Jack Wood of Wood, Lucksinger, and Epstein in Houston was one of the nation’s recognized experts in Medicare rules and reimbursement and was retained to accompany me to the Medicare offices in Baltimore to look for improved reimbursement. We won.

During the winter ACEP Symposium meeting in Bermuda in the ’70s, the option for independent contractor status for emergency physicians was being contested. I asked the Board for $20,000 to march on Washington, and we prevailed. This was a money issue, and this recurrent theme continues in present time.

It became apparent that our efforts to protect the practice of emergency medicine and the interests of emergency physicians needed full-time lobbying, and the College opened its own office in Washington.

We realized that a good message couldn’t reach the ears, hearts, and minds of legislators without numbers and money. This was the birth of NEMPAC.

What was, and remains, largely unknown to most physicians is the incredible effect that the Relative Value Scale Update Committee (RUC) of the AMA has on directing money to emergency medicine. Mike Bishop, MD, FACEP, and others before him have represented EM at the RUC and have done an outstanding job.

As ACEP president, I was at the Reagan White House for the signing of EMTALA into law in 1986. In theory, EMTALA was to protect patient access to emergency care. The net effect to us has been more patients, and that means more opportunity.

We passed a law in California that precluded nonemergency physicians from testifying against emergency physicians in medical-malpractice cases. This was an effort to reduce risk and malpractice costs—again, a money issue.

The EM Landscape Today

One must ask who has benefited from all of these efforts. Arguably, society has as we have improved emergency care immensely, but more specifically, all physicians (and advanced practice providers) who work in emergency medicine have benefitted. Of note, in approximately 40 percent of visits to California EDs, patients are reportedly seen by physician assistants (PAs). They are clearly practicing EM and are not physicians, but PAs do a fine job and are a permanent piece of our workforce.

My experience suggests that, at least outside of major metropolitan areas, most emergency care is delivered by non–EM-trained physicians. Interestingly, they all have the benefits provided by ACEP but contribute nothing when it comes to “carrying the water” on regulatory and legislative matters. Freeloaders? I don’t think so. We’ve refused their help and their participation.