Opinions expressed in the Correspondence section are those of the authors, and not necessarily of the editors, ACEP, or UAEM. The editors reserve the right to edit and publish letters as space permits.

CORRESPONDENCE T h e E m e r g e n c y P h y s i c i a n as Pol i t ica l S p e c i a l i s t

To the Editor: It is apparent that no longer can the emergency specialist

ignore the political and economic issues that have invaded our profession like an aggressive malignancy. The old days of "putting in the hours" and heading home are over for those of us who desire to see our specialty thrive (or even survive) in the marketplace.

We find ourselves competing not only with the large cor- porate infrastructures, but also among ourselves. We have outbid, outlawed, and outperformed our colleagues in an effort to catch that big fish, the hospital contract.

But it seems what we have reeled in is, in essence, an old shoe. Hospital administrators are more than aware of these techniques and can often walk away from the bargaining table with a signed list of their ridiculous demands from the "boys" in the "room." Mter all, they can always go with the Generic Emergency Group at a discount rate, ninety days down the calendar.

Our profession has emphasized quality at a time when, unfortunately, the Joint Commission and many hospital by- laws have opted for convenience.

If the federal government succeeds with DRGs, the next three to five years will see the dosing of between 600 and i,000 hospitals nationwide. The 3,000 to 5,000 emergency specialists who are affected will flood the market, and the

government will have effectively increased competition for the purpose of further limiting physician reimbursement.

What can be done? National ACEP has not been silent on these issues. The

amendment to the Budget Reconciliation Act (HR 4170), which defines "emergency" in ACEP's terms, owes its in- ception to the hard work of ACEP's Government Affairs De- par tment and the contribution of chapter members to NEMPAC. Although the Rostenkowski amendment may well postpone or hamper our efforts at passage, it is notable that support for the emergency definition will insure its eventual legal birthright.

This is the year in which every emergency specialist should become a political "specialist" as well. Involvement in NEMPAC and the Keyman program are starting blocks. It will also require a close relationship with our elected repre- sentatives, along with a "stethoscope" to the heartbeat of Capitol Hill.

Alan D Clark, MD, FACEP Emergency Department Sam Howell Hospital Cartersville, Georgia

E m e r g e n c y M e d i c i n e : L i m i t e d Hor izons?

To the Editor: In October 1983 the Health Care Financing Administra-

tion, the House Ways and Means Committee, and the Sen- ate Finance Commit tee accepted the ACEP compromise definition of a bona fide emergency. Although certainly a significant accomplishment by ACEP, we must recognize that we have won a battle, not the war. We must realize as a specialty society that the current dominant force in medi- cine is not equitable payment or quality, but cost. These battles will continue.

On October 1, 1983, 468 diagnosis-related groups (DRGs) covering inpatient hospital charges were partially imple- mented for Medicare beneficiaries. DRGs are designed to encourage hospitals to expend less money and yet receive a fixed amount of reimbursement~ 1 One example of cost re- duction is to admit patients wi thout having them go through the emergency department; no hospital emergency department Part A facility fee will be incurred.

In 1990 the number of practicing primary care physicians will have doubled within a decade. 2 Although emergency medicine was recently identified as a shortage specialty, our competitors in their offices will be extending their hours, cooperating as group practices, and even reinstituting, in some areas, the house call. Patients do not come to the emergency department because of easy parking, short waits, and inexpensive care - - they come seeking availability. Soon, most patients will have alternatives.

Last year approximately 80 million emergency depart-

ment visits occurred in the United States. 3 Assuming a full- time equivalent physician renders care to 6,000 undifferen- tiated visits per year, 13,333 emergency medicine specialists are needed. As reimbursement disincentives turn people from the emergency department and our competitors pro, vide them with an option, the emergency department will begin to approach as its clientele the 15% who are substan- tial emergencies and those turned away for whatever reason by the private sector. Even considering the fewer numbers of seriously ill or injured a single physician can care for, needed full-time equivalents in emergency medicine may well be cut in half.

Quality and effective medical care is the desired goal for ACEP and the patients we serve. Cost is also a legitimate concern for all of us. In a study that. I conducted from Janja- ary to June 1983 in Charleston, average emergency depart- ment charges for nonadmitted patients exceeded, by a factor of two to three times, the charges for identical services by the same physicians in a non-hospital-based facility. We cannot responsibly ignore these savings for essentially~ the same product.

In October 1983 at a Council of Medical Specialty So- cieties conference in Washington, DC, a prominent repre- sentative of another speciaky society asked ACEP Represen- tative Pamela Bensen, MD, if she realized that the life expectancy of emergency physicians, as a specialty, is rather short and on its way out (personal communicat ion, P

128/300 Annals of Emergency Medicine 13:4 Apr:i11984

Bensen, MD, October 7, 1983). The December 1983 Indiana EPIC mentions in an article on DRGs that "there are those that now question the very viability of emergency medicine as a specialty In the years ahead. "4 These comments are representative of concerns addressing long-term financial stability and career opportunities in emergency medicine. Costly emergency department care will be severely cur- tailed by third-party cost cutting and convenient care in set- tings other than hospital based.

Where lies the future of emergency medicine? What will we be in 1990? In 2000? We will be there in the emergency department caring for the seriously ill or injured, the unem- ployed, the indigent. We will be half our current numbers, salaried employees of the hospital, providing care to fewer, sicker people in need. We will be judged to an ever-increas- ing degree not only on our clinical capabilities and our worth as human beings, but on our effectiveness at keeping our employers' "bad debt" down and our willingness to make the institution more attractive to other members of the medical staff by not calling, not admitting, and by writ- ing orders.

We, as a specialty society, must look first to the future for our patients and then for the needs of our members. We must read the winds that blow about us, see the need to change for our mutual future, and assure society of both cost reductions and quality. Emergency physicians do more than re-start hearts and open chests. We reduce the Little Leaguer's dislocated finger; we remove the inquisitive 4- year-old's nasal foreign body; we sew the unsteady 1-year- old's forehead laceration; we remove the mechanic's imbed- ded corneal foreign body; and we definitively care for the mental uncertainty suffered by parents and patients over the less significant illnesses and injuries of life.

According to the December 19, 1983, issue of US News and World Report (page 64), 'As the men and women now in medical school work their way through years of training to practice medicine, the doctor glut is destined to get worse, creating a time of unprecedented turmoil for American phy- sicians . . . . "

Think to the future. If we become elitist, restrictive, we will see our career opportunities shrink and the positive im- pact emergency medicine has on society's health lessen. If we don't think, make a rational best guess for our future as emergency physicians, we commit the greatest and histor- ically most common error of our profession. We must not fail to recognize the changes that are occurring, the validity of the reasons behind some of those changes, and the need for us to change, too.

Jack Page, MD, FACEP Charleston, West Virginia

1. Schweiker RS: Report to Congress: Hospital Prospective Pay- ment for Medicare. Washington, DC, US Department of Health and Human Services, December 1982. 2. Report of the Graduate Medical Education National Advisory Committees. Washington, DC, US Department of Health and Human Services, September 1980, p 17. 3. Hospital Statistics, 1983 ed. Chicago, American Hospital As- sociation, 1983, p 22. 4. DeHart K: DRGs and emergency medicine, in Purbee B (ed): Indiana EPIC. Carmel, Indiana, Indiana Chapter, American Col- lege of Emergency Physicians, December 1983, p 2, 4.

[F.ddtor's note: Dr Page, a member of the ACEP Board of Directors, delivered this address to the Board on January 20, I984.]

ACEP Must Address the Economics of Emergency Medicine

To the Editor: Simon's letter on "Entrepreneurs in Emergency Medi-

cine" (November 1983;12:722) warrants consideration and discussion. ACEP was founded on the principle of providing emergency medicine care by competent physicians. In the last 15 years ACEP has been successful in convincing the public of the need for full-time, committed physicians in emergency medicine and in gaining acceptance by our med- ical peers of the specialty of emergency medicine. Peer I and II exams, the ABEM certification examination, the four CREM courses, the national conventions, and many other efforts attest to the enormous work and leadership ACEP has expended in the field of education.

Yet when one looks at the economic aspect of emergency medicine something is amiss. Why is there such a continu- ous turnover of emergency physicians in EDs? Why are there consistently, month after month, more than 350 posi- tions advertised in Annals? Why have the FECs had such an explosive growth in the past few years? Why have so many qualified and committed emergency physicians left the ED?

Some of the answers, I feel, may originate in three areas: 1) the dominance of the "entrepreneurs" and "skimmers" in

emergency medicine, 2) the failure of hospitals to grant equal departmental status for the emergency department within the hospital's organization, and 3) absence of the opinions and feelings of the rank and file members of ACEP in the decisions facing ACEP-nationally and locally.

Emergency medicine is the only field of medicine in which large multihospital groups secure contracts from the Atlantic to the Pacific, from the Great Lakes to the Gulf Coast. If hospitals can find qualified, stable physicians for their departments of radiology, pathology and anesthesiol- ogy, why not for their emergency departments? What ethi- cal and economic justification can the "entrepreneurs" give for skimming off a certain percentage of the ED's income for their own profit, especially when they have no direct clinical or administrative contact? Have a large number of emergency physicians become "indentured servants" for some absentee landlord?

The issue of equal departmental status for the emergency department with that of medicine, surgery, pediatrics, and OB-GYN within the hospital organization needs the politi- cal influence of ACEP, the JCAH, and the AMA. No matter

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