Each year, ACEP’s Council elects new leaders for the College at its meeting. The Council, which represents all 53 chapters, 39 sections of membership, the Association of Academic Chairs of Emergency Medicine, the Council of Emergency Medicine Residency Directors, the Emergency Medicine Residents’ Association, and the Society for Academic Emergency Medicine, will elect the College’s President-Elect and four members to the ACEP Board of Directors when it meets in September. This month, we’ll meet the President-Elect candidates.

Jon Mark Hirshon, MD, PhD, MPH, FACEP

Current Professional Positions: professor, department of emergency medicine and department of epidemiology and public health, University of Maryland School of Medicine, Baltimore; senior vice-chair of the University of Maryland, Baltimore Institutional Review Board

Internships and Residency: emergency medicine residency, Johns Hopkins Hospital, Johns Hopkins University, Baltimore; preventive medicine residency, Johns Hopkins Bloomberg School of Public Health

Medical Degree: MD, University of Southern California School of Medicine, Los Angeles (1990)

Response

The other night, during a busy shift, a mid-60s woman came into my ED via ambulance with hypotension and inferior changes concerning for a ST-elevation MI on the EMS-transmitted ECG. Upon arrival, we confirmed the ECG changes and activated the catheter lab, and shortly thereafter, the patient went upstairs for catheterization and stenting. The system worked—a life was saved! Unfortunately, our dysfunctional, fragmented U.S. healthcare system is under siege and threatened from many directions, both internally and externally. While the system worked today for my patient, will it work tomorrow for your patient or family member with a life-threatening emergency?

Assuring appropriate financial and societal support remains a critical external threat to EM. Longtime emergency physician Paul Seward recently penned an article on Stat News describing EDs as “the ‘chewing gum and duct tape’ holding together U.S. healthcare.” As the cost of healthcare in the U.S. has skyrocketed, EDs are viewed as the healthcare safety net—or as stated by a previous U.S. president: “I mean, people have access to healthcare in America,” he said. “After all, you just go to an ER.” Out-of-pocket medical expenses are mounting astronomically while insurance companies are making record profits. Many Americans are only one medical emergency away from poverty or homelessness. We, as frontline providers, see this on a daily basis. Our EDs may be our neighbors’ front door to the hospital, but it is our window to the problems seen in our communities.

ACEP must, and I will, continue to fight to assure high-quality emergency care for all Americans. This is a multipronged approach, including legal, educational, and lobbying activities on both federal and state levels. Last summer, while having lunch with my senator, Ben Cardin, the federal champion of the prudent layperson standard, he was shocked to learn that prudent layperson was under siege again. ACEP and the Medical Association of Georgia are suing Anthem BlueCross BlueShield of Georgia for their policy allowing for retrospective denial for some care delivered in EDs. Previously, we sued the U.S. Department of Health and Human Services to require transparency of data and fair insurance coverage for emergency patients who are “out of network” because of a medical emergency. Our lobbying and educational efforts include almost daily interactions with policymakers and regulators, including high-quality, effective presentations at the RVS Update Committee, to assure that we are paid for the work that we do. We must, and I will, fight to make sure that we receive fair compensation for the care we deliver through supporting legal action, developing coalitions and partnerships, and testifying in front of politicians and the public.

“ACEP must, and I will, continue to fight to assure high-quality emergency care for all Americans. This is a multipronged approach, including legal, educational, and lobbying activities on both federal and state levels.” —Jon Mark Hirshon, MD, PhD, FACEP

However, assuring fair compensation is only one external threat we face. The ever-increasing regulatory burden remains a significant problem, negatively impacting our productivity and our well-being. We face this concretely on a daily basis with the growing burden of documentation as enforced by our electronic medical records. For every five minutes I spend with a patient, I spend 15 to 20 minutes documenting. This negatively impacts my rapport with patients, coworkers, and trainees. Reducing administrative burdens is critical and was a central theme of my testimony earlier this year before the House Committee on Ways and Means’ Health Subcommittee on reducing administrative burdens for physicians in the Medicare program. Decreasing regulatory burdens and improving our work environment are critical aspects of improved care delivery and emergency physician well-being. This will be a critical objective of my time as ACEP President.

Internally, we are faced with the challenge of unifying the multiple voices in EM into a strong and effective chorus. We are a diverse group and bring many different perspectives together in order to care for our varied patients. Companies with greater diversity have been shown to be more successful from a business perspective. ACEP will be more successful through embracing diversity, and not just gender and race diversity but the many aspects of our practices—gender, race, ethnicity, large groups, small groups, academics, rural providers, young physicians, individuals near retirement, etc. Together, we can agree on specific topics and issues and work together collaboratively on these. This will strengthen our voice. On other topics, we can continue to disagree respectfully and professionally without personal attacks. Speaking with one voice will allow us to be heard above the discordant clamor found in Washington, D.C., and in many state capitols.

Emergency physicians are caring, thoughtful professionals. We work hard, and we play hard. We care about our patients and for our colleagues. ACEP and EM play a critical and ever-increasing role within the healthcare system. I will work together with our many partners to forcefully advocate for EM and to sustain and to grow the support for our important work. Working together, we can and will make a difference.

William Jaquis, MD, FACEP

Current Professional Positions: senior vice president, Alliance Operating Unit–Envision, East Florida Division; attending physician, Aventura Hospital, Aventura, Florida

Internships and Residency: emergency medicine residency, Case Western–Mt. Sinai Hospital, Cleveland

Medical Degree: MD, Medical College of Ohio, Toledo (1989)

Response

Externally, the biggest threat is our current form of funding and paying for healthcare. The “system” is far from a coordinated entity but more a collection of stakeholders with their own interests exceeding the needs of the system as a whole. Those who fund and pay for the care are often deeply separated from the consumers of care, and the complicated approach to payments leaves us all confused. Consumers should have more transparency about what the cost to them for their care will be, but we are unable to give it to them because we have no idea across our delivery system how we will be paid, if at all. We have insurers who have hidden lists for which they will retrospectively deny payment, and every day it seems there is a new story or “study” that highlights “excessive” ED costs. In this setting, it is incredibly difficult to provide timely care for patients, help them understand the costs of that care to them, and appropriately staff and reimburse our providers. EM is unique in this battle from our EMTALA mandate to see all patients regardless of ability (or intent) to pay. Addressing this issue will take all of us acting in many different venues. For our patients, we need to continue to advocate for access by requiring essential health services to be covered and paid according to prudent layperson laws. This also has and may continue to require legal action such as the current suit (July) against Anthem. We have some solutions that are improvements to the issue of fair coverage, and that message needs to continue through coalitions, the courts, social media, and public relations.

“We have insurers who have hidden lists for which they will retrospectively deny payment, and every day it seems there is a new story or ‘study’ that highlights ‘excessive’ ED costs. In this setting, it is incredibly difficult to provide timely care for patients, help them understand the costs of that care to them, and appropriately staff and reimburse our providers.” —William Jaquis, MD, FACEP

Internally, our biggest threat is our inability in many situations to find a shared vision as a physician community. As the phrase goes, we have met the enemy and he is us. I cannot determine how many meetings I have attended where the physicians spent a great deal of time arguing with each other while the non-physician team stands by, leading to no directed action. Through many means in society as a whole, we are becoming more polarized rather than recognizing what is shared in the middle. This is true of EM at times as well. Do not misunderstand: I highly value the discourse of opposing views, as they often lead me and us to a better understanding of an issue. We must, however, make sure that, in doing so, we do so with respect, and we understand there must be a forward direction. We can do so by continuing the dialogue on our important issues with civility, keeping our criticisms more private, and moving forward publicly with a shared vision and praise.

We are well positioned to address the threats and the opportunities to EM. The leadership of the College—both physician and ACEP staff—is strong and well-informed. The working relationships with Committees and Sections and Task Forces are constructive, utilizing the immense talent we have within the College. The Council leadership and the members of the Council have consistently shown their dedication to defining the important work we do. Our leaders have influence not only in the College but within their groups, within other specialty societies, and with leaders in the health systems. At the turn of our 50th year, we should recognize the tremendous growth and influence we have had not only in EM but in the entire healthcare system at a national level. Honoring that growth, we also remain vigilant, building our practice and our leaders for the next 50 years.