Leading ACEP is a team effort, with emergency physicians and staff working together to represent and advocate for the specialty. Last month, we interviewed ACEP President Michael J. Gerardi, MD, FAAP, FACEP, about the challenges and opportunities ahead for emergency medicine. This month, Jay A. Kaplan, MD, FACEP, who was named ACEP President-Elect in October 2014, shares his views on the key issues facing emergency medicine with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP.
Explore This IssueACEP Now: Vol 34 – No 04 – April 2015
Dr. Kevin Klauer: So, Jay, I want to make sure that people understand what your vision is for your presidential year. It starts way in advance and probably not even with your President-Elect year, but the ground is laid for many programs from one president to the next.
Dr. Jay Kaplan: The President, the President-Elect, and the Past President, along with our Executive Director Dean Wilkerson, have weekly leadership calls where we go over issues affecting the college on a month-to-month, week-to-week, and sometimes a day-to-day basis. We talk about leadership, and we talk about the issues that are important to emergency physicians. The Past President, the President, and the President-Elect along with our executive leadership work very closely together in order to keep the ship on course.
KK: On those weekly calls, can you give us a sense of what important issues you’ve dealt with recently?
JK: Recently, we’ve talked about quality issues, the value-based modifier, and the pay-for-performance issues that are affecting emergency physicians. We met recently in Washington, D.C., and one of the issues that came up was medical liability reform, in particular, safe harbors. We discussed how we can approach Congress with regard to that. We reviewed our Qualified Clinical Data Registry and getting that up and running so that emergency physicians do not take a hit in terms of their reimbursement as pay for performance becomes more challenging. We talked about fair payment because reimbursement is also a major issue for emergency physicians and the whole issue of the banning of balance billing and the “greatest of three” rule, which relates to how physicians are compensated by insurance companies.
“I have concerns about how we’re going to be paid for the increased number of patients we expect to see. Value always relates to what you get for the dollars that are spent. If we want more dollars in our own pockets, which is what I want for my colleagues…we’re going to have to show our value.”
—Jay A. Kaplan, MD, FACEP
KK: This sounds like a good segue into what you feel are the biggest challenges for emergency medicine now and in the future.
JK: Showing our value. Emergency medicine has been scapegoated. We are known as the most expensive place to receive care when that is not the case. We have tried to tell our legislators that we’re only 2 percent of the health care dollar, but they haven’t bought it. As we move into the era of Accountable Care Organizations and bundled payments and less reimbursement per patient, we’re going to have to show our value in terms of consistent practice, following practice guidelines, and decreasing cost. We can’t do anything about patients coming to us, but we can create programs for our ED super-users to improve appropriate utilization. As our population ages, I have concerns about how we’re going to be paid for the increased number of patients we expect to see. Value always relates to what you get for the dollars that are spent. If we want more dollars in our own pockets, which is what I want for my colleagues, we’re going to have to look at whether to admit patients or not and our choices regarding expensive advanced imaging. We need to show that by being more consistent in our utilization of admission and of imaging, we can save the “system” money, and therefore we deserve to be paid fairly.
Burnout is another big issue for emergency physicians. I’ve been very involved with wellness for many years. There have been articles published that have said that emergency physicians are second in terms of the percentage of physicians who report burnout. I want emergency physicians to have long, successful, and fulfilling careers, and we have to be active in making sure that our members have the resources that they need to give the kind of care they want to give their patients and not feel exhausted, burned out, and fatigued. Reimbursement is another area. There is going to be a fight for every dollar, and again, we’ll have to show our value. Another issue is medical liability reform. Unfortunately, we’re in the midst of a number of do-nothing Congresses, so I’m not sure how successful we can be; however, we will continue to push for that. Congressman Charlie Dent (R-Pennsylvania) reintroduced the Health Care Safety Enhancement Act, which would classify emergency physicians (providing EMTALA-mandated care) as federal employees, receiving the same protection as public health service physicians. I am hopeful that we can push for EMTALA liability reform and even better safe harbors. Ensuring that we have an adequate workforce is critical. The number of graduate medical education slots that emergency medicine and other specialties have is currently based on a mid-1990s study. Clearly, we have more medical students who are graduating now. We have a huge need for emergency physicians, and we need to try to increase our residency positions so we can graduate the number of doctors that we need. The gold standard for delivering emergency care should be delivered by emergency medicine residency–trained, board-certified physicians, and we will not have enough of those in the foreseeable future.
KK: What do you think the likelihood is during your presidential year that we will either have a safe harbor act enacted or have EMTALA reform that’s meaningful?
JK: We have a greater opportunity for the EMTALA mandate than we do for safe harbors. I would put that at around 50 percent.
KK: Tell me how you feel you can justify the value of dues dollars to the members. If you had to convince one person to join, what would be your elevator speech?
JK: I would point out a number of advocacy successes that we have had in the last number of years. Physicians who are recently out in practice may not remember that we had to initially fight for the prudent layperson definition of an emergency, which passed at the state level, then at a federal level, and then we fought hard and had it included in the Affordable Care Act legislation. It is now a federal mandate that patients have a right to come to the emergency department based on their belief of whether they have an emergency or not rather than on a retrospective determination. The Relative Value Scale Update Committee determines our payment, and while a number of other specialties have seen a very significant drop in their reimbursement, we have not seen that in emergency medicine because ACEP has been representing members at the federal level for years. Also, ACEP offers some of the best educational opportunities for emergency physicians. If you’re a member, you receive that at a discount. ACEP’s Education Committee, along with the ACEP staff heading up education, have been very proactive and on the cutting edge. There are a number of other aids, such as Portfolio Tracker, which ACEP now provides for emergency physicians, as well as what’s coming soon, a Qualified Clinical Data Registry (QCDR). If you’re a member, you will get the QCDR at a very large discounted rate, and that will save emergency physicians several thousands of dollars per year and will be a no-brainer return on investment.
“ACEP’s Education Committee, along with the ACEP staff heading up education, have been very proactive and on the cutting edge. There are a number of other aids, such as Portfolio Tracker, which ACEP now provides for emergency physicians, as well as what’s coming soon, a Qualified Clinical Data Registry.”
—Jay A. Kaplan, MD, FACEP
KK: Jay, what do you say to the nonmember who says, “All of the great work that ACEP is doing I benefit from anyway, so why do I need to write a check? Why can’t I just ride on the coattails of those who have already paid their dues?”
JK: Well, that’s one way you can look at it. I would like to think that there are people who contribute and that they have a certain integrity, which goes along with, “If I’m going to receive benefits, then I deserve to contribute to the organization that is providing those benefits.”
KK: What would you say if someone approached you and said, “I think ACEP favors contract management groups and is in bed with Big Pharma”?
JK: I’d say that is what the perception was 15 to 20 years ago. While I’m a member of a large group, it is a democratic group, and every physician has a say. Every physician, after you’ve been in the group for five years, owns as much of our group as somebody who may have been in the group for 30 years. If you look at recent leaders of ACEP, they have included academic physicians. The leadership has not been representative of large contract groups. I think that ACEP as an organization needs to represent all different models of practice. I cannot say that there is one way better than another, and I do think that emergency physicians need to have a say in their practice and need to be fairly compensated. There are a number of ways that that can be done. I will say for myself, when I was in medical school, we were one of those medical school classes that chose not to take stethoscopes from a pharmaceutical company. It’s a fine balance, and ACEP has done extremely well with regard to that balance. I have been very careful, and the ACEP Board has been extraordinarily careful with regard to how ACEP, as an organization, has interacted with large insurance and big pharmaceutical companies.
KK: Am I hearing you say that you believe the membership criteria should be broadened a bit?
JK: Well, no, you didn’t hear me say that. I am a champion of the little guy and will always be. It is true that, as a professional organization, we need to stand for our patients, and we need to recognize that a large percentage of patients right now are currently seen in emergency departments that are not staffed by ACEP members. They’re not staffed by ACEP members because in order to be a member of ACEP right now, you need to be board certified in emergency medicine. The only way that that can happen is if you do an emergency medicine residency, and we still have a lot of physicians who are rendering care in emergency departments, particularly in smaller emergency departments, who are not trained in emergency medicine. The real question is, do we want to leave them outside of our organization or is there some way that we can find to bring them in?
EMRA, the Emergency Medicine Residents’ Association, is the future of our specialty, and anything that ACEP decides to do needs to be done in partnership with and in close collaboration with EMRA. If we could somehow capture those people who might not currently be members but would like to be members, and we can do so in a way that does not put them at the same level of the gold standard of an emergency physician, then we should see if we can do that.
Right now, we’re an organization of just about 33,000 emergency physicians, and I want people to think about what kind of power we could have in terms of our advocacy and in terms of our patients if we had 50,000 members. What could we do in Washington to fight for reimbursement, to fight for medical liability reform? The larger you are, the more presence you have. The larger your voice, the more represented you are and the more you get what you want for yourself and for your patients. We need to work with our young physicians and have them understand that doing so would not constitute a threat to them, that they’ll always be the gold standard, and that if we could be more inclusive, it could actually be a win-win-win-win. It could be a win for those physicians, it could be a win for ACEP, it could be a win for our young physicians, and it could be a win for our patients.