The Central Line’s Interview with ACEP President Jouriles (Pt 1)


I had the pleasure of interviewing Dr Nick Jouriles, the President of ACEP, regarding the state of Health Care Reform and where Emergency Medicine and ACEP stand in regard to it. It was an enjoyable and wide-ranging conversation, which I will be posting in three parts over the next few days, due to its length.

It should come as no surprise that Dr Jouriles was well-versed and fluent in the language of healthcare reform. In fact, I was highly impressed by the power of his wonk-fu. Today’s installment starts with a general discussion of the challenges facing Emergency Medicine:

Dr. Yore: It must be pretty exciting to be the ACEP President during such a time of change.

Dr. Jouriles: Well, it is very exciting because we’ve always talked about emergency medicine as being the center of healthcare and what we do is important. We always talk about making a difference when you are in a leadership position and it all seems to be coming together right now. It’s very exciting.

Dr. Yore: As the ACEP President, you’ve got a challenging role in that you’re an advocate for the professional interests of emergency physicians but ACEP is also an advocate for the patients that we serve in the ER and I can see those interests could be competing at times. How do you balance those priorities?

Dr. Jouriles: It’s easy because there really isn’t much of a balance. I can’t imagine often, if at all, when there is competition between the two. We’re in a very nice position as emergency physicians in that what’s good for our patients, is generally good for us. In the concept of healthcare reform, we don’t really have to go out and talk about what’s good for us. We really have to talk about what’s good for the patients and that’s a pretty easy thing to do. When we get into competitions it may be with other specialties, but in terms of the general concept of what’s good for the public, what’s good for the public is good for us.

Dr. Yore: What do you perceive to be the most pressing threat to the fabric of the emergency safety net today?

Dr. Jouriles: Well the current system that we work under, which is the Medicare system, which was designed in the 1960s, does not provide resources for emergency care. So back for the first 20 years of Medicare when there weren’t quite so many demands on the system and there weren’t quite so many demands on physicians and there was a fee for service and environment where there is a lot of cost shifting — you could charge somebody double what you needed to in order to pay for the people who wouldn’t pay. It worked out great until we got into the 1980s where EMTALA said you must treat everyone. In the 1990s where we got into managed care, where the insurance companies said, “We are going to put our profits ahead of paying you.” So the resources started to come out of the system. So demand has grown and the resources have gotten worse and the threats from the liability issue have increased.

We are at a point where you are actually getting penalized under the current system if you take care of patients in an emergency situation. That’s true for hospitals; that’s true for emergency physicians; that’s true for the on-call doctors. So if you look at what’s happening, people are trying to work away from taking care of sick patients; physicians and healthcare providers and hospitals and what not are trying to get away from taking care of sick people except for on an elective basis for the high margins. If you talk to the public, the public just assumes that there will be care for them when they get sick in their moment of need. There is absolutely no resource for that. That’s what the threat is. The opportunity for us is to educate the public that if they truly want healthcare to be their for them in their time of need then they need to put the resources into it. I think once the public gets it that Congress will come along.

Dr. Yore: It’s interesting how all those crises we talk about in emergency medicine: the overcrowding crisis, the lack of on-call specialists, the problem of boarding patients in the ER, can be traced back to a fundamentally flawed reimbursement system.

Dr. Jouriles: Which can be traced back to the way Medicare was set up. Remember when Medicare was set up emergency medicine did not exist. Then on top of that, we have been playing catch up ever since. But then you throw on top of that the EMTALA mandate which was never funded so now you have the liability issue where we are required to provide 24×7 state-of-the-art care for every single medical problem yet there is no funding for that infrastructure. And there is no funding for the patients we are told we have to take care of whether we want to or not. It’s a privilege to take care of the patients but without being paid for any of this we, as emergency physicians, bear an undue burden for uncompensated care. Orders of magnitude more than the primary care doctors, yet we are not being perceived by the powers in DC as being of value. We’re looked at as a failure of the system when in reality we are providing more care per physician than any other specialty.

Dr. Yore: There are a lot of exciting things happening on the hill these days. ACEP’s legislative priority has been the “Access to Emergency Care Act.” You want to talk a little bit about that and where it stands now?

Dr. Jouriles: Sure. We have been privileged to have two wonderful sponsors in the House and two wonderful sponsors in the Senate with Bart Gordon of Tennessee and Pete Sessions of Texas as our Democrat and Republican in the House and then Debbie Stabenow is our Democrat in the Senate and Arlen Specter formerly as our Republican Senator. We’ve been able to get close to, in the last Congress, 200 co-sponsors and now I think we are hovering around 150 co-sponsors. That’s a lot. It’s probably not going to get passed as a standalone but it looks like as of this morning pieces of our bill are going to be incorporated into the global bill that’s going to go in front of the House and the Senate.

Dr. Yore: What is ACEP doing to ensure that the voice of emergency physicians is being heard in Washington as these massive health reforms proceed?

Dr. Jouriles: Well there are two things that matter in DC. One is votes and one is money to get votes. The more we can get the public on our side, that means more votes and the politicians respond to their constituents. We have launched PR campaigns, both nationally and locally, to try to get the word out about the need for emergency medicine. Every politician has to run a re-election campaign so we have tried to collect a lot of PAC money so that we can support the people who support us. We have been sending record numbers both for the number of media hits we’ve had and also for the number of PAC dollars. Our goal, at least my goal as President, was to make sure that we had the largest medical PAC because we want, during the time of healthcare reform, to make sure we have more access than everyone else.

Dr. Yore: How close are we to that point?

Dr. Jouriles: We’re number four and we’re about half of where the AMA is, yet only one out of every five members actually contributes to NEMPAC. If we could simply double the number of people who contribute or if we could get up to where half of our people contribute, we would clearly be number one.

Continued here with Part Two

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