Each year brings new challenges for our specialty to face and a new President to the lead the charge. Michael J. Gerardi, MD, FAAP, FACEP, who took over as ACEP President in October, shares his views on a few of those challenges with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP.

Kevin Klauer: What are the greatest challenges for emergency physicians today?

Michael Gerardi: Overcoming myths that have been promulgated over the last five to six years in the health care reform debate, such as EM is expensive and doesn’t provide great value and that patients should avoid emergency departments at all costs. Hearing such ludicrous stuff drives me crazy, and we have to stop this nonsense. I think our patients already know that when they are sick or acutely injured or unsure of what ails them, they’re going to get the right answer in the ED. You have heard me say publicly that, in America, we are the greatest diagnosticians in the world, and it starts in the emergency department. We are the prime comforters in times of crisis, we are great diagnosticians, we are the MacGyvers of medicine, and we know how to innovate from the perspective of access to care and putting together care plans.

The more we get involved and lead, as we are developing a qualified clinical data registry (QCDR), establishing relationships with other societies, getting involved with the big house of medicine, etc., the more people are going to look to us and say, “There is something about those emergency physicians; they just seem to be out there in front and to see things before they happen.” I want people to view us as visionaries about where medicine needs to go and what it should be. Our challenges come from being misunderstood and not being valued.

KK: What do you think ACEP members get for their dues dollars?

MG: I think the value they are getting is fantastic. First of all, they’re getting Annals of Emergency Medicine, one of the most impactful EM journals by the ratings of medical journals. Second, they get current information through the daily briefings from ACEP and ACEP eNow. But perhaps the greatest value of membership is this: if anyone who practices emergency medicine has an issue, frustration, or problem, I would be surprised if ACEP does not know about it and is not fighting to fix that problem already. ACEP is doing it’s best with more than 110 staff members, hundreds and hundreds of volunteer committee members, and thousands of section members, to improve our practice. I think one of the most gratifying things to do is to join a section or dive into a cause and realize, “Look at how many people think the way I do.” It’s really galvanizing, and it supports the case that you want to be a part of something bigger. It helps you enjoy your practice more to know that someone is working on your behalf to solve a problem that is frustrating you.

If I’m missing some of the frustrations, by the way, they are what our board members and chapter leaders are finding out when we go to these meetings and get involved locally. We go to chapter meetings and members step up to say some situation is headed to an intolerable level. ACEP is there to listen and ready to solve problems. An organization can’t be successful or have the resources to put forth to solve a problem unless it has content and dedicated members. Members are our lifeblood.

KK: What would you say to the emergency physician who says, “I get all the benefits even if I don’t pay my dues because everyone else paid their dues”? Basically, herd advocacy.

MG: I’m not going to say that everyone should contribute to the overall welfare of our specialty. That’s your own personal choice. I just think that if people were to investigate what the College is doing, they would find colleagues who are like-minded. Camaraderie and esprit de corps are invaluable to your own personal being. If you stand on the outside, you will feel isolated and lonely. You won’t be part of the overall changes that impact you. Our members have the benefit of thought leaders constantly debating, having discussions, and writing about where things are heading. You are at a disadvantage if you don’t see what is coming.

KK: What has ACEP been doing to support members in meeting Physician Quality Reporting System (PQRS) requirements?

MG: I feel like our specialty has been wrestling with a technical expert panel, trying to find quality measures that the Centers for Medicare & Medicaid Services (CMS) will accept for emergency medicine. It has been a very frustrating process because, even working through the National Quality Forum and others, our recommendations sometimes fall on deaf ears.

In 2014, CMS removed approximately 75 of 370 measures for all of medicine, many that impacted emergency medicine. Fortunately, we also learned that there was another option for PQRS reporting, called a QCDR.

ACEP met with some experts in Washington, D.C., in August and found if we were to create our own QCDR, then we could create our own quality measures, get them approved by CMS through the QCDR methodology, disseminate them to our members, and be able report in 2015. Otherwise, we were looking at a potential 6–10 percent reimbursement cut in 2017 if reporting is not done in 2015. Obviously, this was a front-burner item—some things present themselves and we have no choice but to address them immediately.

ACEP Executive Director Dean Wilkerson, JD, MBA, CAE, the staff, and members of the board rapidly put out a request for proposals for development of a QCDR. I’m happy to say that we finalized a contract to have a software developer create an ACEP QCDR, the Clinical Emergency Data Registry or CEDR. We will immediately task the Quality and Performance Committee, QIPS (our quality improvement and patient safety section), our technical expert panel, and other committees to help us produce quality measures so that we can begin reporting by the third quarter of 2015. This will protect us from a draconian cut in 2017. I can’t emphasize how important this initiative is.

With a QCDR, you can also develop your own patient-satisfaction tool. We may not necessarily be beholden to EDPEC, the Emergency Department Patient Experience of Care survey, which is going to be the ED version of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. We will also be able to use the QCDR for Maintenance of Certification with the American Board of Emergency Medicine and American Osteopathic Board of Emergency Medicine. This is a project that will have far-reaching effects on the function of the College. I think we can be leaders in the house of medicine in this process.

KK: What do you say to those who say ACEP is just another organization in bed with big pharma and practice management or contract management groups?

MG: If you look at the College from the outside and don’t choose to be a member, I think that’s the kind of rationalization rhetoric you hear. I see ACEP as the organization that truly represents me—as a practicing physician—and also my patients.

Let’s talk about pharma. Pharma employees go to work every day trying to make or design more effective drugs at less cost; that’s their fundamental mission. Are there examples where companies are profiteering and may be charging too much? Yes, but that’s an economic discussion for a future article. If pharma is willing to help support research for a vexing problem, I don’t call that being in bed with them. I call that having a partner who is willing to invest resources to help us do research.

Let’s talk about the large contract management groups. When I put on my white coat to care for patients, I am just a physician (with a little gray hair), and I hope I can take care of their needs. But behind me is a billing company or somebody who helps me do my schedule, or helps me recruit for the shift that’s open, or provides medical liability insurance, or helps me convene quality improvement committees, or runs interference with a hospital administration that doesn’t see eye to eye with me about what our mission is. All those people working behind me are supporting my ability to practice and focus on the patient and their family, and I don’t see why that is necessarily a bad thing.

There are certain benefits in larger numbers. Some of our smaller contract groups that have one, two, or three contracts sometimes need help. I think the College represents both the individual practitioner and members who work for a large management group that helps support their practice. Our members are free to choose their employment model, but I really hope they become ACEP members because of what the College represents: the physician at the bedside and the patient rather than these other entities.

“Just go to the chapter meeting and step up to say this situation is intolerable or headed to an intolerable level. ACEP is there to listen and ready to solve problems. An organization can’t be successful or have the resources to put forth to solve a problem unless it has members. Members are our lifeblood.”
—Michael J. Gerardi, MD, FAAP, FACEP

KK: Consolidation is occurring, systems are growing, and the way we deliver care is changing. Some have asked whether free enterprise has extended into unfair business practices. Do you have any thoughts on that?

MG: I don’t see that coming from the consolidation of hospitals, systems, contract management groups, or ED groups. I see unfair practices being implemented against emergency physicians by payers right now. In the negotiating process, we are at an extreme disadvantage. Unless you’re in a rural market where they have very limited choices, where they can’t play one group off of another, payers are using the excuse of the rising cost of health care as a justification to mistreat emergency physicians. The better ACEP is able to get us fair treatment and demonstrate our value, the more your practice is protected at the bedside. That’s why out-of-network care, the greater-than-three rule, and being treated fairly are such big issues for the longevity and the viability of our specialty and the choice to practice in the environment that you want. For some, being an employee is a good thing. For some, it’s anathema to their personal DNA. We have to let members have choices because when people have options, you find drivers to create efficiency and satisfaction with their practice.

One of our major initiatives last year was to look at the wellness and the longevity of our physicians. We have to find ways to make it so that every shift is like that occasional shift you have when everything clicks and goes just right. That’s going to take a unified effort from different practice environments and people with different resources. I believe in accomplishing this through collaborative relationships with the Emergency Department Practice Management Association and other professional organizations like the American Academy of Emergency Medicine, American College of Osteopathic Emergency Physicians, Emergency Nurses Association, and American Medical Association.

KK: What are your thoughts on advanced practice providers and how they should be incorporated into the workflow and staffing models in emergency medicine?

MG: I think advanced practice providers—and I want to include scribes—are great career enhancers, people who can take some of the work that we are caught up with that distracts us from our highest abilities and practicing to our level of expertise. We need to be able to use our brains and experience to handle the more-complicated issues because our patients are getting more elderly and more complicated with comorbidities and very complex diseases.

Advanced practice providers can help us improve flow; they are a great friendly face to take care of that laceration or ankle sprain or more of the straightforward work-up. Advanced practice providers are definitely my colleagues, working shoulder to shoulder with me even with complex patients, but they expand my ability to touch more patients than I would be able to just working by myself. Advanced practice providers and career supporters like scribes not only make your shifts more enjoyable, but they make you feel like you’re practicing to the top of your license. I think that’s something that we all should strive to do, including advanced practice providers.

KK: Out-of-network payments have been a big issue with health care reform. Could you summarize the issue?

MG: A good element of the Affordable Care Act (ACA) is adoption of the prudent layperson definition of an emergency. In other words, people should have emergency care provided in their health plans. However, part of the payment structure in America is that a group or an emergency physician has a choice to participate with a particular plan and insurance company or not participate. If you don’t participate, you’re out of network. The hospital may be in network, but the emergency physician is out of network. If they are out of network, the physician has the right to provide a bill that’s not covered by the insurance company’s usual rate. Insurance may only pay 60 percent, so a physician will send a bill for the balance—that’s called balance billing. Out-of-network bans say the doctors in emergency departments can’t send that balance bill for out-of-network care.

With the ACA, banning balance billing is not allowed. For billing fee disputes, the ACA created a rule called “the greatest of three” to help determine a fair reimbursement schedule. A reasonable usual and customary rate is: [1) the average amount negotiated with in-network providers for the emergency service furnished; 2) the amount for the emergency service calculated using the same method the plan generally uses to determine payments for out-of-network services (such as the usual, customary, and reasonable charges); or 3) the amount that would be paid under Medicare for the emergency service]. The lack of this type of methodology created the Ingenix crisis in New York state, when Attorney General Cuomo sued Ingenix because they were taking away some of the higher reimbursements in their nontransparent database, causing a downward spiral in the usual and customary rates in their database and saying that was the usual and customary rate. We have to revise the out-of-network rules and the CMS final rule on this regulation such that there is transparency—like in the FAIR Health data repository—and not a black box so that we can have a fair discussion about what is the usual and customary rate for out-of-network care.

Emergency physicians are not the guilty party when it comes to exorbitant out-of-network rates. You’re seeing them with some of the surgical specialties, surgical subspecialties, and hospitals, etc. We are fighting to have a fair database that compiles billions of charges to determine what is the 80th percentile for a usual and customary rate for an emergency physician for a level 3 or 5 code. We feel that would provide us some negotiating stance when we take on payers who are, almost by extortion contracting, forcing us to accept rates that are unacceptable for our practices.

KK: Final thoughts?

MG: Let’s not forget about several other initiatives launched this year. We are tackling the disparity of care available for behavioral health and psychiatric emergencies and the psychiatric boarding problem.

Second, we have created a task force to promote a national discussion on end-of-life care and advance care planning. Emergency physicians are often stuck in the difficult situation of prolonging life because patients and families have not had an opportunity to discuss their wishes on how the patient wants to be treated when nearing death. These discussions should occur when patients are not in crisis, when they and their families are not under the duress of an ailment or terminal illness.

Third, emergency medicine needs to “own” sepsis care. We are the front line in recognizing sepsis and pre-sepsis syndromes and immediately initiating lifesaving therapies. We have convened an expert panel to review and summarize the science and develop educational materials for our members and the public.

Finally, please remember, in these times of change, our specialty will lead our country in creating an improved health care system and, at the same time, we will be recognized for the tremendous value we provide.