EG: What you’ve raised is a huge issue, I believe, because when you talk to docs about what the expectation is of those specialists, the specialists will literally not come in and treat the patient until all of what you’ve described has been done in advance. It’s the expectation of your specialist, who is essentially demanding that you should do all this additional service. That messaging about who is driving the utilization of advanced imaging, for example, is not being made in my opinion, but it is going to be critical when it comes to bundled payments, ACO, different payment arrangements versus fee-for-service. Now, all of a sudden, maybe my client is in a gain-sharing deal and costs per patient are a factor, so she’s viewed as high cost but at baseline quality. Then her gain-sharing group’s going to look at me and say, “Hey, what’s your problem? You seem to be working up these patients very extensively,” but that’s what the specialists are expecting. Changing the specialists’ expectations for those comprehensive workups could be a major practice challenge with these new payment models.

KK: Those are great comments. I’ll throw in, for the readers and emergency physicians out there who may not be aware of how the value-based modifier for the physician fee schedule is rolling out, that 50 percent of value-based modifier calculation is about cost and utilization. We just don’t have a very good idea yet how they’re going to calculate cost and utilization. It seems clear to me that if we’re spending dollars that really should be spent by other providers, we’re accepting financial responsibility for things we don’t need, and that’s a problem.

GH: I think fundamentally the discussion about cost is a very important one—that is, keeping cost in the ongoing discussions about value. Cost accounting is an old discipline, but it’s one that’s missing, if not lost, in emergency medicine. I believe it needs to be front and center. I’m not talking charges but actual cost so that we can argue the value of emergency medicine. I think that if you were to match an hour’s worth of fully loaded cost to an hour’s worth of net revenue, the average legislator and regulator would be very surprised to see how close the margins are in the large majority of EDs.

KK: That’s a great perspective. I hadn’t thought about it that way. I really like the way you think on that, Greg. Caral, any additional thoughts on that?