KK: I think those are huge, and I appreciate the segue into the specific challenges for emergency medicine. Let’s reverse the order here on the challenges specific to EM. Caral, what do you think? Any particular challenges you see that are unique to emergency medicine that haven’t been mentioned already or that are more global to health care in general but something specific to emergency medicine?

CE: I think we’re still the front door to much of the health care that is provided, but what happens on the other side of that door has been significantly redefined and will continue to be redefined. We have Walgreens and Walmart now providing urgent care, and patients don’t quite know where they fit and where they’re supposed to go. I think that’s going to be a huge challenge for emergency departments. The hospitals are pushing the emergency physicians to get into some involvement with urgent care, some involvement with hospital medicine, some involvement with Walgreens and Walmart type urgent care to assure quality in their areas, to try to compete with them, and our physicians are doing a lot more than seeing patients.

GH: I think simply getting the message out about the unique payer mix and payment stream for emergency medicine is a major and vital challenge. I’ve developed a suite of tools or talking points for advocates within our organization and even utilized it to some degree within our trade association. I liken the emergency department group to swimmers in a very turbulent ocean, and that’s because fully 50 percent or more, often 60 to 70 percent, of the patients who arrive are either low pay, that is Medicaid, or no pay, that is uninsured. The average would be 20 percent uninsured and 30 percent Medicaid. Now, what other business has 50 to 60 percent of its customers in a status of no pay or low pay and whose revenues fund about one-third of the cost to deploy the service? None.

So what are the lifelines for this swimmer who’s in very turbulent waters indeed? Well, there are two lifelines: the one is fair commercial payments—that is, from the Blues and from the other national payers, such as Aetna, Cigna, United—and the second would be a hospital subsidy. A lifeline is necessary whenever there is inadequate and unfair payment from the commercials to offset the losses from the uninsured and Medicaid, and what you see now with the “Greatest of Three” taking shape is a massive shift back to the very patient who is unable or unwilling to pay. The question is: will the hospitals now be able to step up and increase their subsidies—or, in some cases, start subsidies for the first time—in order to strengthen the one remaining lifeline keeping the emergency group intact? Of course, I don’t know for sure, but I am worried about the fiscal health of many of our hospital partners in an age in which disproportionate share support has been scaled back massively and value-based measures will result in steep penalties to hospitals.