New ACEP president calls for greater partnership with managed care

An interview with:
Nancy J. Auer, MD,
President of the American College of
Emergency Physicians
Irving, TX

Editor's note: Nancy J. Auer, MD, the new president of the American College of Emergency Physicians (ACEP), says she would advocate a system in which EDs would function much like public utilities. It may be an extreme but plausible solution, Auer says, to the present reimbursement crisis afflicting EDs. Chattanooga, TN-born Auer came to emergency medicine while working on her residency training in neurosurgery. She is taking over the reins as the first woman president in ACEP's history at a time when emergency physicians are wrestling among themselves over whether to openly oppose the inroads made by managed care or to work to achieve change within the system. In addition to her duties as ACEP president, Auer is medical director of emergency services and chief of staff at Swedish Medical Center in Seattle, WA. She spoke to The Managed Care Emergency Department in January.

MCED: What do you hope to do for emergency physicians during your tenure as president of the college, particularly in light of the many issues they are facing under managed care?

Auer: Well, there are two things. One is to have the college take a hard look at where emergency medicine is going. We need to begin looking at our own future as a medical speciality under managed care. I have asked several committees at ACEP to help assess where the specialty will be in five or 10 years and what our needs are going to be for residency training and medical students. Manpower issues under managed care are going assume greater importance in the next few years as we consider whether we may end up with a physician surplus.

I also firmly believe we have to pay close attention to controlling our own health care costs as a specialty. As emergency physicians, we have not been successful in managing costs.Managing costs is relatively new for emergency physicians. And no matter whether there is a backlash by physicians against managed care practices, we still have to play a larger role in cost containment. Those are two important areas for me.

MCED: As president of ACEP, what do you believe is the biggest single issue or threat to your colleagues in the practice today?

Auer: The biggest threat today are the cutbacks in payments brought about by retrospective denials. I believe these denials have brought about a situation in which many hospitals won't be able to stay in business. We are already seeing rural facilities closing EDs due to these financial strains. There are inner city hospitals closing their departments because they can't afford to stay open. This is a genuine threat.

MCED: What are the solutions?

Auer: One solution that we would certainly need to explore further is having emergency medicine become a service modeled after certain public utilities, somewhat like police and fire department services. Unless EDs achieve more fairness and recognition from payers for the work they are truly performing, transforming them into something like tax-supported organizations would be a necessary option.

Granted, it is an extreme measure that is not the current model for many hospitals and physicians. I would much prefer working together with payers and the government in getting appropriate patient access and fair reimbursement for what we do.

I also believe that part of the reimbursement puzzle would be solved if we work harder on achieving higher levels of quality care. I am a big proponent of clinical guidelines, pathways, and outcomes research in emergency medicine. I truly believe that quality factors play a central role in the economics of emergency medicine. A lot of the cost found in the system would be eliminated if we focused on providing efficient medical care.

MCED: How viable is the idea of turning EDs into public utility-based models?

Auer: I don't think this is an issue the college needs to spend a lot of energy on currently. There are other reimbursement issues that are more immediate-such as more physician involvement in negotiated contracting-that could provide solutions to some of the dilemmas that we face.

But, I think this is a possible solution to keep in mind. When you look at relevant surveys, what matters most to the public is appropriate access to emergency medical care. So if we fail in providing that access in our current venue, then we may need to look at something radically different.

MCED: Emergency physicians today seem to be expressing a different, perhaps more conciliatory, attitude toward managed care than they did only a few years ago. Do you think providers are looking at managed care differently?

Auer: I am getting the sense that emergency physicians are caring more as individuals about economic responsibility. Part of this is a function of the growing phenomenon of providers creating formal partnerships with managed care organizations. Personally, I have always felt that we have a responsibility to our patients to consider their financial means as part of the whole health care picture when we evaluate them.

So if we say: "To hell with patients. I don't care whether or not they get stuck with the bill." I think we may be doing the patient a disservice. And if it does take an extra phone call to straighten things out for them or if it takes a few extra minutes to sit and talk to the patient and ask questions about their insurance coverage, everyone, including the patient, wins in the end.

MCED: So you agree with the role of the physicians as partner in the system?

Auer: Absolutely. It appears to be the prevailing attitude with many physicians today. Emergency providers should be entrusted in making decisions or taking a leadership role in the patient's overall well-being. But today, we are compelled to balance our clinical concerns with economic realities. We cannot separate what is right for the patient from what is right for the physician.

I also believe that physicians need to provide options to patients, to let them participate in the decision-making. That is a radical change.

Many patients come in with expectations that they need x-rays and other ancillary services. They feel they are entitlted to these services even when they're not medically necessary. And they get angry if we don't satisfy them.

I can remember attending conferences 20 years ago in which we debated whether it was proper for physicians to inform patients when a particular surgery wasn't covered by the insurer. Then, it was an ethical dilemma. Now, it is a financial necessity. We will have to increasingly assume the role of financial guides for our patients. In effect, we have become gatekeepers for our own part of the system. It is not a role [that] many physicians find comfortable.

MCED: Earlier you mentioned physicians playing a larger role in contract negotiations. What did you mean?

Auer: It's already beginning to happen. Emergency physicians, like all doctors, need to have an educated, sophisticated sense about the business of medicine. You have to understand the underlying factors that drive the practice. It is essential that providers play a direct role in the contracting process.

It is obvious that payers don't have good grasp of clinical issues. We've continued to debate that point in our specialty. But we haven't done enough to participate in that education process. For our part, by better understanding our own businesses and working with payers on clinical issues, we have a real opportunity for both sides to come to mutually agreeable solutions that will benefit ourselves and our patients.

Physicians have been insulated from this for too long. The government is looking at incidents of fraud. In many cases, the problem stems from sheer ignorance about government contracts and regulations. If we know what we are contracting for and what our entire business looks like, we will inevitably have much greater control of our professional lives.