Let's understand something about the American healthcare system: The problem is not the emergency department nor emergency physicians

In our system of healthcare and the concomitant industry reporting on the incredibly fast changes occurring within this system, there has been a constant and persistent focus on our emergency departments.

This focus gives one the impression these emergency departments and emergency physicians are somehow the sore spot and the cause of many of our problems. Perspective and a bit of a reality check are needed to clarify many current misperceptions existent today.

1. The Emergency Medical Treatment and Labor Act (EMTALA) formally established by Congress in 1986 is a hallmark of emergency medicine, establishing the unfunded mandate requiring everyone presenting to an emergency department receive a medical screening examination, regardless of their ability to pay for the services provided to them. This federal law set the standard for emergency medicine care being available to all patients 24/7/365. Emergency medicine today provides the highest incidence of EMTALA mandated care among all medical specialties.1

2. Emergency physicians' commitment to their patients is no more clearly evident than in the preservation and value placed on the prudent layperson definition of an emergency, established in Sally Richardson's letter2 in 1998 and in the Affordable Care Act. This is a hallmark of emergency medicine's commitment to the preservation of patients access to care. The specialty has always been committed to this principle. Today it is especially important to review this definition here, precisely because this core principle is in jeopardy. It is also critical to understand the establishment of this principle effectively halted the unwarranted denial of emergency physician medical claims many years ago. A return to those days is unthinkable and would be counter-productive today.

"The Balance Budget Act defines emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body functions or serious dysfunction of any bodily organ or part. While this standard encompasses clinical emergencies, it also clearly requires managed care organizations to base coverage decisions for emergency services on the severity of the symptoms at the time of presentation and to cover examinations where the presenting symptoms are of sufficient severity to constitute an emergency medical condition in the judgment of a prudent layperson."

Note the critically important issue of the significance of the patient's "presenting symptoms" not an adjudication made after the visit to the emergency department.

3. Emergency physician reimbursement averages between $150-$200/visit,3 a number far below what is many times confused and portrayed in industry articles.

4. A recent article asked the question- "Who pays when someone without insurance shows up in the ER?"4 For the true uninsured patients, from the emergency physician perspective these particular patients simply do not pay. If a patient is truly uninsured the historical reimbursement rate on these physician claims has marginally been cents on the dollar.

5. Expanding the scope of emergency care to include EMS to the patient's final disposition, including laboratory and radiology, emergency medicine accounts for just 2% of our nation's health care expenditures.5

6. In a given shift emergency physicians make on average 10,000 decisions along with approximately 4,000 clicks on their patients' electronic health records (EHRs).6 These EHR metrics exist despite many physicians decrying " how EHRs take time away from patient contact..."7

7. The current annual statistics for emergency department visits in the United States shows the following: 150,000,000 patients seen. This equates to 411,000 patients per day; 5 patients per second. The number of 411,000 patients per day is effectively the size of the population of Oakland, California.8 Worth repeating here...that is 411,000 patients per day seen in our emergency departments

8. Average new patient physician appointment wait times have increased significantly. The average wait time for a physician appointment for 15 large metro markets surveyed is 24.1 days, up 30% from 2014.9

9. Alaska Regional Hospital recently announced the closing of its primary care clinic, specifically opened to address "non-emergent" patients being seen in its emergency department. A principal reason for the closure was the increasing acuity of its clinic patients.10 Emergency physicians have been experiencing increasingly higher acuity patients being sent from primary care physician offices for years.

Similarly the explosive growth of retail clinics has done nothing to reduce the incidence of lower acuity patients seen in our emergency departments.11

10. Regarding reimbursement for emergency medicine physicians it is becoming more common for payers to propose either Medicare rates or a modicum above these rates. It is critically important to know and understand if these types of rates become commonplace, it is no exaggeration many of our emergency departments will literally close, i.e. shut down as it will be fiscally impossible to keep them open. No one in healthcare has ever considered Medicare reimbursement rates as equitable, fair, nor justified.

Bottom Line:

Our emergency physicians and their departments have been described as the safety net of our healthcare system. They are available 24/7/365 to everyone. They represent the healing edge of our system today, in many ways far more than a safety net. Emergency physicians are positioned within our healthcare system as both master diagnosticians and masters in knowing all of the strategic nuances of care alternatives, follow up sub-specialists and downstream care options within their hospital systems for their patients. Additionally emergency physicians are true care innovators evidenced by such innovations as telehealth programs developed by emergency physicians at many medical centers across the country today, with Thomas Jefferson in Philadelphia-Jeff-Connect-On-Demand Video Visits12 and New York-Presbyterian Hospital in New York being two prime examples. Sharma, et. al.13 present dramatic results of their Express Care Program at New York-Presbyterian in the table below. This is just one example of a solution offered by today's emergency physicians.

ZotecGraph

There are many pending and open-ended questions today as we move toward a value based system of care. A critically important, core, stable and very vibrant force supporting and sustaining many of the areas of our healthcare system today are indeed our emergency physicians. Stated directly and succinctly...emergency physicians simply get things done; they provide solutions. As we migrate down this path it would be both wise and prudent to heed the following words:
"No one manages uncertainty better than emergency physicians."14

1 Physician Marketplace Report: The Impact of EMTALA on Physician Practices." American Medical Association. February 7, 2003.
2 Richardson, Sally. Letter to State Medicaid Directors, February 20,1998.
3 Holstein, Augustine, Kaplan, Parker, Rosenau. American healthcare's one constant in a sea of change: Emergency Medicine
https://www.beckershospitalreview.com/facilities-management/american-healthcare-s-one-constant-in-a-sea-of-change-emergency-medicine.html 12/9/2016
4 Groppe, Maureen. Who pays when someone without insurance shows up in the ER? USA TODAY Published 3:13 p.m. ET July 3, 2017 | Updated 1:44 a.m. ET July 4, 2017
https://www.usatoday.com/story/news/politics/2017/07/03/who-pays-when-someone-without-insurance-shows-up-er/445756001/
5 "U.S. Health Care Expenditures and Emergency Care: Can Emergency Visits Be Prevented? Will Significant Costs Be saved?" American College of Emergency Physicians.https://www.acep.org/uploadedFiles/ACEP/newsroom/NewsMediaResources/StatisticsData/Just%202%20booklet.pdf
6 Lex, Joseph, MD. "49+ Years in the Pit: Lessons Learned." Maryland ACEP Conference. June 20, 2016.
7 Orenstein, David. " Hospital, office physicians have differing laments about electronic records." https://news.brown.edu/articles/2017/07/electronic-health-records." July 5, 2017
8 Augustine, James, MD, FACEP; Sama, Andrew, MD, FACEP. "The Value of Emergency Medicine-Colin Rorrie Jr. Presentation. American College of Emergency Physicians, October 2016.
9 "2017 Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance Rates" Merritt Hawkins. 2017
10 Hanlon, Tegan. "Alaska Regional Hospital temporarily closes new Mountain View clinic" June 30, 2017
https://www.adn.com/alaska-news/health/2017/06/29/alaska-regional-has-temporarily-closed-its-new-mountain-view-clinic/
11 Pines, Jesse, MD. Why Retail Clinics Do Not Substitute for Emergency Department Visits and What This Means for Value-Based Care. Annals of Emergency Medicine. October 2016.
12 On-Demand Video Visits
http://hospitals.jefferson.edu/jeffconnect/types-of-visits/on-demand-video-visits.html
13 Telemedicine and its transformation of emergency care: a case study of one of the largest US integrated healthcare delivery systems
https://intjem.springeropen.com/articles/10.1186/s12245-017-0146-7
14 Nedza, Susan, MD. ACEP Reimbursement Conference 2015.

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