October 15, 2016
Las Vegas, Nevada
Councilors, it’s been my honor and privilege to represent you as President elect this year. As I travel the country, I tell people what I know: it’s easy to advocate for emergency physicians. We treat all people 24/7/365, regardless of race, religion, sexual orientation, gender identity, nationality, socioeconomic class, or the ability to pay. We are passionate about our specialty and our patients.
Congratulations to Jay Kaplan and his accomplishments this year. Jay, we’ve been friends for a long time, and it’s been a pleasure and a privilege working with you on the issues challenging our specialty. And Mike Gerardi. Thank you for your years of Board service, and your passion for emergency medicine. We will miss your voice and optimism at Board meetings, but look forward to your continued contributions.
Mike, Jay, and I worked together to redesign the presidential roles, because lasting changes take more than one year to implement. We divided the work amongst the three of us, effectively expanding a one-year term into two or three. We worked together to help each other help you. An effective collaboration. We will continue this model with the new President elect.
I want to recognize my family. A strong support network is key to accomplishing anything. I am blessed with a strong support network.
In the back of the room, my father-in-law and mother-in-law: Lenny and Sherry Parker. My other mother-in law and my sister-in-law: Jennie and Susie Parker. Thank you for making me a part of your family over 20 years ago.
Next my siblings: Mike and his wife Robin, Lori and Beth Bollinger; I am the youngest sibling by 8 years, and these three are my brother and sisters, my parents, my mentors and my friends. Thank you.
My Father Jerry Bollinger and my step-mom Lynne, and my Mom Sharon Bollinger, please stand. I blame Dad for my love of coding, and my Mom for my professorial style. I credit you both for my intelligence, my tenacity, my passion, and my core belief that with hard work we can accomplish anything. Thank you.
Finally, I’d like my Parker men to stand: Matty, Joshua, and Jacob Parker. Jacob is the first Board baby. I had him during my second year on the ACEP board. Joshua and Jacob you are my light, my soul, my everything; I love you. Matty, we met teaching music 24 years ago. You’ve been here since the beginning, and when I came home from conferences would ask “What did we sign up for now?” Well, this time its something big! You are my rock. I love you.
Our ACEP family, is our support network. ACEP is our home. The home of 37,000 emergency medicine advocates who selflessly save lives every day. We are emergency medicine. In this age of constant change and challenges, we need strength through unity. We need our researchers to question and analyze, our business docs to manage and anticipate trends, and our academicians to grow and nurture the next generation. And we need all of us to compassionately take care of the patients. I see us working diligently towards those ends, and a potential future of great promise for our beloved specialty.
As President my goal is to secure our home financially and fortify it with our best asset; our secret weapon: YOU.
Together, we will be stronger, resilient, and soar to new heights. We must focus on why we became emergency physicians: that tricky diagnosis, resuscitate that sick patient, to comfort a family when they need it most. To make a difference.
We have a good and extensive strategic plan. There are three priorities that I plan to focus on this year: the balance billing/Fair Coverage fight, the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), and ACEP’s diversity and inclusion initiative.
Last Wednesday, I was working in Waukegan, Illinois. This suburb of Chicago has a mixture of families that immigrated there in the 1800s, migrated out of the city, or immigrated from other countries, looking for the American Dream.
I took care of a Hispanic woman, around 40; sick for a week with a cough. Clearly sick. Short of breath. Working to breathe. No medical problems. Not a smoker. She worked as a medical assistant at a clinic, and the PA had written for a course of Augmentin midweek. But she got sicker. Much sicker. And with her anxious husband by her side, I threw all my tricks at her, hoping not to intubate her.
Why didn’t she seek care earlier? Her high deductible plan.
The possible out of pocket cost. The average American’s deductible has skyrocketed to over $1,300. For those on the Exchange Silver plan it’s $6,000. The average American has only $700 in the bank for unexpected emergencies ñ you do the math. She is not alone; and emergency physicians are eyewitnesses to insurance industry bad behavior every day. As insurance companies raise deductibles, narrow networks, and negligently abuse our EMTALA obligation, they increasingly shift costs to our patients. Insurance companies are destabilizing the Nation’s safety net, while portraying physicians as predatory billers. Yet THEIR profits are at an all time high, and they’re still asking for big annual premium increases. This is wrong and it must end!
Doctors need fair payment. Patients need fair coverage. Insurance companies treat everyone unfairly. This year the insurance industry spearheaded a state by state campaign introducing legislation that bans balance billing, forcing doctors to take low rates, taking away our ability to negotiate fair payment. Insurance companies tell legislators that doctors send patients “surprise bills”. This is a lie. The bills are actually the patient’s high deductible, forced on them by the predatory insurance companies. Our patients deserve Fair Coverage, not Surprise Coverage Gaps.
This brings me to my first priority: the balance billing/Fair Coverage fight. In fifteen plus states we saw these active efforts to ban balance billing. We anticipate this number to increase after the November elections. We must be ready.
Jay mentioned many of this year’s tactics yesterday - ACEP’s Fair Coverage PR campaign, our state battles fought by our outstanding state chapters and leaders, our joint task force with ACEP and our friends at EDPMA, as well as ACEP’s federal lawsuit against the CMS regulator CCIIO.
We have new friends in this fight. Starting last January we began to work with the American Society for Anesthesiologists, exchanging information on diverse business models, and found common ground. We shared our key documents and our Fair Coverage PR campaign, and they were impressed. We rocked. I am proud to announce that our two national societies have agreed on a core set of principles and strategies, supported by our joint ACEP-EDPMA task force document. This national collaboration is already paying dividends at the state level. It is a working document, but we have a strong foundation, and we will grow stronger as we add other specialties to the fight. All of organized medicine groups must stand united as we fight the Goliath insurance industry at the state level. It will take resources, experts, PR campaigns, and strong local leadership. To the states, I’m here to tell you: We are ready for this fight, we are here for you, and we will prevail.
Amidst this battle, we are creating a new system which shifts us from fee for service to payment for quality and outcomes. This brings me to my second priority: implementing the Medicare Access and CHIP Reauthorization Act: MACRA.
Congress overwhelmingly passed MACRA, also known as the SGR repeal, into law in April 2015. MACRA does two things: it stabilizes the physician Medicare base rate and establishes two options for a bonus program: MIPS (Merit Based Incentive Payment System) and APMs (alternative payment models).
Think of the first as PQRS on steroids, and think of the second as programs such as Accountable Care Organizations.
As a hospital-based specialty, the vast majority of us will participate in these Medicare programs. The amount of money tied to our salary for the bonus program is substantial. For MACRA’s first bonus option, MIPS, it will be a +9% or -9% swing in our pay, or plus/minus 15,000 dollars per full time partner per year. For MACRA’s 2nd option, APMs, it’s a 5% bonus, or around 8,000 dollars per full time partner per year. I know what you’re thinking, fantastic, more acronyms. Because that’s what I thought. But I want you to think differently. We need to take this opportunity to redesign the practice of emergency medicine.
Consider Andy Slavitt, interim head of CMS, when he said that he wants physicians to create their own quality measures; simpler, more meaningful measures for us as bedside clinicians. And he stressed the importance of specialty society registries as a solution.
This year, ACEP invested heavily in our specialty registry, the Clinical Emergency Data Registry, or CEDR. It is greatly expanded and fortified with new staff and resources. CEDR is critical for our future. First, it allows us greater flexibility in creating measures; relevant emergency medicine measures, for less cost. ACEP is good at developing quality measures; we’ve done it for years.
Second, these quality measures count for both bonus options in MACRA: 50% of your MIPS score and the quality requirements for APMs.
Third, you can use registries for all payers, not just Medicare. This simplifies your reporting process to the other payer programs already developed by insurers such as Blue Cross.
Fourth, ACEP wants to make CEDR a registry that pulls your data from your electronic record, simply and seamlessly. Fifth, the American Board of Emergency Medicine will count your CEDR participation to meet part four of your Maintenance of Certification. Sixth, and finally, we will have blinded data to use for research and to show the continuing value of emergency medicine.
As physicians, we will gain unprecedented control over our quality programs, and it’s about time. (applause) How do these MACRA programs help practice redesign? Look at ACEP’s Alternative Payment Model task force; a group of volunteer members from health policy research, practice creation, and operational implementation. The APM Task Force designed three APM options for ACEP to submit to CMS: admission reduction, case rate payments for discharged patients, and population health management.
This provides a multitude of possibilities to improve our daily practices. ACEP members are already piloting some of these models. For example, in Maryland, their hospitals participated in a state-wide bundled payment initiative. Their EDs saw new resources including more case management, care coordination, and outpatient options. Other ACEP members are experimenting with care coordination using telemedicine and community paramedics.
Imagine working a shift, yet having physician-led teams, case management, paramedics, and telemedicine to control the acute care conditions of a patient population near your hospital. The opportunities are enormous and accessible to any group, regardless of business model. ACEP is striving for practice design that improve the lives of both the patient and the physician.
My third priority is diversity and inclusion. Last year, I spoke to the Council about the importance of diversity and inclusion to our specialty and to ACEP. I spoke as a woman physician, but mindful of others affected. It struck a nerve with our Council and membership. Councilors debated the topic in their caucuses, members stopped me at ACEP15 and thanked me for taking on the topic. I learned about initiatives sponsored by our friends at the Association of American Medical Colleges, the National Medical Association and the Society of Academic Emergency Medicine, and of other networks spearheaded by emergency physicians. Throughout the year the supportive comments continued, as I traveled the country and spoke to chapters, residency programs and other organizations.
Last December, your Board discussed this at their retreat. We agreed that this would be a multiple year project. The Board made it one of our 13 objectives within ACEP’s strategic plan to “Promote and facilitate diversity and inclusion, and cultural sensitivity within ACEP.” We started by hosting a summit last April and invited over 20 ACEP members to participate, using a diversity expert as a facilitator. We focused on 5 groups of members with key staff: generations, gender, race, religion, and LGBTQ. We spent a day and a half in Dallas sharing stories, talking about emergency medicine, and ACEP. Out of the summit came many ideas and concepts, but two things were clear: ACEP needs a burning platform as to why it should embark on this journey, and we need an organizational tactical task force. With the support of staff, summit members, and Dr. Steven Stack, I authored and submitted an editorial about that compelling case, that burning platform, to Annals of Emergency Medicine.
Here’s why diversity and inclusion is crucial to the future success of our specialty and for ACEP. The U.S. population is diversifying quickly. Just over half of America’s population are women, and 38% are minorities. By 2044, the minority will mostly likely be the majority, and in some urban areas this is already true. In my hometown of Chicago, 45% of the population is Caucasian, 33% African American, 17% Hispanic, and the remaining 5% other minority groups or people of 2 or more races. Second, our medical school workforce is diversifying. In 1970, women were 7% of U.S. medical school graduates, but for about the last 15 years, the average has been just under 50%. Minorities are about 38% of U.S. medical school graduates. We are low in underrepresented minorities, especially African-American men. Notably, the American Association of Medical Colleges has a focus on diversifying the student population, and now requires their medical schools to recruit students who reflect their surrounding communities.
Third, we are not as diverse as we could be in the field of emergency medicine and ACEP membership. We definitely do not reflect the diversity of our patient population. Women emergency medicine residents remain flat at about 38%, and the percentage of female attendings and ACEP active members sits around 25%. We have seen an uptick of minority emergency medicine residents in the last 20 years, currently at 34%, although we still have a need to attract underrepresented minorities. Within ACEP, our database needs to be redesigned to track our minority physicians. In the meantime, our best estimates are that about 1% of our members are African-American and 1.5% are Hispanic.
Fourth, looking at ACEP leadership, women leaders quickly drop off the ACEP leadership track. Women representation starts at 27% of our councilors and drops to 12.5% of our ACEP Board of Directors. ACEP’s national leadership is significantly underrepresented by minority physicians.
The people in this room, the power and will of the Council, can turn the tide. Our chapters are successfully attracting and training diverse physician leaders. We want them to be up here with us. We need to change our traditional thinking about what diversity is. It’s no longer just about a specific state, stage of career, or a type of group practice. It’s about people. Unique people with stories, built from ethnicity, gender identity, our generation, our families, and our personal experiences. We are brothers and sisters bonded in the value of helping others in the darkest hour of need: anytime, anywhere, anyplace, to anyone. Now diversity becomes the wealth of knowledge, skills, ideas, and passion we need as an organization that truly represents ALL OF EMERGENCY MEDICINE.
As the physician pipeline continues to diversify, ACEP needs to be ready to break down our traditional barriers and open new opportunities. Create new networks for collaboration and support, and to share new concepts on the art of practicing medicine in a diverse society. And as ACEP leaders, we must actively advocate for these physicians, and help them battle challenges they cannot face alone, such as unconscious bias, pay inequity, and unfair treatment.
ACEP’s future success is directly tied to this generational shift in diversity. They ARE our organization and we take care of our own. ACEP is their home. As ACEP leaders, let’s welcome them home.
This is the charge of the diversity and inclusion task force, under the wonderful and strong leadership of the Chair, Aisha Liferidge with Steve Anderson as Board Liaison. Both of you please stand, and those members of the Diversity and Inclusion
Summit and Task Force please stand also. Thank you for your leadership and dedication to all of us and our specialty. Now I would like to ask Dean Wilkerson and Jay Kaplan to stand, along with our Board of Directors and Council Officers. Without the support of the majority, initiatives like this cannot succeed. Thank you all for opening our hearts, our minds and opening ACEP.
In the end, it all ties together. We must fight the insurance industry for fair payment and for fair coverage for our patients. We must create new practices using the MACRA programs of MIPS and APMs, bringing all of our experts and tools together. By coming together to support our diverse physicians and our diverse patients we will deliver the best possible care while taking care of each other. Together, by building on our individual strengths, we are stronger, more resilient, bringing back the joy of the practice of medicine.
I want to thank you for the honor of representing you as President. You are my colleagues, my friends, and you are my family. Thank you.