BA: I’ll give you some great questions from Pat Lencioni, which are great questions to answer whether you’re considering a merger or not. They are really helpful and powerful: Why do we exist? (What is your mission?) How do we behave? (What are your values?) What do we do? (What are we really trying to accomplish together?) How do we think we’ll be successful together? If you are considering a merger with another entity and you don’t have alignment at all in the first four, it might not be the best idea.

Brent, as a hospital administrator, are you and the American Hospital Association willing to sit with me as President of the College and have a discussion about why hospitals are shifting huge overhead to the emergency departments? Since over 75 percent of emergency hospital bills are related to hospital charges, could we have a conversation about making the visit cheaper for the patient? —Jay Kaplan, MD, FACEP

RM: Here’s my last series of questions: How does emergency medicine best grow? Where are we going to be? Where do you see us being as a specialty in five years? What kind of structure do you see us operating in?

BA: There’s a huge opportunity in alternative payment models to help at the interface of inpatient and outpatient care. Emergency medicine will always be at that interface. I think the groups that are helping systems get at value and lower their costs (avoid potentially avoidable admissions, creating alternatives to admission, providing care-transition support) are going to be a growth opportunity. The ability to do free pricing for freestanding centers is going to be eroded pretty quickly. Run your pro forma both ways under freestanding and hospital-based pricing because it could get pretty ugly on the hospital-based pricing front. Not all systems are interested, but the ones that are in virtual care are going to be in good shape.

SB: I’m going to quote Wes Curry. He tells me all the time, “I think we’re at a tipping point.” Those groups that will continue to demonstrate performance will succeed. Those who have tried to become the lowest-cost bidder yet deliver a very weak product will fail.

RI: There’s a lot of business wisdom that says stick to your core, but there’s a lot of exciting stuff going on with virtual medicine, navigation, population health management, and care management. I’d rather be the one providing those services, or at least providing the navigation through those services, rather than someone else. I do not want to be walking around five years from now with the same three tools in my toolbox: doctor, physician assistant, and scribe. I’d like to have 10 different tools.

The ability to do free pricing for freestanding centers is going to be eroded pretty quickly. Run your pro forma both ways under freestanding and hospital-based pricing because it could get pretty ugly on the hospital-based pricing front. —Brent Asplin, MD, MPH

JK: I have quoted Tom Peters for years: “If the other guy’s getting better, you better be getting better faster. If that other guy’s getting better, you’re getting worse.” This means, paradoxically, you can be getting better and getting worse at the same time if the other guy is getting better faster than you are. The only thing you ever have is a leading edge. We have to rebrand emergency medicine. Myles Riner did a study a number of years ago where he looked at over 6,000 claims. He found that if you took the 20 percent least-acute patients out of the system, you’d save only 4 percent of the cost. If you decrease computed tomography scans by one out of 12, you would save that much money as well. We have to do away with the myth that the emergency department is the most expensive place to receive care. ACEP has an alternative payment model task force. We have one looking at Medicaid access. We also have one looking at out of network and balance billing.