Rebecca Parker, MD, FACEP, who completed her term as ACEP President in October, recently sat down with ACEP Now Medical Editor in Chief Kevin Klauer, DO, EJD, FACEP, to share her views on the key accomplishments from her year as President. Here are some highlights from their conversation.

KK: Becky, you’re approaching the end of your very, very busy presidency. Let’s review what has happened in your year.

RP:  It’s truly been an honor to represent emergency physicians, but this year has reemphasized that honor and that mission. Emergency physicians are passionate and care about their patients. That has made this job so much easier when it comes to tough decisions.

KK: What an ominous responsibility to be representing 37,000 of your closest friends. What were some of your key achievements this year so far?

RP: I wanted to look at and watch health care reform and the changes going on in the Affordable Care Act (ACA), which is heavy on the reimbursement piece. The second piece was heavily focusing on diversity and inclusion.

Third, I walked out of the Council meeting into ACEP16 and right into out-of-network balance billing. Some very controversial press, negative for emergency medicine, came out through a perspectives piece in the New England Journal by Zack Cooper.¹ We got a query from one of our long-time reporters we work with at The Wall Street Journal who was interested in our CIGNA parody video that Dr. Jay Kaplan had done as he finished his presidency. As we talked to that reporter, we found out that the Cooper article was being published the next day but had not been shared with us, and clearly, all the press had been lined up. There was an NBC Nightly News piece, already filmed, to be released the next day. Our PR team in D.C. calmly said, “Hey, can you send us the article?” Within 12 hours, we had talking points, and we brought up the salient issues for that article. Within 24 hours, I gave multiple interviews, some while working a shift. I was doing a long shift at a Level 2 high-acuity trauma center, and our unit secretary said, “Um, NBC Nightly News is on the phone for an interview, but I see that you’re intubating that patient.” “Tell them I’ll call them back,” I said. We got quotes into over 80 publications and a clip of our parody into the NBC Nightly News when they interviewed Dr. Cooper.

ACEP had been on the road to solving this problem since 2010. Before the Cooper article, ACEP put together a joint task force with the Emergency Department Practice Management Association that came to consensus on the key concepts and key strategies on this very complicated situation. To get all our experts together to come to an agreement was a monumental achievement.

We were starting to see state laws pop up. Anesthesia was very active at the state level. They actually approached ACEP the year before and said, “Hey, we want to work on this together.” Jeff Plagenhoef, MD, president-elect of the American Society of Anesthesiologists (ASA), and I put together a meeting in 2016 that brought together all the hospital-based specialties, surgeons, orthopedic surgeons, and American Medical Association (AMA). We came to a consensus and drafted a consensus document.

The next step was to start supporting our state chapters. As we got queries from states, we had key documents, talking points, and our agreements with the ASA, so that state chapters could communicate these positions. We asked the joint task force to work on model legislation. Nine specialty societies cosigned. It went to the June AMA meeting. Dr. Steve Epstein and our section council did a fantastic job, resulting in a passed resolution directing the AMA to start writing model legislation for this upcoming cycle. The AMA is working on a model to give to their state medical societies so we can unite at the state level to tackle this issue.

On the federal level, we continued our lawsuit against the Centers for Medicare and Medicaid Services (CMS) regulator, Center for Consumer Information and Insurance Oversight (CCIIO), that had given a very unfavorable description based on the “greatest of three” of how we should be paid when we’re out of network.

The “greatest of three” comes out of the ACA. Every year, the federal government puts out a set of proposed rules for the fee schedule. They allow 60 days for open comments. We were concerned because there was this definition for emergency services, specifically if a patient was out of network, of how people would be paid, and it was based on the greatest of three elements: 1) the average amount negotiated with in-network providers; 2) the amount 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.

The problem with the second one is that it was very vague. What’s “usual and customary?” For 25 years, we had used a percentage of charges through Ingenix, which was put together and supported by United Healthcare, which was a charge database owned by the insurance industry. Well, that fell apart when the state of New York sued them for fraudulent behavior and there was a $300 million settlement that paid for a new type of database called FAIR Health that was transparent and independent, etc. However, Ingenix was clearly flawed, and it was also fraudulent.

The question was, What does “usual and customary” mean? We had people go to the Hill and meet with CCIIO multiple times. Then they suddenly released the final rule after all this work, and it came out with “usual and customary” amounts. In effect, the insurance companies could pay us whatever they wanted because that is a black box for us. For the first time ever, and the only specialty society to do so, we sued CMS.

The judge agreed with us that CCIIO had not been forthcoming on why they’d made this decision. They did not follow the rules of the registry, and the judge directed the agency to discuss specifically what “usual and customary” means.

With our legislative and relationship ducks in a row, we expect the judge to say, “CMS, you have to correct this, you have to look at this, you have to explain yourself.”

Out-of-network has been more of a focus than I anticipated—we were able to build that consensus through the AMA to prepare us for solutions coming up into the next state legislative cycle, and to be able to get a partial favorable decision on our CCIIO lawsuit tops it off. That became all-encompassing, and it was a surprise to me that it would move this quickly, but I’m hopeful that we’ll finish it up soon.

KK: Can you speak about your successes with diversity and inclusion? Why is this important to the membership?

RP: The topic came up when I was running for President. I spoke from the position of a woman emergency physician when I talked about diversity and inclusion. I saw this as an opportunity in terms of leadership development within the organization.

The response was quite amazing and surprising, regarding the amount of people who really embraced this. After I won the election at ACEP15, I had people stop after the Council meeting to talk about how important this was, thanking me for doing this. So this clearly has been important to the membership, but how could we move forward? We hired a consultant to help us work through how we could approach this. We put together a summit, and two directives came from it: why are we doing this, and we needed a task force to come up with some strategies and tactics. Using the information from that terrific group, I sat down with Dr. Steve Stack and Dr. Sandy Schneider and put together an editorial that was published in the Annals of Emergency Medicine.²

There are a couple of key points regarding why ACEP should do this. Our population is diversifying, and in some cities, those considered a minority are actually a majority in the population. Medical students are also diversifying. In fact, the Association of American Medical Colleges is focused on regulations for medical schools that they must recruit medical students that reflect the communities around them.

The percentage of women in emergency medicine is below the average that is in our medical schools. We’re not capturing women and other minorities in the same way that other specialties are.

Our leadership doesn’t always reflect membership, even with women not making up 50 percent of our specialty. Where’s the disconnect? We’re not capturing all of our talent or all the types of people that we have. What about the care we deliver? We know that genders experience pain or different diseases differently. We know that people in different cultures describe their symptoms differently and have cultural differences, which impact health care choices.

Our task force has identified three priorities: 1) engaging the emergency medicine community, 2) identifying and tackling barriers to professional development, and 3) the health disparities piece.

In the end, we’re stronger as a College and specialty if we’re accepting of all of our unique differences.

KK: What’s going on that people should expect to see in the future?

RP: A partnership with the CDC to combat the opioid crisis.

• A collaboration with The Joint Commission to improve safety of boarded mental health patients.
• Wellness resources derived from a wellness summit including many emergency medicine organizations.
• Collaborative work with ABEM regarding the maintenance of certification process.

KK: Let’s end with your elevator speech. Convince me to renew my membership next year.

RP: The value of membership. ACEP represents all emergency medicine. ACEP is an organization that is advocating on the Hill, doing public relations, working with other specialty societies on behalf of emergency physicians, and is very effective at that. We have the high impact at the highest levels.

It’s your home away from home. ACEP is the place where, for me and for many others, I’ve got friends and where I’ve got my family. It’s where I found my professional mission and my professional and personal home, as well. It’s that type of organization for you, no matter what stage of your career. It’s a place for you to find your home. You’re welcome anytime, particularly when you need it most.

References

1. Cooper Z, Scott Morton F. Out-of-network emergency-physician bills—an unwelcome surprise. N Engl J Med. 2016;375(20):1915-1918.
2. Parker RB, Stack SJ, Schneider SM; ACEP Diversity Summit 2016 Attendees. Why diversity and inclusion are critical to the American College of Emergency Physicians’ future success. Ann Emerg Med. 2017;69(6):714-717.