I see so many changes with so many of the payers. Many of them have now set up their own internal audit departments to audit our claims and track whether our charges go up the slightest little bit or if one physician is charging higher than another. Sometimes they don’t really care about the reasons; they just want to bust your chops about it, and we have to defend ourselves. I see that more and more groups are spending more and more money on nonclinical care just to stay ahead of the audits and stay ahead of the impact of electronic medical records (EMRs) and their documentation issues. So, what I see is money tightening up and nonclinical expenses very necessarily going through the roof.

I can see the ED of the future having more to do than provide ED care. …I can see our role changing, and if we’re indeed going to be responsible for that and accountable for these outcomes, we’re going to need a lot more influence…
–Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC

KK: Those are great follow-up comments, and I have to apologize: when you’re not going first, it leaves you a little less to say, but you’ve found some great things to add to the conversation. So, John, what do you think?

John G. Holstein: There are a couple of things I always like to include in the top health care challenges in general: one being the development of health information exchanges and the second being heath care going mobile or health care going retail. Shifting to the top emergency medicine issues, I really believe there are three of them, one of which is defining emergency medicine’s role and function in the care continuum. The second one is emergency medicine self-defining the value metrics by which it will be measured, and the third challenge is the specialty has to really assess and address some macro issues that I truly believe are directly impinging upon two core issues, namely EMTALA and the prudent layperson definition of an emergency. These issues are the infusion of the newly insured; the urgent care explosion; the high-deductible plans, as my three colleagues have mentioned; hospitals going into the insurance business; and what I would call the “retailization” of health care. When patients can self-direct getting their own lab tests today, the landscape has truly changed. I believe these landscape changes are going right at the heart of core issues of the specialty.