Between the healthcare overhaul and the Supreme Court’s subsequent landmark challenge, it’s been an interesting year in healthcare, and ACEP president David Seaberg has had a front row seat. At October’s ACEP Scientific Assembly, Seaberg will pass the torch, but before he does, EPM’s Greg Henry caught up with him for a final conversation about how the year went down – what worked, what didn’t, and how you just can’t make everyone happy.
Greg Henry: The real test of leadership is not what things are thrown at it, but how it responds to adversity. David, I’d like to start out by asking you what you learned in your 11 months as president of the largest organization representing emergency physicians?
David Seaberg: First of all, it was a real honor to represent the emergency physicians in emergency medicine this last year. We truly have a tremendously talented group of caring and competent physicians. I think in an organization of now over 31,000 members, the challenges are you always have to do what’s right for the organization and try to see the big picture. And that doesn’t necessarily make everyone happy. When you have 31,000 members, you have about 32,000 opinions.
To me, the challenge was trying to see what strategically was best for emergency medicine, advocating and speaking eloquently on that position, knowing that maybe not all of our members agreed with that. It’s all about trying to look at our strategic plan and trying to prepare for the future of medicine and how emergency medicine fits into that. I think that’s probably been the biggest challenge.
Henry: In the last 10 years, the use of physician assistants has gone from the three to five percent level to upwards of 20 percent in some places. And I know that California emergency physicians, as of last year, had 40 percent of its patients seen by mid-levels. Where is this going? And what should we be doing in ACEP about the concept of supervision and payment with regard to mid-levels?
Seaberg: You bring up a very important question. The statistics on physician assistants should not be surprising to anyone. Although you may not necessarily like that trend, it’s all about cost control. I mean, it’s about value. Value equals quality divided by cost, plus service excellence. But the big driver is cost. We’ve got to look at reducing costs, and bringing on physician assistants, nurse practitioners and other mid-levels is something that we have to prepare for as we deal with this.
ACEP has been working particularly with SEMPA – the Society for Emergency Medicine Physician Assistants – and proactively asking: How do we train or prepare physician assistants to practice in emergency medicine? But we’re also looking at what is the best team to be practicing emergency medicine? It may not always be the board certified emergency physician in every emergency department. Now I personally think – and ACEP thinks – that board certified emergency physicians should be leading or managing emergency departments. But I’m not sure we’ve really figured out what the proper alignment is between physicians, nurses and mid-level providers.
ACEP has been working proactively on this question. We do the management contract for SEMPA. I participated in the American Association of Physician Assistants meeting two months ago where we talked about some of these issues. As the dean of a medical school, I think we need to start looking at our health centers and at our training. What is the best model of the future? I don’t think we’ve determined that yet. I think emergency medicine is going to have to move into transitions of care if we’re going to be part of the medical neighborhood. And I think there’s certainly a role where the physician should not be doing all that, but maybe should be directing. In needs to be a team approach.
But it should be of no surprise that cost is going to be the major driver here. We as a country cannot economically survive if we keep spending on healthcare the way we’ve been spending. So we need specialty organizations such as ACEP out there to think proactively on how we’re going to use mid-levels and other healthcare providers to make us more efficient but yet maintain our income.
Henry: Well, let me challenge you: You’ve gotten to see the big picture now. Where is that experimental hospital going to be where we can vary the staffing and see what we can produce? Because we’re like all other businesses; we have to produce a reasonable product at reasonable cost. Of the 4,100 emergency departments in the United States, who is actually scientifically varying the staffing – you know, less nurses, more techs, fewer doctors, more PAs, and physician scribes? I mean, we talk about cost, but the things that a physician does actually don’t take very much time from a knowledge and decision standpoint. It’s the Mickey Mouse work which takes up time. I don’t see why, with good scribes, an emergency doctor couldn’t see six and eight patients per hour as opposed to the 2.2 or 2.5 which is now being seen.
Seaberg: Well, Greg, you’re asking a rhetorical question because you know out of those 4,100 there’s probably not one right now that is doing that. But there needs to be. And I would take it a step further. I think our health centers need to start looking at this. Take the University of Tennessee where I’m at. We’ve got nursing, we’ve got a physician’s assistant program, we’ve got pharmacy. We’ve got the college of medicine. We need to start looking at this from a more scientific point of view; there has to be more research on it. Some of the innovations that may come out of the CMS innovations – the CMMI – may be helpful.
And I think there will be more hospitals in the future, Greg, that are going to have to start looking at this because as you know that bundled payments and accountable care organizations are coming. If you think fee for service is going to last another five years, it may, but that’s going to be the outer edge. We’ve got to start looking at the different models out there. We’re still going to need emergency physicians. They’re still going to have to run emergency departments. But we have to find the right mix to make them more efficient with the less costly providers.
Henry: Let me give you another challenge on cost. The last time I looked at the numbers at my own group, there was a five-fold difference in the use of the CT scan between the high and low utilizing doctors. How is ACEP going to address this question since we can double or quadruple the cost of care simply by checking a box for which the physician pays no price himself? What are we going to do to put in place intelligent productivity and cost savings to reward the physician? And by reward, in this society at this moment in time, that means better payment for less utilization of resources.
Seaberg: That’s a tricky question. Clearly, if we move to a bundled payment, you will get rewarded. The models for emergency medicine have not been worked out very well in the accountable care bundled payment, but we are starting to look at that. But theoretically you will get rewarded for saving money. There’ll be some gain sharing. The problem is it’s not such an easy thing in emergency medicine. We were asked to participate in the “Choose Wisely” campaign. Well, we had three subcommittees. This started in President Schneider’s tenure, when we formed a committee to look at it and they decided not to participate. Then the question came up again. I formed another independent subcommittee to look at it, and again they said we should not participate. There was a real cry, particularly from some of the more academic centers, calling me a dinosaur and other names because we wouldn’t participate. So once again I formed a committee to look at it. We decided that the “Choosing Wisely” campaign was not the right vehicle. Number one, it said: “What are the unnecessary tests?” We had a hard time defining what “unnecessary” meant in emergency medicine. Emergency medicine’s practice environment is somewhat different. And we thought the “Choosing Wisely” campaign was just too limited of a vehicle.
So we formed a cost effective emergency care task force of some leading experts in emergency medicine to determine the high value things that we do, and the things that may not bring value to the system. Some of those may be “unnecessary” tests. Some of it may be very high value, using practice guidelines, such as getting a D-dimer first in low acuity PE patients and not getting the CT angio. But we needed to look at the issue at a higher level than the “Choosing Wisely” campaign, which, frankly, was more of a PR campaign than it was changing the practice of medicine. We wanted to look at a more comprehensive model.
But one of the things that needs to happen if we are going to be using best practices practice guidelines is that we need to have a medical liability safe harbor for doing so. ACEP pushed HR157, which is giving liability coverage for EMTALA-related care. But my own personal opinion is that caps and changing the negligence standards make malpractice insurance cheaper and easier. I’m not convinced it changes physician behavior.
We’ve trained at least two, if not three, generations of doctors to order tests rather than to think about patients. And so if we really truly want to change physician behavior, let’s have good, well-developed practice guidelines, best practices and give medical liability protection for using those. We’ve got some excellent practice guidelines: the Nexus guidelines, the Ottawa Ankle rules, the Wells criteria and the various PE guidelines.
Henry: When it was looked at to see who’s using the Ottawa Ankle guidelines, it’s the Canadians – not us.
Seaberg: Because they’ve got protection.
Henry: Well, it’s not so much the protection. I think it is a set of habits that we’ve developed. The academic centers may be a part of our problem as a well as a part of our solution, because this is where the twig is bent. And as the twig is bent, so grows the tree. When it learns that all these things must be done, then all of a sudden that becomes a “standard of care” for the new graduates. I mean, I see this as a difficult situation. But let me get back to the question of bundled payments for a second. What prevents ACEP from going to the government and proposing our own bundled payment program, an experimental program? At least we could cut out the 10 or 15 percent cost in billing charts, which is money that goes to no benefit in care.
Seaberg: Well, there’s nothing that would stop us. But I don’t think there’s an understanding of where emergency medicine fits in. I actually met with Secretary Sebelius recently. I was one of ten medical leaders to talk about Medicaid. I wanted it to be clear that yes, emergency medicine would be in favor of the expansion of Medicaid because 15 to 20 percent of our patients are self-pay and don’t pay anything. But I also wanted to make it clear that insurance doesn’t equal access and that we need to start looking beyond the medical home, which will not be prepared to take all these people. I don’t know of any primary care doctors that are clamoring to take on more Medicaid patients. And so they’ll end up in the emergency department. But we need to be part of the solution. We can’t just say we want our own bundled payment and negotiate that without having an understanding of what that means.
If we’re going to be part of a bundled payment, we’ve got to look at better managing the care of patients across the spectrum. I think the emergency department is ideally suited for that, which is why I started a task force on transitions of care. We have such huge access to patients: 136 million patients each year in the emergency department. We’ve got another 130 visitors with those patients that are captive. We need to look at providing better prevention, wellness, disease management and palliative care. We need to get them better integrated into a medical home – if they have one – or into their specialist. We could be using innovative methods such as having paramedics to go out and check on patients and see if they got their prescription, or to go to check their blood pressure. We should be using telemedicine to a greater degree.
Before we can go and say, “We want a bundled payment,” we have to really truly decide in emergency medicine that we are going to be a part of the medical neighborhood. That is still a sell for some of our members. And again, I’m not asking the emergency physician back in the pit to do this. I’m asking for us to look at creating systems around the emergency department to help better integrate; but have the emergency physician or the emergency physician groups lead that. Because if we can control that patient, we control the funding and we can help control access.
Henry: I remember 10 or 15 years ago people poo-pooing the “doc in the box,” urgent care clinics. And yet when I went to speak to the Urgent Care Association of America meeting, I recognized many of the faces. They are emergency doctors who got tired of practicing emergency medicine and are running urgent care clinics. What should be our relationship? First of all, they claim 85 percent of what’s seen in an emergency department can be seen in urgent cares. Secondly, they’re saying that because of the cost structures imposed by hospitals rules, work rules and nursing rules, they can see patients better, cheaper and faster. What should ACEP’s relationship with the Urgent Care Association of America look like?
Seaberg: Well, first of all, their figures are wrong. Eight-five percent of what’s seen in emergency departments cannot be seen in an urgent care center. There’s no surprise that emergency physicians are moving into urgent care; it’s a good business to be in. It’s a cash business, and they can siphon off the paying patients from the local ED. Urgent care centers are growing by leaps and bounds; in some cities it feels like there’s one on every block. Last I checked they were seeing about 30 million patients, and yet our ED businesses are growing. So I don’t think they’re stemming the tide of emergency department visits. It’s shifting the payer mix slightly because they may be taking some of the paying patients out.
In some ways the rise in urgent care represents a failure of emergency medicine to address the needs of lower acuity patients and find a better way to deal with them within our system. ACEP is looking at this. Our problem is not the emergency physician bill, it’s the high overhead and facility fee that the hospital charges. How do we develop the emergency department as an acute care model and not throw that large fee on top? Because frankly, the emergency department is still where these patients are best seen. Patients do a poor job of self-diagnosis. Sometimes they can, but if it’s more serious, there’s no better place for them to be than at an emergency department.
All that said, we have to work with the Urgent Care Association. A lot of our members are doing urgent care. But as emergency medicine, we need to again look at an acute care model as a business line within emergency medicine and do it better. We’re going to need the hospital support, of course, because most of the costs of an emergency department are fixed. The marginal costs of seeing one additional patient is not that much greater, so it doesn’t make sense to spend more money on urgent cares and keeping doctor offices open late. There’s a cost to that as well. And again, these patients are better served in the emergency department. When you look at low acuity patients – and I’ve done this in my emergency department – and see why they are in the ED, 64 percent think they’re having an emergency. Twenty-eight percent were sent by the primary care doctor. So the majority of the people have a reason to be in the emergency department. We just need to find a better model with the hospital so that we don’t put large charges on top.
Henry: You understand, David, that emergency medicine is the only business in the country that talks out of both sides of their mouth in this regard. We complain when there is overcrowding, and we cry when those patients head off to other places. I mean, would you agree with me that we have had sort of a dichotomous view of this that is going to have to change? I mean, you either want business or you don’t. And if you want business, then you have to make it comfortable for business to come.
Seaberg: I wouldn’t disagree with that. And frankly, the lower acuity patients provide a higher margin for emergency medicine. Over the years, I think it was important to talk about crowding, though we’ve moved a little bit away from that to talk more about boarding. But crowding was very important as an issue because 10 years ago a hospital viewed crowding as solely the ED’s fault. I really think ACEP over the years has changed that discussion, that this is a systems issue. We need to get the hospital more involved. And I truly think hospitals are starting to understand that. A recent article by Smallowitz in Annals Of Emergency Medicine showed that now over 50 percent of admissions are coming through the emergency department. If you want to truly look at saving money, it does not mean decreasing access for low acuity patients. That’s chump change. It’s about handling our admissions better. It’s about looking at the number of tests that we order and being more cost effective or cost efficient in our diagnostic work-ups. That’s where the big money is. It’s not reducing access. But I think the discussion that ACEP really moved forward is that hospital crowding is a system’s issue. I don’t think it ever was a discussion that, “We don’t want to see low acuity patients.” I think that model has failed over the years.
Henry: Right. Just build a bigger tent and then sort it out in the tent and decide where they need to go.
Seaberg: Absolutely. Don’t throw a $400-$500 facility fee on a sore throat. I mean, the charges are what put us out of the ballpark and really raises the ire, not only of patients but of regulators and legislators. We need to start thinking outside the box of different models on how to deal with this.
Henry: Where should ACEP be at this moment in time with the question of end-of-life issues? What could we do proactively? Is it visiting the nursing homes? Is it talking to the families? We tie up time and resources on people who quite frankly should have been allowed to quietly die.
Seaberg: You’re exactly right. When I talk about transitions of care, palliative care is a big portion of that. One percent of the population spends 21 percent of all healthcare. Ten percent spends about 65 percent. And it’s usually at the end of life. We have had meetings with the Hospice and Palliative Care Society. We’re trying to educate our members. One of the things that we can certainly do is look at the POLST (Physician Orders of Life-Sustaining Treatment) and the living wills and be more proactive with our patients in emergency medicine. We should be working in the medical neighborhood with the primary care physicians to really ask how much care we should be providing to certain patients. We should probably have interdisciplinary rounds with some of the primary care and the hospice and palliative care doctors.
The European countries are much farther ahead than we are on this. We need to take a cue from them. We need to start opening the conversation. And I think emergency medicine could be a big player. We are going to continue our discussions with the Hospice and Palliative Care Societies and look at what we can do from emergency medicine to reduce end-of-life care costs.
Henry: Well, thank you for your time, David. It’s certainly been a busy year. The great curse of the Arab world is: “May you live in interesting times.” And you certainly have.
Seaberg: Thank you, Greg. It certainly is an interesting time. I think some of the biggest changes in probably our lifetime regarding where medicine is going are occurring now. I’m glad to play a part of it. And I was very honored to represent ACEP and emergency medicine in this past year.
David Seaberg, MD President of the American College of Emergency Physicians (ACEP)
Greg Henry, MD Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.