Long after the elected legislators have cast their votes, the agency administrators write the rules and regulations that interpret the law and give it meaning. The Accountable Care Act is poised to fundamentally change how we practice emergency medicine, but the scope and impact of those changes will be determined by the rule writers. And that is exactly where the emergency medicine action fund (emaf) is focusing its efforts. Wes Fields, MD [pictured] has been active in emergency medicine political advocacy for years and heads up the EMAF. EPM caught up with him for his insights into this grassroots fight for the life of our specialty.
Mark Plaster (MP): Can you give us a thumbnail of how the Emergency Medicine Action Fund developed? 
Wes fields (WWF): It’s really based on a model of tax deductible advocacy that was developed in California several years ago. I chaired the Emergency Medicine Advocacy Fund in California as well as EMPAC. In addition to the hard-dollar contributions to EMPAC, soft dollar contributions are two or three times the rate of PAC dollars. The new national EM Action Fund is basically the same notion. It’s group-based support for everything beyond the hard dollar political contributions to advocacy. And the notion is that there are a lot of really important things that have to happen to represent emergency medicine well that have nothing to do with giving checks to candidates for elected office. So everything but the hard dollar approach, which is not tax deductible for IRS purposes, is what we’re about. 
Last year when the Affordable Care Act looked like it was going to pass despite a lot of skepticism and decades of stasis, I started talking to Angela Gardner, who was the President of the College at the time, and later Randy Pilgrim, who was chairman of EDPMA at the time, as well as the rest of the ACEP board and senior staff, about using the same model to do something targeting the federal regulatory agencies and all the rule writing that surrounded the implementation of ACA between 2010 and 2014, and beyond. Sandy Schneider, the current president of ACEP, did a great job in recruiting all of the academic EM organizations to join the College in support of the Action Fund.
MP: How is EMAF organized and administered? If I were to write a check right now to EMAF, who would I write it to? And who will decide how it is spent?
WWF: The Action Fund is a restricted reserve account with stewardship by the College, but whose owners are the contributors and supporters of the Action Fund. The funds have come from dozens of groups and hundreds of emergency physicians, as well as every significant organization in emergency medicine. All the contributors are at the table, either as part of a coalition that has a voting position on the board of the Action Fund or through the organizations that have representation in governance. 
MP: How is EMAF different from a PAC?
WWF: The Action Fund is about everything that goes on in Washington DC that’s not on the Hill, or directly related to legislation by Congress. It’s about a heightened focus on the rule writers and the policymakers that have careers at the federal agencies that have oversight over emergency care one way or another. 


EMAF is a restricted reserve account with stewardship by ACEP. The owners are the contributors and supporters of EMAF. The funds have come from dozens of groups and hundreds of EPs, as well as every significant organization in emergency medicine. All the contributors are at the table, either as part of a coalition that has a voting position on the board of the Action Fund or through the organizations that have representation in governance.


MP: I understand that all the contributors are represented, “at the table” but who really calls the shots?
WWF: EMAF has a governance process that’s driven by the Action Fund Board of Governors. We had our first meeting in July. This is very much a coalition-based activity, and in a sense it’s a coalition of coalitions, because it represents every significant interest in emergency medicine. The mission is to find common cause within our own house and wind up with one set of messages, careful coordination of resources, and an intense focus on trying to have a higher-quality conversation with policy makers about how emergency medicine fits in the future of health care in this country. 
MP: How is it that an individual would find themselves represented by the Action Fund? Is this just giving voice to large contract management groups? Give me an example of a “coalition of coalitions”. 
WWF: The New York Coalition is fascinating to me. As you know, a lot of physicians throughout New York and the Northeast are directly employed by hospitals. The New York Coalition is anything but a contract management group, or a mega group. It’s essentially several dozen individuals that Andy Sama put together, the vast majority of them directly employed by hospitals, and many of them involved in education. [These individual EPs] and a couple of groups with one or two contracts formed a coalition because they see the same issues in New York that I see in California and physicians are seeing in Texas and in any other part of the country. 
MP: So these coalitions are based more on interest than location?
WWF: [There are] four coalitions that are made up of small to mid-sized democratic groups. Two of them are based on current clients of PSR, a company that provides practice management services to EM groups. PSR doesn’t manage or own these contracts or the groups who are clients – it doesn’t even bill for them. They get together every year at a national meeting, they share notes a lot, and the PSR staff help clients do a lot of problem solving in an ad hoc way. 
I’ve had nearly 10 years of experience in California doing advocacy with coalitions of groups that compete directly against each other for hospital contracts in the marketplace, but who realized that when you face either state government or federal government, your competitor becomes your ally. And finding common cause to promote the interest of the specialty and the industry and its practitioners makes a whole lot of sense. 
Among other things you wind up being able to avoid having competing messages, competing forms of advocacy, and a duplicate of costs for lobbyists and attorneys.
MP: But remind me how this is different from any other PAC activity?
WWF: Most advocacy is about building relationships based on access. But PAC contributions are intended to get the attention of elected officials. The Action Fund is a similar approach, but targeting the staff and thought-leaders in and around federal regulatory agencies. Over time, you build relationships with the rule writers and policy makers, which are incredibly important. We think it will work better with the agencies that do regulatory stuff than with elected officials, who tend to come and go, and are usually not health care specialists. . 
MP: It’s clear that it makes more sense to deal with policy makers and policy writers. That’s kind of getting down in the weeds with the people who are actually implementing policy. That makes total sense. But I want to really drill down on this issue of governance because it has to do with the message put out by the EM Action Fund. Are you saying that what’s good for one physician is always going to be good for another physician? What’s good for a mega group is going to be good for a small independent group?
WWF: Think less about the groups for the moment than the organizations at the table. Obviously the Academy does not agree with every position of EDPMA. The College doesn’t necessarily agree with every position of SAEM. And I still get a little bit lost myself thinking about the distinction between CORD and the Association of Academic Chairs.
What’s really more important to the Action Fund and it’s governance is the long term view of the specialty. And that is why there was a high level of consensus around the table at the first meeting of the EMAF board, even if there are still things about which don’t all agree. The two most important things that people around the table [at the July meeting] all agreed on, whether they were from a big group or a small group, whether they were from academic emergency medicine or from the private sector, was the importance of having a workforce in the future that is adequate in size and more than adequate in terms of training, and that EPs be reimbursed well for their clinical services. And that they also had to have adequate amounts of research funding to support good evidence-based medicine. That was really a wonderful thing for me because there was a lot of diversity in the room, lots of intellectual competition, lots of cultural conflicts, if you will. 
MP: How does the Action Fund go about implementing that and actually showing deliverables?
WWF: The answer is a concerted multiyear focus that’s going to have to be in place for 3 to 5 years, maybe longer, as we continue to go through these transitions in the overall health care system in this country. The Action fund has two consulting firms, Health Policy Alternatives and Hart Health Strategies, and a new regulatory law firm, Alston and Bird. Our senior legal counsel, Tom Scully was the administrator who changed the name of HCFA to the Centers for Medicare and Medicaid. 
Those are pretty good friends to have in town. And perhaps more importantly, these consultants come out of the agencies with whom we are dealing. They have strong relationships with the current administrators and program directors within the agencies. 
It winds up being a matter of developing relationships with the key people who define the policies and write the rules and largely tell Congress what it needs to do. 
It’s a matter of having access to them and our ability to provide them with compelling data, a strong message that is consistent that allows them to understand better how we fit in healthcare and why we’re an important part of reform. 
MP: Have you set benchmarks that will tell you whether you have met the goals that you laid out for yourself. Everyone who goes to Washington to change things ends up being changed. They start chumming around with one another, spending a lot of money, and at the end of the day they say they understand what we need to have. But nobody really knows whether you’ve accomplished what you set out to do other than you made some friends. 
WWF: Well it’s a fair question and it’s something we’re working hard on. But this isn’t a social club. And it’s going to continue to unfold over a next few years. So having the Action Fund Board set those interval benchmarks is really important. Among other things we need to have a sustainable set of supports to be able to retain the consultants and do the research and do the fly-ins and have the meetings for several years. You need both short and long-term benchmarks.
What’s going on with the debt ceiling limits and all the budget issues and all the partisan stuff that goes on between the parties, it’s apparent that in the future there will be heavy pressure to reduce the volumes of visits and also reimbursement for visits, procedures, and imaging. If we wind up being where we are right now, if we are anywhere close to even on the size of the workforce and how it is reimbursed, and there is a respect and acknowledgment of the importance of the specialty; if there is just an understanding by the policy makers of those things, and if there is a sustaining level of support for research and education, we will have done a great job. Because obviously the rice bowl is not getting any bigger and a lot of people are going to get hurt on the provider side. 
MP: Isn’t it going to be a little difficult to sell the message that keeping the status quo as ‘winning’?
WWF: I’ve been in advocacy for emergency medicine for a long time and I think that that the bitter truth is that sometimes a really good year is one where you succeed in blocking the efforts of your enemies to take something away from you.

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