Viewpoint: Why emergency physicians haven't lost under the ACA — yet

Emily Rappleye (Twitter) - Print  | 

Physicians have had a trying couple years. Implementation of the Affordable Care Act has brought on change, both good and bad. Physicians now have more patients in their waiting rooms while declining reimbursements and changing payment models drive significant redesign of healthcare delivery.

Emergency physicians, in particular, are acutely aware of these changes. As the uninsured move onto insurance rolls, more patients hit emergency departments around the country. Yet the healthcare space has turned on ED admissions as a sign of ineffective prevention and overpriced care, making the ED a taboo "entrance to the hospital."

When Becker's Hospital Review published an essay earlier this month on the winners and losers under the ACA, physicians came out on bottom as a mere "cog in the machine" and not in the driver's seat in healthcare. Naturally, this stirred the pot among our physician readers, especially those in emergency medicine.

Here are their perspectives.

Editor's note: Responses have been edited lightly for length and style.

Dominic Bagnoli, MD, CEO of U.S. Acute Care Solutions in Canton, Ohio
I absolutely disagree physicians are losers under the ACA. I believe physicians are in the perfect position to help drive the change we all know we need. The idea physicians will become "cogs in the machine" only happens if they allow it to happen. Plenty of physician-led organizations are taking this opportunity to bring together other physicians and lower costs. In the end, this is about bringing better care to patients.

Physicians become physicians because they want to take care of patients. Whatever we do that improves how we deliver care makes physicians and patients winners in this. If providing more people with Medicaid coverage allows them to access the system earlier in their disease path, then that's good for patients and physicians. The fact physicians have to work in bigger practices or be responsible for outcomes or patient experience scores isn't a bad thing — It's good for medicine.

Take Walmart for example. Do consumers view Walmart as more convenient, easier to access and less expensive? Yes. Do small hardware stores? Probably not. But the question wasn't, "How do we make this better for people with small businesses?" It was, "How do we provide a better experience for consumers?" Patients are consumers of healthcare and the system needs to meet their needs.

Physicians are winners because physicians win when patients win. In emergency medicine specifically, we work 24/7/365. Emergency medicine has grown 2 to 3 percent a year for 30 years no matter what we've done with insurance. Financial changes don't discourage people from coming to the ED. They still come. If it's 10:00 p.m. on a holiday weekend, that's where they're going, because there is no one else available to see them. With the ACA expanding coverage, it allows self-pay people who did not have coverage to get the care they need, and that is good for the entire healthcare system.

John Holstein, director of development, Zotec Partners in Carmel, Ind.
What I've really responded to…is physicians and the American Medical Association being losers in this environment we all live in. It's not that I disagree, but I think it's a huge mistake by payers and the whole industry.

The reality is everyday in every emergency department, the entire spectrum of human accident, illness and infirmity are presented to emergency physicians. Despite efforts to drive people away from the ED, emergency physicians are the best diagnosticians to decide where patients belong.

I call them master diagnosticians and master play callers. I use that sports analogy because in the so-called healthcare continuum, emergency physicians are centrally positioned to care for and direct patients. They are also the physicians who are pivotally positioned to address the hospital admission and readmission issue and one of the ways they can do that is through observation in the ED. Their diagnostic skills and thorough knowledge of the infrastructure of their respective health systems and its physician networks make them an invaluable resource in addressing this issue.

It is seemingly becoming a negative thing to say [the ED is the hospital's front door]. EDs account for upwards of 70-plus percent of hospital admissions. If you flip that to treat-and-release patients, emergency physicians provide considerable downstream revenue to subspecialists through their referrals. It's almost a bad thing to say today — to talk about hospital admissions, yet hospitals, to a significant extent, survive on revenue from admissions, in addition to surgical procedures.

Emergency physicians are not the bad guys in the environment we live in. People use the ED as a safety net. I prefer to use the expression the ED is the "only net". Until the primary care physician network is fortified with however many thousands more providers, the ED is the primary place to go, not only for the ill and injured, but it's also a major resource for the mental health population.

It's a serious mistake to eliminate physicians from healthcare's driver's seat. They need to be at the table. As a person who has worked specifically in the emergency medicine space for a considerable amount of time, I consider this a call to action to emergency physicians. We need to change this evolving dynamic. Emergency physicians need to be in the front seat with a critically important role both providing and also directing their patients' care.

Jay Kaplan, MD, president, American College of Emergency Physicians
The news shows UnitedHealth may pull out of the ACA market because they have lost so much money. They don't mention their revenues from other lines of business are so huge they ought to far more than counter balance providing care on the exchanges.

In emergency medicine we have no capability to do that. We are the one specialty that takes care of all patients; we are required to by federal law. Emergency physicians comprise 4 percent of all physicians in the U.S., but we take care of 28 percent of all acute care visits and account for 50 percent of care given to Medicaid and children's health insurance recipients. We take care of 67% of outpatient care given to the uninsured.

We can't say to our patients, "We are not going to cover you anymore," which is what UnitedHealth is going to say to patients. We are the safety net. Candidly, I think insurance companies should be forced to do the same thing.

For emergency physicians, many of our members work in safety net hospitals, inner city or urban hospitals or in poor rural areas as well — where they have patients coming in who have no insurance, who basically pay nothing for the care they receive. Now, at least in some settings, physicians are getting some payment for the care they give to these patients. In that sense, some physicians have done better, but in regard to recent rulings interpreting what the ACA law meant, I think physicians have been losers. And so have many patients. Patients have been offered insurance with low affordable premiums, but their deductibles are so astronomical that if they do have an acute illness or trauma, they cannot afford to pay what they then owe. Insurance companies have deftly shifted payment for care rendered from their responsibility to the patient's, and reimbursement to physicians has been cut.

I'm not going to play victim here because I like to think I'm a people doctor. I speak for emergency physicians in general — a lot of us are people doctors. We wouldn't have gone into emergency medicine if we didn't care about our patients. We take care of a lot of people no one else will see. I am going to continue to fight for patients and I am going to fight for our profession — medicine and emergency medicine in particular — because I think we are a crucial community service.

 

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