KK: Ed, do you want to comment about 2014?

EG: We frequently hear from Medicaid agencies that the way they’re going to reform Medicaid, or a principle way they’re going to reform Medicaid, is to keep people out of the emergency department, and we’ve seen those attempts despite the EMTALA mandate. We’ve seen that in Washington state initially with their very restrictive diagnosis and ED visit limitations. We’ve seen expanded cost sharing (eg, coinsurance) for non-emergency use of the ED in what I call the “Arkansas Model” of Medicaid expansion. This premium support model has been picked up by Pennsylvania, Iowa and several other states seeking to use federal matching funds to purchase Medicaid health plan policies for the working poor. In North Carolina, Medicaid is looking at Accountable Care Organizations (ACOs) to drive significant percentages of patients out of the ED. Yet the Oregon Medicaid expansion study showed that when Medicaid expanded in Portland, ED utilization went up approximately 40 percent. It highlights the challenges we have of the moral and legal imperative of the EMTALA mandate and the issues surrounding the chronic conditions, which you know much better than all of us, in terms of that Medicaid patient base and how we deal with it. How do we arm the state chapters to be able to go and make the case that reforming Medicaid on the backs of emergency physicians is not the answer? Maybe 20 years ago, we heard, “Stand behind EMTALA and prudent layperson, and don’t engage in the conversation.” I don’t hear that much anymore—emergency physicians want to be at the table. As Dr. Lynn Massingale of TeamHealth has said for years, “We’re either at the table or on the table,” and that is very hopeful for the future that the level of engagement of ED physicians has really changed for the better.

KK: Something you mentioned the readers might want to hear more about: you noted cost-sharing models that are out there. Is there anything you would like to expand upon beyond just high-deductible plans shifting burden to the patient?

EG: You know the ACO, the shared savings models, and the bundled payment experiments that were done in what was called the ACE demonstration, which is now the Bundled Payments for Care Improvement Initiative on the Medicare side. I think both of those types of programs appear from a 40,000-foot perspective as an attempt to move away from fee-for-service to something else. The question is: how do you move chronic care and patients with multiple comorbidities into a bundled payment? Maybe a bundled payment works great on hips and knees or coronary artery bypass grafting, but is it really going to affect how Dr. Klauer is going to work up the nursing home patient who is weak and dizzy, has several chronic conditions like congestive heart failure, and does not know why he doesn’t feel good? How much is his ordering or diagnostic treatment protocol going to impact the total bundle payment at the end of the day? I think the good news for us is nobody’s totally figured out emergency medicine yet from an ACO or bundled payment perspective—we’re in the very early innings. We’re the X factor. When you listen to officials of leading hospitals who have experimented with bundled payment and ACOs talk about bundled payment arrangements or ACOs, they scratch their heads and say, “Well, but we had to carve out emergency medicine.”