aspects of what we do: how we work, how we are paid, and how we interact with our patients. In short, it will redefine the specialty of emergency medicine.
By 2025, an average family of four will have to spend up to 40 percent of its income on health insurance. By that same time, Medicare and Medicaid will account for nearly 40 percent of the federal budget. This is what bending the cost curve in medicine is all about. Now is our time to act – to shape the way we will practice and to determine our future.
As you know, there are three pillars of healthcare reform: Access, Quality, and Cost. The first goal of the Accountable Care Act was to provide insurance to those who do not have any. This aspect of the legislation has sparked great controversy and will most likely be settled by the Supreme Court. But this country must still face the issue that those of us in emergency medicine have always known. Insurance coverage does not equal access to care. Regardless of insurance status, emergency department visits increase every year and now account for nearly 136 million encounters.
The two other pillars of healthcare reform – Quality and Cost – comprise the value equation. To enhance value, one must improve quality at the same or lesser cost. The federal government sees integrated care delivery systems, such as accountable care organizations, bundled payments and episodes of care, as viable solutions to reduce costs while improving the quality of care delivered to patients.
Just how will emergency medicine fit into this new paradigm? In my travels representing ACEP over the last year, I have heard insurance companies state over and over their desire to get patients out of the emergency department. I have heard their vision of emergency medicine as acute care gatekeepers. We have seen a movement of state Medicaid programs to reduce what they perceive to be unnecessary ED visits or only pay for a certain number of visits. It is problematic that insurance companies and policy makers do not see the value of emergency medicine. A visit to the ED has now somehow been inappropriately characterized a failure of the system. But remember, emergency medicine only accounts for two percent of all health care expenditures each year however, emergency physicians provide 28 percent of all ambulatory care visits and nearly two thirds of all visits after hours. This is true value, indeed.
I believe it is incumbent on our organization to highlight the value of emergency medicine. We have value today in being the rapid diagnostic center, of reducing patient cycle time and returning patients back to work sooner, we reduce readmissions and potentially avoidable admissions through our observation units, and we help prepare our nation for disasters and provide syndromic surveillance.
Yet, I want to promote another vision of the value of emergency medicine. Emergency physicians must consider stepping out of our perceived comfort zone and perception of only providing acute care. As we all know, the primary care medical home is wonderful in theory but in practicality, it does not exist today. Nor will it in the near future. We do not have enough primary care physicians to fulfill this role but we have a need for the integration of medical care for the patient.
In preparing for this speech, I re-listed to Greg Henry's ACEP President's address to this very Council 16 years ago. In his speech, Dr. Henry called for the emergency department to serve as the central hub. I am renewing this call, one in which the ED is not only the central hub but a bridge to an integrated delivery system.
Could the emergency department, with its 136 million visits each year, with another 100 million visitors who come with patients, be a conduit or bridge to an integrated delivery system? I feel the ED and emergency medicine should consider the benefits of redesigning itself with support from the hospital and third party payers to provide an additional team of health providers – physicians, mid-levels, nurses, techs, case managers, and social workers – who could provide preventative care – such as immunizations and health care screenings; who could promote wellness through education on exercise, diet and other lifestyle choices; who could enhance our observation units to further reduce readmissions and potentially avoidable admissions; and who could develop better disease management and palliative care protocols to prevent these patients from their continual cycle of ED visits and admissions.
We can use our access to patients as a vehicle to enhance emergency medicine’s value by serving as a bridge to integrated medical care – saving cost to the system and promoting quality care that keeps patients well. Just think how powerful emergency medicine could be as a leader and key contributor in the integrated health care delivery system. That is a future worth creating.
To accomplish the goal of enhanced value, we need medical liability reform. Defensive medicine continues to hinder our ability to practice efficient emergency care, but we have the opportunity to push federal tort reform as a larger part of the healthcare reform movement. At a minimum, we should be protected when we follow identified best clinical practices. And with EMTALA as one of the largest unfunded mandates in history, we must have medical-liability for EMTALA-related services.
I think I’m in a room where I can safely say that emergency physicians deserve fair payment for their services.
ACEP has had major successes in this area over the years, but we still have many battles ahead. Congress has not found a fix to the sustainable growth rate formula, which could lead to a nearly 30 percent cut in Medicare payments as of January. ACEP also continues to push the issue of balance billing. Our members have worked with the National Commission of Insurance Legislators to draft model legislation for balance billing in emergency medicine.
We also must monitor and advocate against the impending state Medicaid program cuts. If emergency medicine continues to serve as the health care safety net, we must work innovatively with states to ensure adequate reimbursement for their Medicaid enrollees. Programs that limit ED visits must be actively fought, and the prudent layperson standard must be upheld for emergency visits.
When we consider all of these issues and what they mean for the future of emergency medicine, we can’t lose sight of those physicians coming up behind us. Current budget negotiations are underway to limit funding for graduate medical education, and this comes at a time when we are facing a potential shortage of emergency physicians and emergency care providers over the next 20 years. Emergency medicine residency programs could be at risk, so we must devote resources to fight these cuts.
We also know that rural areas are particularly vulnerable to physician shortages. This highlights the obvious need for innovative solutions to providing emergency care to all areas.
I feel the time has come for ACEP to open its doors to collaborative efforts to provide quality emergency care for everyone. We will need to work with non-board certified physicians who practice emergency care to provide them education and advocacy so they can effectively and efficiently take care of their patients. We also need to work with our advanced practice practitioners and mid-level providers to create efficient emergency care teams. The emergency department of the future will have a patient-centered team approach involving many practitioners dedicated to quality and efficient emergency care.
I am encouraged for the future of emergency medicine. Along with the ACEP Board of Directors, I will spend this next year tackling the very issues I have just outlined. One important step in creating a strong future for our specialty was the recent creation of the Emergency Medicine Action Fund.
The Action Fund is a historic collaboration of emergency medicine organizations and leaders that will enhance emergency medicine’s advocacy efforts on the regulatory front. Our voices must be heard to protect our practice and our patients, and the work of the Action Fund Board of Governors in conjunction with ACEP’s ongoing advocacy efforts, will be essential in making that happen.
I want to challenge all of you to help us create the future we want to see for emergency medicine. In addition to supporting the Action Fund, your contributions to NEMPAC make all the difference in impacting our advocacy efforts. We truly appreciate your continued support.
I recently led an emergency medicine delegation to Rwanda. The Rwandan people have suffered much hardship yet they greeted us each day with a saying:
Neweeno ureybey, aharee ubushakey, beeosey birashowbokah -- which means come and see, where there is will, everything is possible
As I enter my 25th year in emergency medicine and ACEP, I realize I must double my efforts for change – less for my career, but more for our younger members, residents and patients. We must focus on value and value-added services in emergency medicine. We must strive to provide the highest quality medical care to our patients. These next few years will be crucial for all of medicine. I ask you to join me in laying the foundation for our future. Let’s demonstrate why we are, and will continue to be, true leaders in the House of Medicine.