ACEP Now Medical Editor in Chief Cedric Dark, MD, MPH, FACEP, conducted interviews with each emergency physician running for Congress in 2022. The abridged versions of the interviews were published in the September 2022 print issue.

What do you think your greatest accomplishment has been that has benefited emergency physicians?
Dr. Green: I basically gave the economics of emergency medicine/the economics of health care lecture to the entire Republican caucus. Because they were really going in the wrong direction. On balance billing and collective bargaining and some of the issues that hit us as emergency physicians, we really saved the No Surprises Act because they were going to put the power all in the insurance companies’ hands. By explaining how cost shifting works and the basic economics of contract medicine in a hospital, I was able to move the Republicans away from their stand and we went with the bill that was more New York style with arbitration. The problem was, of course, that the administration interpreted it incorrectly. Fortunately, a lawsuit in Texas recognizes that the intent of Congress was significantly different than the way Health and Human Services interpreted it. So, it’s still working its way through the courts. We’ll get it fixed. But, keeping that from going in the wrong direction was probably the biggest accomplishment that impacts emergency physicians that I’ve had in Congress.

What do you think that emergency physicians should be paying attention to in Congress right now that we aren’t focused on?
Dr. Green: Saving rural hospitals and then allowing rural freestanding emergency departments. That bill will continue to come up until we’re [Republicans] are in charge. Nancy Pelosi’s just not been allowed to solve that problem, if you’re more than 35 miles from another ER, a freestanding ER can’t bill CMS for Medicare and Medicaid. So, I’m trying to get that removed because when a rural hospital closes, we’ll at least keep the ER as a freestanding ER.

Maybe a business model would be that the rural hospital becomes a freestanding ER and a nursing home or something like that. That way you keep the jobs in the rural community and you keep some emergency medicine coverage in that rural community. I’ve run this bill every year that I’ve been in Congress and I can’t get with a Democrat co-sponsor. I can’t get Nancy [Pelosi] to let the bill be heard.

You founded a hospital ED physician group in Tennessee. Can you tell me more about that? The trend right now is of independent physician groups apparently being swallowed up by either hospitals or by investor groups. And I was wondering what your thoughts are about that.
Dr. Green: I founded [the company] and we grew the company up to 52 contracts in 11 states when I left. We had about 1,000 clinicians when I sold the company. The way I did it was the physicians owned the net revenue from their local facility. It was almost like a franchise and I believe the company that took it over from me continued to do that. The company that took it over from me was American Physician Partners. I like the idea of the doctor owning the upside of their business at their local place now. The advantage of having larger groups is you can negotiate better rates with the payers. You know, a small ER group of eight guys and gals working in their own ER goes to Blue Cross Blue Shield (BCBS). BCBS says you’re going to get 85 percent of Medicare on your reimbursement rates, whereas if you’ve got 75 ER docs then you might get 150 percent of Medicare from Blue Cross Blue Shield. If I was to do it again, I would probably try to find some way where there could be a coop or an association of independent groups so that they can negotiate together, but the laws are a little bit restrictive on how you can negotiate because antitrust. The turnover in the company was less than two percent. In fact, the only people that left the company for the first three years were asked to leave because they had customer service, patient satisfaction issues, or competency issues.

Why was the No Surprises Act a bipartisan effort from members in Congress, especially emergency physician members in Congress?
Dr. Green: It was fascinating because there were Democrats and Republicans. On each of the two sides, right. So you know, there were Republicans who got it and there were Republicans who didn’t. There were Democrats who got it and there were Democrats who didn’t. And so it was one of the unique times where you see this meshing in Congress that you just don’t see. It shows you that doctors have impact with both sides of the aisle, but so do insurance companies. In the end, I think we won. I still have the 3X5 cards that I handed out to my Republican colleagues that had the lowest common denominator on insurance reimbursement rates and how that impacts our ability to cover no pay or self-pay patients.

What do you think that emergency physicians should be paying attention to in Congress right now that we aren’t focused on?
Dr. Green: We should be watching what’s happening in the Coronavirus Select Committee because they’re hopefully going to address the worker shortage, particularly as it relates to nursing. So, many people are leaving nursing.

We’ve got to work to get more residency slots in America, and that’s not just specific to emergency medicine, but it’s specific to all specialties as we’ve allowed more and more Medical schools to open. But the choke point now is residency, and that’s GME funding from CMS and Congress. So we’ve got to push that. Those are probably two big issues.

What do you see as your role right now in trying to help address some of the things that we’ve seen come out of this pandemic, like the demands on emergency doctors, stress, burnout, all those sorts of items?
Dr. Green: Well, it kind of goes back to the pipeline, right. Think about Bernoulli’s equation for flow through a pipe. If you don’t widen the diameter of the pipe, you don’t get an increased volume. If you board a couple of beds, it exponentially decreases the flow through the ER. Applying Bernoulli’s equation works very well to make hospital CEOs understand.
It’s the same for creating emergency physicians through residency. we’ve got to widen that pipe. We have to make sure our physicians and our nursing staff understand that the pandemics happen. We weren’t around when the Spanish flu, but that was devastating.
I was in combat. The soldier has to make friends with the fact that Combat sucks.
Getting shot could result in your death. It’s something you have to overcome. It’s a barrier you have to overcome in your own head. Courage isn’t the absence of fear. It’s what you do with that fear. So, we got to make sure that our providers and our nursing staff understand if you’re in healthcare, pandemics are going to happen.
But at the same time, we got to make sure we have the staffing numbers. So that goes back to training programs and that goes back to funding from Congress. And if we do then we can get a surge capacity built into the system.

Any final thoughts?
Dr. Green: I appreciate what ACEP does. ACEP is the voice up here and ACEP has stepped into the breach and has really stood up for our patients and for the doctor-patient relationship. I just encourage all emergency physicians to be a part of the process.