The Crisis in Emergency Medicine: ACEP President Addresses the Issues

     Since Frederick "Rick" C. Blum, MD, FACEP, assumed the presidency of the American College of Emergency Physicians (ACEP) last September, his plate has been more than full with a multitude of critical issues ranging from ED overcrowding and ambulance diversion to lack of funds for disaster preparedness. According to Blum, associate professor of emergency medicine, pediatrics and internal medicine at the West Virginia School of Medicine in Morgantown, the overarching issue is access to care capacity.

     "Emergency medicine is, by and large, a safety net for the whole healthcare system," he says. "As other parts of the healthcare system fail or don't perform the way they should, more falls on emergency medicine. So, what we're seeing across the country is that ED volumes have gone up and we have limited capacity. ED crowding then becomes an issue that spills out to the EMS community in increased off-loading and turnaround times and ambulance diversion."

     There are other critical issues for emergency providers, says Blum. "About 50% of all care for emergency medicine is unreimbursed, and I suspect it's a similar number for EMS. There is also the issue of preparedness. As a country, we've spent billions of dollars on preparedness, but virtually none of that has gone to emergency departments, and my understanding is that precious little has gone to the EMS community. We know that during a natural disaster or a terrorist event, a large number of patients will bypass the EMS system and present directly to the ED, so that's a big issue."

     In the recently released, first-ever National Report Card on the State of Emergency Medicine, the nation's emergency medical care system received an overall grade of C-, proving that emergency care in every state has significant deficiencies. The report card was the product of a task force of experts assembled by ACEP, which used a range of available data to develop 50 measures for grading each state on a scale of A through F for their support in four areas: access to emergency care, quality and patient safety, public health and injury prevention, and the medical liability environment. The result: 80% of the country earned mediocre or near-failing grades. That was not unexpected, says Blum.

     "You have to understand its intent," he explains. "Its intent was to call attention to some of the problems that we're facing as emergency physicians and providers. It was not to paint emergency medicine in the best possible light, but rather to bring out the problems that we all have."

     ACEP officials will continue to measure state efforts and improvements in emergency care over time, using the report as an initial benchmark.

     Under Blum's leadership, ACEP is taking major steps toward solving some of the problems.

     "We have a bill before Congress--H.R. 3875--that addresses some of these issues," he says. "It would provide some special liability protection for emergency medicine, at least with regard to our care for the uninsured. We've also asked for some special reimbursement consideration for dealing with our EMTALA-mandated services, which are unique to the specialty of emergency medicine. Part of that bill would include incentives to hospitals to end the practice of ED boarding, which would help alleviate our crowding situation so we can receive EMS patients in a more efficient manner. I would also like to see the federal government acknowledge our unique role in preparedness. Reimbursement is going to continue to be a challenge. We're going to have to deal with the pay-for-performance system that's going to be developed in the next year or two, and that will be a priority for us over the next couple of years. Taken together, those issues are pretty much a full plate."

     One of Blum's personal goals as president is to make the organization a stronger, more cohesive group.

     "One of the problems in emergency medicine is that there have become various factions and fractions," says Blum. "My intent as president is to try to pull those entities together to focus on some of the more significant problems rather than on our differences."

     So, what can prehospital personnel do to help physicians?

     "The more we can work together, the more successful we'll be," says Blum. "ED boarding issues directly impact EMS, so if that community can support some of the legislative and regulatory solutions that we have, it would go a long way toward affecting ambulance diversion and off-loading. Also, finding issues of common interest with regard to preparedness. What's it say when the emergency physicians and EMS community are not getting any benefit from all the billions of dollars spent on preparedness? My question to the government would be, 'Where are you spending the money?' That's an area where we can work together. The relationship between EMS and the emergency medicine community is unique in comparison to other relationships between physician and nonphysician providers. We've always shared a common bond in what we do, and I look forward to taking advantage of that for our mutual benefit and trying to get some of our problems fixed."