Faced with the promise and the threat of looming health reform, members of the widespread emergency medicine community have put aside their differences to join the Emergency Medicine Action Fund, an initiative designed to provide advocacy and education to regulators and politicians who will shape the future of medicine in the United States.
Seven stakeholder groups — the American College of Emergency Physicians, the American Academy of Emergency Medicine, the American Board of Osteopathic Emergency Physicians (ACOEP), the Association of Academic Chairs of Emergency Medicine, the Emergency Department Practice Management Association, the -Emergency Medicine Residents Association (EMRA), and the Society of Academic Emergency Medicine — sit on the board of governors of the new fund and direct its efforts.
“The Patient Protection and Affordable Care Act [PPACA], which is the enabling legislation for health reform, is game-changing,” said Wesley Fields, MD, the chairman of the fund and a member of the board of CEP America. “It is the most significant thing to happen since EMTALA [the Emergency Medical Treatment and Active Labor Act] or Medicare/Medicaid. How emergency medicine fits into the equation is a big deal for everyone.”
The new Emergency Medicine -Action Fund differs from the National Emergency Medicine Political Action Committee (NEMPA) because it will not be used to support candidates, but instead will enhance advocacy aimed at the regulators who will draft new rules about how patients receive care and how health care providers are compensated. NEMPAC can only be used to support candidates, said ACEP President Dr. Sandra Schneider in a February letter that announced establishment of the new action fund.
Many small to midsize groups are joining, Dr. Fields said, an encouraging sign that they see this as important for them, too. “It doesn't matter whether you are employed by a hospital or a large health care entity or in private practice. Our purpose is to ensure that whatever happens with reform makes emergency care better for providers and patients,” he said. “There are so many things broken in the system that we try to put Band-Aids on. It would be wonderful if reform got us close to what we'd like to do, in particular for patients who don't have good access to follow-up or specialty care.”
One of the larger stakeholders to join the group, the American Academy of Emergency Medicine (AAEM), has traditionally taken an adversarial -position against large contract managements groups, which are also part of the fund. AAEM's leaders polled its members, laying out the pros and cons for them of participating in the fund. Although proponents said joining the fund would give AAEM the ability to speak out for independent physician-owned groups and positively influence the fund's direction, opponents called the move a giant step backwards that would make it more difficult for AAEM to fight against fee-splitting, denials of due process, and the corporate practice of medicine. Roughly 70 percent of those who replied to the survey were in favor of joining the group, prompting AAEM to contribute $25,000 to fund and accept a voting membership on the board.
“There was a lot of animated discussion on the board. We felt the only way we could have a sense of what our members would want was to ask them directly,” said Howard Blumstein, MD, the president of AAEM. “We got hundreds of responses. In the written comments, a fair number of respondents who were in favor of us participating still didn't like the idea, but they felt that the academy had to be at the table.”
Dr. Blumstein said he is not sure the fund will accomplish what his group expects. “I am afraid that the number of interests at the table who put business issues ahead of physician issues will be overwhelming,” he said, adding that the board of governors could be influenced by business interests that can afford to contribute more money to the fund than nonprofit groups. -According to the fund's website (www.acep.org/EMActionFund), groups, coalitions, and individuals -contributing at least $100,000 to the fund are eligible for one of 10 seats on the EMAF Board of Governors. The fund has already raised more than $1 million, with ACEP contributing $450,000 to launch the initiative, and ACOEP, CEP America, EmCare, EMRA, and TeamHealth donating $100,000 each. (Full list of contributors at http://bit.ly/EMAFcontributors.)
Businesses can take money from their revenue to devote to lobbying, but advocacy groups depend on the generosity of the people for whom they are lobbying, Dr. Blumstein said, although he added that emergency physicians and businesses have many interests in common. “They want to make sure that reimbursement for professional activities is fair,” he said. “I have no problem working together with anyone on an issue like that.”
Dr. Blumstein said the Patient Protection and Affordable Care Act could make it more difficult to practice emergency medicine and fundamentally change the relationship between patients and doctors. “If I was a business interest or hospital interested in directly employing physicians, I would be in favor of using the PPACA to further that agenda,” he said. “If I were advocating for preserving the doctor-patient relationship, I would be against that.”
He said he hoped EMAF lobbied in favor of preserving the doctor-patient relationship, but said he was “afraid that there are business interests for whom that sort of activity would go against their business model.”
James Adams, MD, the president-elect of the Association of Academic Chairs of Emergency Medicine, said his group felt it was essential to take part in the fund because of the many conversations going on in health care today, from funding and health care delivery to patient safety and the way insurance is structured. “It seems that every dimension of health care is being talked about and changed,” said Dr. Adams, also a professor and the chair of emergency medicine at Northwestern University Feinberg School of Medicine. “To manage the complexity, we have to simplify our messages. We have to stay patient-focused and have very clear thinking about what's best for our individual patients. While there are a lot of differing opinions in emergency medicine, there are a lot of things on which we agree. This organization can be effective.”
He, like others in the field, is concerned that misinformation may be informing the conversations, like the one that had Congress finding that patients in extreme need with no access other than the emergency department don't need to be there. “Of course they do,” Dr. Adams said. “They have no options. Those hearings are held without emergency medicine at the table. That's potentially tragic for our patients.”
He said he expects the Emergency Medicine Action Fund to be grounded in patient care, the specialty's fundamental ethic, while preserving the emergency physician's ability to complete his mission, which means well trained clinicians who have an economically sustainable model to continue to deliver care. And that, Dr. Adams said, is not a foregone conclusion.
Brian Zink, MD, a professor and the chair of emergency medicine at the Alpert Medical School of Brown University in Rhode Island and the secretary-treasurer of the academic chairs group, said the power of collaborating means a stronger voice for emergency medicine. Like Dr. Adams, he said the group will be most effective when it advocates for better patient care. “Many academic health centers are in urban areas with vulnerable and underserved populations. We feel the need to be able to speak for those patients who often do not have a lot of clout in medical politics,” he said. “They need help in bringing attention to their needs in terms of access to care and having high quality emergency care available to them.”
Dr. Zink said the fund also should advocate for augmenting the physician workforce and funding resident education, both of which are threatened. “If we are really going to move forward with the planned changes in health care, which includes medical homes and increased primary care access, a lot of those things depend on a physician workforce that's adequate,” he said, adding that current plans for reform do not adequately buttress the under-resourced primary care infrastructure. “To assume that there will be less emergency department utilization in the near future is foolhardy,” Dr. Zink said.
Dr. Fields, the fund chairman, said the California Emergency -Medicine Advocacy Fund, which included the California chapters of ACEP and AAEM and other emergency care providers, proved powerful in that state. Using that blueprint, he said he hopes to change the national conversation. “From the words coming out of the mouths of people in Congress and HHS [the U.S. Department of Health and Human Services], I don't think they understand that the emergency department is the interface between what happens in the community and what happens in hospitals,” he said. “We've been creating standards of when it's safe to be in the community and when it's safer to be in the hospital. That's a valuable resource and skill set.”
Those who write the federal rules often have little or no experience in health care, and don't even understand that all emergency physicians are not employed by hospitals, Dr. Fields said. “We need to teach health care 101; find a way to educate rule writers and policymakers.” He said the Emergency Medicine Action Fund is “very much policy driven,” not a potentially partisan political activity. He expects fund leaders to kick off activities around July 1 and for the full board to meet in the summer or early fall.
Already, he and other leaders are identifying consultants and counsel, many of whom have proven records in the advocacy arena. One group — Alston + Bird — has already drafted a summary of draft regulations for accountable care organizations, a key component of health reform. Regulatory agencies are tough to access, Dr. Fields said, and communicating with them is yet a bigger challenge. In collaboration, the Emergency Medicine Action Fund can access the services and people who can help package and endorse a message that meets the need of emergency -medicine as a whole, he said.
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