I write to you as a person with four decades of experience on the business side of health care, specifically in the revenue cycle industry. Importantly in those forty years, the overwhelming majority of my time was spent serving all of you in emergency medicine. At the outset of this article, I wish to express my appreciation and gratitude to each, and every one of you, for the opportunity to have served you. Throughout my tenure in the industry there were many moments spent in awe and admiration of what each of you do every day when you open those doors to your departments. Over the years I have come to know many of you personally. Particularly as your years of experience increase, I learned your preferred mode of interaction is to downplay the contribution you make with your patients in an almost self-effacing way. As a person who has encountered this numerous times, I continue to appreciate, stand in awe, and respect each of you.
In the following paragraphs I offer you a series of observations about your specialty, developed over time as well as some concluding thoughts I trust you will find encouraging.
Implicit trust
In the constantly expanding world of patient experience there are certainly some patients who do their own research about emergency departments and the associated staff. That said, when push comes to shove, and the patient’s clinical reality precludes any advanced research, your emergency departments are places where patients enter offering you implicit trust that you will take care of them. I suggest to you there is no other specialty where this quality of trust exists.
The special case of multi-tasking
Your ability to multi-task is special, indeed it is unique. A surgeon must maintain focus on the exact patient on the operating table. An office-based primary care physician, indeed may have twelve other patients in the waiting room, however, remains focused on the individual patient in front of her/him. You, however, are multi-taskers in a special manner. Within minutes your shift can pivot to include the multi-vehicle accident on the interstate, with twelve incoming patients; the cardiac patient who codes, while you are speaking with the weak-and-dizzy eighty-three-year-old grandmother, after stepping out of the exam room with the twenty-three-year GSW victim. These scenarios all characterize “routine” experiences you swiftly shift and manage with amazing cognitive and organizational abilities, I suggest best described as “multi-crisis” capabilities. This is, without question, an incredible mix of experience, knowledge, and wisdom all blended into both a mindset and skillset that separates you in the House of Medicine.
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Patient resource for their entire spectrum of care options
When referring your patients to their next point of care specialist your direct experience offers them the full spectrum your hospital and/or system can offer them. You have knowledge of all downstream care options, unlike other specialties. In many cases you may even actually personally know the specialist you direct your patients to, further reinforcing and substantiating your patients’ implicit trust described above.
Revenue source for your hospital and/or system
Even as care continues shifting to outpatient sites, emergency medicine continues to be a significant and substantial source for inpatient revenue. Since the financial aspect of this is masked due to the emergency department facility revenue being absorbed into the inpatient finances, you are nonetheless a key driver of hospital revenue. This can always be a legitimate conversation and even negotiation tactic with hospital administration.
The insurance industry: Everything has been thrown at you
Not authorized; no prior authorization; not medically necessary; out of network; non-emergent; bundled; down-coded; timely filing; suspended; medical records request; denied due to high-deductible; No Surprises Act, with associated arbitration delays, denials, lengthy negotiations, and cash-flow impediments. The latter referenced case of high-deductible plans merits a special note, as the bottom-line reality is through these plans insurers continue shifting more of the financial responsibility for care onto the backs of their members/your patients.
Many of the above codes date back literally into the original managed care era. Over time there has even been an evolution in the variety and extent of insurance carrier denials. One pivotal change caused this, namely the establishment of the prudent layperson definition of an emergency in the Balanced Budget Act of 1997. Even this definition has, however, not had a smooth history as insurers found ways to circumvent it.
I propose to you that emergency medicine has been the pilot study for insurers to evaluate and implement rejection codes, which has resulted in an unfathomable amount of financial hardship to the specialty.
Special case of COVID-19
I respect and understand the reluctance in accepting any connotation of “hero” being assigned to emergency medicine during the COVID-19 pandemic. Certainly, the entire House of Medicine experienced some impact of the pandemic. That said, dating back to the very beginning days when no one knew, nor understood the lethal capability of the virus, you never flinched in staring it down. You may not want to be known as heroes, but you will always deserve the highest degree and level of respect for all you did for all of us.
Recommendation for the future and BTW, what’s up with the “Land that plane” reference?
Special case of the American Academy of Emergency Medicine (AAEM) and the American College of Emergency Physicians (ACEP): Given that there is close to 100 percent agreement of virtually all issues germane to the specialty, I implore you to put aside any remaining issues for the sake of presenting an organized and unified front to all industry partners. I suggest division within the specialty has never benefited you.
The place of technology. As diseases and clinical presentations continue to pose obstacles to diagnosis and care, certainly any technological advance easing these challenges and enhancing better care will and should always be accepted. On the business side of emergency medicine, I strongly recommend partnering with organizations who are first, steeped in their commitment to continually innovating and developing new technological solutions to patient engagement, all matters pertinent to revenue cycle and especially keeping pace with and even staying ahead of what the insurance industry continues to throw at you. I implore you to embrace technology, while keeping a keen eye on all matters of compliance, ethics, integrity, and the necessity for human insight and oversight. My career spanned forty years with over twenty-five of those years working with the same core group of colleagues. I qualify my statements by reinforcing that I am not selling anything here. I will, however, make an emphatic statement that my career ended with Zotec Partners, a company who embodies the characteristics I recommend to you here.
The hospital C-suite. Always understand that any revenue cycle issues your practice is experiencing are also issues for your hospital administration partner. This presents you with a consistent and constant opportunity.
“Land that plane”
As I hope and trust I have demonstrated above, you as the specialty of emergency medicine have a unique blend and brand of experience, expertise, insight, knowledge, and skillset that separates you from other specialties. Combined, these characteristics bring you to the forefront for hospital partners and leadership positions. The health care industry is constantly changing and evolving, but for you it is time to slow down, embrace the moment, and back off the throttle. See the whole landscape from horizon to horizon. It is time to fully embrace your leadership opportunities in hospital administration, industry roles, and powerful political advocacy roles. You have what it takes to lead this health care industry as you leverage both your unique perspectives, gained over many trials, as well as your incredible decades of advocating and defending your patients. You have already flown through turbulent times, giving you all manners of experience. It is your time for you to now land the plane and move valiantly ahead as the respected leaders the industry desperately needs.
John Holstein is a patient advocate.
