RHealth care reform is sending a message to patients, hospitals, payers, and providers that business as usual is over. We emergency physicians need to figure out how to redesign ourselves so that we become part of effective change.

How did we get here? Health care spending is out of control. The Centers for Medicare and Medicaid Services projects that by 2018, we’ll be spending one-fifth of the total U.S. economy on health care costs. Hospitals currently account for about 32% of all health care spending in the United States. This is not sustainable. At the same time, we have a ballooning national deficit and an aging adult population.

The current political reality is sobering. Even now that the health care reform bill has passed, it’s not going to be easy sledding. A lot of massaging will go on in this bill.

People have argued, “Why not just contain costs first? Why don’t we bring things under control in what we spend before we expand care?”

At this year’s ACEP Leadership and Advocacy Conference in Washington, D.C., we learned from health care economist Len Nichols that the health care system is already stretched and that three-quarters of hospitals currently lose money on Medicare. If you just started to contain costs further, too many things would likely fall apart. Cost containment with coverage expansion is more likely to succeed, but we have to be careful how we do it.

Payment reform alone is not enough, because there are several components to payment. You have to change the culture of how we get reimbursed in our health care system. Documentation and proof of patient experience will need to be kept intact in some way.

Key provisions in the health care reform bill that directly affect emergency medicine include no prior authorization for EM services, expansion of the prudent layperson standard to all health plans, and an essential benefits package that includes coverage for EMS.

The bill also includes a program to strengthen ED and trauma center capacity by funding research projects and developing demonstration programs to design, implement, and evaluate innovative models for emergency care systems.

The bill also establishes a workforce advisory group, funding for wellness/prevention programs, a demonstration program to bundle payments for episodes of care, a 5-year demonstration grant program for states to develop and implement alternatives to tort litigation, and plans for a regular and reserve corps for public health and disaster preparedness.

As I see it, the most interesting and most challenging aspects of the health care reform bill are the plans to establish a nonprofit Patient-Centered Outcomes Research Institute to identify research priorities and clinical effectiveness, as well as the plans to establish an Independent Payment Advisory Board (IPAB).

This board will examine what’s being paid in health care and will determine if spending targets are being met.

If they’re not, the board will make a recommendation to make sure what’s being spent comes in line with what should be spent—bypassing Congress.

I suspect that this board could potentially have tremendous power over how we get reimbursed in the future. Many people are concerned about IPAB having this kind of latitude.

The bill also creates an innovation center within the CMS to test and evaluate different payment structures and methodologies to reduce program spending.

One of the strategies being explored is the bundling of payments for episodes of care.

Among my concerns about the bill is that current Medicaid and Medicare rates do not equal fair payment.

There’s also no specific mention of emergency medicine workforce issues or the ongoing problems we routinely encounter in terms of boarding and overcrowding.

In the future, I believe that the pressure to deliver value, not just volume, will intensify over time. Better care will require better information systems, incentives, coordination, management and leadership, patient engagement, and employer buy-in to force multipayer cooperation.

How emergency medicine physicians will fit into this new paradigm is unclear—but we are the most talented, most diverse group of physicians to lead this change.

Why? Because we do it every day. We’re always being innovative. We’re always thinking outside the box. We’re always thinking of ways to get around systems that are obstructing us.

The road ahead may not be so clear. But the best way to predict the future is to create it.

Dr. Johnson, a member of the ACEP Board of Directors, practices emergency medicine at Mission Hospital Regional Medical Center in Mission Viejo, Calif.

He is also a member of the California Commission on Emergency Medical Services.