June 23, 2025 • 19 mins
Dr Gillian Schmitz former ACEP president and current vice chair of education at Naval Medical Center San Diego, examines emergency medicine's financial crisis and its consequences. She identifies the fundamental contradiction in how America treats emergency care as a universal right while funding it as a privilege, creating an unsustainable system where nearly 70% of ED patients don't cover their care costs.
• Former ACEP president with extensive experience in civilian and military emergency medicine
• Healthcare in America faces a fundamental conflict between right vs privilege approaches
• Nearly 70% of emergency department patients don't pay the full cost of care
• Insurance companies making billions while avoiding fair payment for emergency services
• Boarding and overcrowding have reached dangerous levels affecting patient safety
• Physician groups facing consolidation as independent practice becomes financially nonviable
• Potential solutions include better insurance accountability and reconsidering funding models
• Some physicians consider unionization and collective action as necessary steps
• Media portrayal through shows like "The Pit" helps public understand emergency medicine challenges
We need the public to understand how emergency care is funded – or not funded – and the impact of this unfunded mandate on the entire healthcare system. Without addressing the root cause, boarding, violence, and consolidation will continue to worsen.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
ask you to say that again who are you?
Speaker 2 (00:03):
and what do you do?
Hi Mel, I'm Jillian Schmitz, Iam a professor at the Uniformed
Services University and Icurrently am the vice chair of
education at the Naval MedicalCenter, San Diego.
Speaker 1 (00:15):
And you've had a sort of an interesting career.
Tell us that you're not activemilitary.
Your husband is, but youstarted and ran a residency for
like 11 years.
Speaker 2 (00:23):
Yeah, so I've been in academics all of my career and
I helped start a civilianresidency program in San Antonio
back in 2011.
And we were there for a numberof years.
And then, because my husbandwas active duty military, I got
interested in military medicineand working with our military
residents, and so I worked for anumber of years at Brook Army
(00:46):
Medical Center, which is acombined Army Air Force
emergency medicine residencyprogram, and we just moved to
San Diego about 18 months ago.
So now I'm with the Navyresidents at a four-year program
in San Diego.
Speaker 1 (01:00):
And you were also the president of ACIP.
Was it 2020 or 2021?
Speaker 2 (01:04):
2021.
So I've been very interested inhealth policy and advocacy and
that's sort of my way ofcombating burnout is trying to
get involved and trying to makea difference and finding
solutions to some of thesevexing problems that face the
specialty.
Speaker 1 (01:19):
So you have some history with emergency medicine
at the highest level.
So this RAND study came out.
I talked to Al Cicchetti andPeter Vecelio, dave Schreiger,
and they're a little older thanyou and I in their 70s so they
were able to talk about whatemergency medicine was like
practicing in the mid 80s.
It was a really interestingconversation, but I wanted to
(01:39):
get your take, having recentlybeen the president of ASEP,
about what you think are thetake-home points from this RAND
study.
Speaker 2 (01:46):
I think the take-home points to me is the really
fundamental question of ishealthcare a right or is it a
privilege?
And we are a littleschizophrenic in our country in
how we address that.
That for years we've beenfeeling like it is a right and
you've heard several USpresidents say well, if you need
healthcare, you go to the ER.
They'll take care of youanywhere, anytime, anyplace, and
(02:08):
that is our privilege and ourhonor of emergency physicians to
do that.
But we've been funding it as ifit's a privilege and those two
tenants are really incompatibleat best and really you know at
this point you know incompatible.
And we've said for decades thatwe are the safety net of
healthcare in the United States.
But that safety net has becomeso frayed that we now have giant
(02:31):
holes in that safety net thatit's really loose threads.
We're seeing hospitals closing,physician groups consolidating
and I think all of the long-termaspects of boarding,
overcrowding, violence in theemergency department,
consolidation those are all theaftermath of really how we
finance healthcare and thisreport just a couple hundred
(02:54):
pages of light reading reallystrikes a chord of.
We need to figure out how topay for EMTALA and this unfunded
mandate that we've somehowsubsidized for the past couple
of decades is no longersustainable and if we don't find
a solution to this, healthcareand access to emergency care as
we know it will fall apart.
Speaker 1 (03:14):
There's a new dog in town, and when you were ASIP
president, you probably spentsome time talking to a lot of
Congress people and had a senseof where things might go.
Do you have a sense now wherethings might head now in terms
of our current administration?
Speaker 2 (03:28):
I don't think anyone knows the answer to that
question.
I do know that there isn'treally an appetite for providing
more funding for healthcare.
If anything, the government istrying to make cuts and there's
a couple of bills being proposedright now that would tie
Medicare to at least inflation,which would be a step up from
(03:50):
where we are now.
We'll have to see, you know,ultimately, if that passes
Congress.
But the problem and the way Ikind of oversimplify it for my
residents is you know, obviouslyevery emergency department has
their unique payer mixes.
But if you could take all 5,500emergency departments in the
country and put them into onebig pie chart and you look at
(04:10):
who comes to the ED and how isit paid for, over two-thirds of
our patients do not pay the costof care.
Let that sink in for a second.
How would any other businessstay open if, if two thirds or
nearly 70% of their customersdidn't pay for the cost of
services?
It's like if they've told youMel, you know you have to open
(04:32):
up a McDonald's and people arehungry and we want you to give
them free hamburgers.
We're not going to pay you forit, but you have to do it.
It's a mandate and if you don't, we're going to fine you for
tens of thousands of dollars.
The only way to make thatsustainable is to charge really
expensive milkshakes right tooffset and subsidize that cost,
(04:56):
and for years the way we've donethat is to charge essentially
the private payers.
So people like Brewcloth,spooshield, united, aetna would
help essentially pay that extracost of the uncompensated care
that we're providing.
But they're not doing thatanymore, right, they are coming
up with every sort of reason notto, and downcoding and delaying
payments, which ultimately wehave now this big gap of who's
(05:17):
paying for all thisuncompensated care, and we can't
.
The patients aren't paying it,the government's not paying it
and now the insurers aren'tpaying it, and so at some point,
how do we get this funded iskind of the fundamental question
.
But when we go to Congressevery year, you know they are
very reluctant to say, well,that's great.
You know, as they empty outtheir pockets, where is that
(05:39):
money going to come from?
You know who's going to pay forthat.
You know we can't even pay forMedicare Social Security as it
is right now.
Where is that funding going tocome from?
Speaker 1 (05:49):
That's a bleak picture.
I didn't realize it was 70%.
I thought it was like 50%, butnearly 70%.
It's crazy.
So where does this go?
Can you put on your sort ofwizard hat and say where do you
think this will be in one year,five years?
Because, I agree, I don't thinkthat there is any political
will to add funding at all.
(06:10):
I mean, all we're seeing isreducing funding, and I get it.
I'm a fiscal conservative inthat.
I think our debt is incrediblylarge and we need to fix it.
But is this the place to fix it?
So where do you think thingsare going?
Speaker 2 (06:22):
So this report kind of calls on state and local
agencies to help provide fundingfor things like substance abuse
, for a lot of the preparedness,and some of that makes sense to
me and I think when you look athow we fund fire departments
and police departments you knowit isn't necessarily just for
the calls they get, it's forpreparedness, right, being ready
in case something happens andrecognizing that we have to pay
(06:44):
for preparedness.
And I being ready in casesomething happens and
recognizing that we have to payfor preparedness and I think
COVID, you know, reallyhighlighted that that things
happen, that we are notanticipating and we have to be
ready no matter what.
And there is a cost of that.
And I think you could make acompelling argument for the
government to have some sort ofsubsidies to pay for that
emergency care.
But where I really see adifference is holding insurance
(07:05):
companies accountable.
When you look at how much theyare making billions of dollars
in profits, like not millions,literally billions, trillions
that they should be doing theirfair share.
And we passed some legislationto try and have some fairness in
the no Surprises Act and tryingto have patients taken out of
the middle.
But it is not really beingexecuted to the point where it
(07:27):
is holding insurance companiesaccountable and they continue to
kind of get away from payingtheir fair share.
And I think if the governmentcould at least put in some
guardrails that would reallyhold insurance companies
accountable and have them reallybe the person who helps fund
that safety net.
It would help provide somefinancial relief for emergency
(07:49):
departments.
Speaker 1 (07:50):
How are other countries dealing with this?
The entire Western world isaging.
More people are using theemergency departments.
On the one hand, it feels goodbecause your job's not going
away anytime soon, but it's allabout compensation.
So how is Canada doing it?
How is Australia?
How's?
Speaker 2 (08:06):
England Everyone pays a higher tax rate where you
have same and similar access tocare.
There are certainly pros ofthat model.
There's also some cons, where alot of places they have to wait
months, years to get a hipreplaced.
So there's advantages anddisadvantages.
A lot of companies have, orcountries have, a two-tiered
(08:29):
system where there is a publicoption and there's a private
option, where some healthcare issubsidized by the government
and then if you want to pay foradditional services or premiums,
that those are available.
There's a lot of differentoptions that have been put out
there.
I think politically it has beendifficult, as we've had
discussions on Medicare for allif that's something our country
(08:51):
could support how that wouldaffect Medicare and Medicaid.
But when Medicare was enactedright, there weren't as many
people who were 65 and older and, as we've seen, that baby
boomer generation now get intotheir 70s, 80s, 90s and patients
are becoming sicker.
They're consuming moreresources.
We don't have the funds tocontinue supplementing it the
(09:15):
way that we have.
But politically nobody wants totake anything away from seniors
.
So how do you thread thatneedle and how do we continue to
fund it?
I've seen over the last 10 yearsa shift, I think, in physicians
, where 20 years ago, talkingabout Medicare for all or having
some kind of public system wasuntenable.
(09:36):
I'm hearing more and more atthe AMA and other organizations
about really advocating for this, and I think part of it is
recognizing that we can'tcontinue what we're doing, that
it's not sustainable and that weneed to have a better system.
In particular, the way thatinsurance companies and this
vertical consolidation thatwe've seen is changing the
(09:57):
landscape of healthcare, I thinkis concerning people and
recognizing that we have to dosomething different.
Speaker 1 (10:03):
The numbers when you look at the summary of the RAND
report, all in the wrongdirection.
The complexity of patients isgoing up, the age of the
patients is going up and thepayments are going down.
There's only one outcome forthat if things don't change, and
that is the collapse of thesystem.
And what we're seeing is, Ithink, that collapse right now,
with boarding and other thingsgoing on.
Where it's interesting becausePeter Fogelio said we've had
(10:26):
this crisis for 40 years Now.
He was talking about this inthe 80s and there was some
really strong discussion betweenthose guys, but I've never seen
it this bad.
I've been here for 33, 34 yearsand I've worked at UCLA.
When I first got here and itlooked completely different than
it does today, the residentstoday have 60, 80 patients
(10:49):
waiting.
They are doing hallway medicine.
We didn't do any of that when Idid my residency in the early
90s.
That wasn't a thing.
Speaker 2 (11:00):
So it is worse, and I hear that from almost everybody
.
Yeah, I think boarding has beenaround a long time but to the
point now where the majority ofpatients we're seeing are
actually in the waiting room isbecoming the norm and that's
frightening and that's dangerous.
And yet we've had so manystudies showing that increases
mortality that this is obviouslybad for patient satisfaction.
It's high risk management butit continues because of the
financial structures thathospitals aren't staffing half
(11:23):
of the floors upstairs, we don'thave enough nurses and people
are trying to figure out how dothey cut staffing in the
emergency department to savecosts when, if anything, you
should be investing and havingmore staffing so we can get to
these patients.
And it really is infuriating.
But I think this is all atrickle-down effect of how we
pay for health care and if wegot paid, if we could even keep
(11:44):
up with just inflation, thatwould help subsidize some of
those costs.
That would allow us to be moreproactive.
This report also calls for anincreased primary care net right
of recognizing that some ofwhat we do in the emergency
department is not just emergencycare but acute, unscheduled
care and having a system thatwould better take care of those
patients where they have amedical home and a place to go
(12:06):
where we can be both primarycare, emergency care,
preparedness, like there'slimits to what we can do in an
eight-hour shift, like there'slimits to what we can do in an
eight hour shift.
And until we fundamentallyrecognize that and pay for it
and set up a structure thatsupports that with more
coordinated care, it's going tocontinue to be a challenge for
us in the emergency department.
Speaker 1 (12:23):
So there was a suggestion, two suggestions from
the prior panel, and one ofthem came from Dave Schroeger
said the only way we're going tofix this problem is if we go on
strike that we keep year afteryear, decade after decade, just
solving the problem.
Nobody's going to listen.
This isn't going to get fixeduntil there is basically a we
(12:43):
unionize as physicians and go ona national strike and say we
can't do this anymore.
So that was one radicalsuggestion.
And then Al Cicchetti was onthe other side.
Like I can't do that.
I'm an ER doc, I'm in there,I'm seeing patients If they're
sick.
I can't not do that.
So where do you stand with?
We're at a bad place.
(13:04):
Is it time for radicalsolutions like Dave Shredarigo
is suggesting, or is that justgoing to fail because ER docs
are just going to go to work andlook after people, because
that's what we do going to go towork and look after people?
Speaker 2 (13:12):
because that's what we do.
What a great question.
We were actually just talkingabout this yesterday.
There's a resolution in the AMAand their code of ethics of
what do physicians do aboutunionization?
What do we do about striking?
And fundamentally it seems likethat is a contraintroduction to
what we do with our Hippocraticoath that we guarantee that
we're going to take care ofpatients and that by striking,
(13:33):
by definition you're puttingpatients potentially at harm.
But there are ways you can setit up.
Where you have other people,you make sure you have coverage,
that there's no gaps wherepeople can make a stand, and
we've really ASAP has lookedinto this of what are the
benefits and the cons ofunionization, of striking, as
we're seeing that more and moreacross our specialty over the
(13:54):
last couple of years, of tryingto have a collective voice and
collective bargaining to improveour workplace environment, and
in some places it can be veryeffective.
I think one of the thingspeople have to understand is not
everybody can strike and noteverybody can unionize.
So, by definition, if you arean independent group and you
have ownership in your practice,you can't be part of a union.
(14:15):
So there's limits on if you'rehospital employed, depending on
your employment structure, ofwhether you are allowed to be in
a union really limitspotentially what you can do.
But I do think there is a rolefor collective bargaining, of
really making this more of apublic issue.
Clearly, the legislators are nothearing how desperate the
(14:35):
situation is, and I think thiswas the intent of the RAND
report was to the audience.
Is not emergency physiciansright?
We all know that boarding,crowding, violence this is our
everyday life.
The audience here is really awake up call to legislators of
like this situation is gettingdire and we need to address it
now.
But if this doesn't work and ifpolicy is not working, I kind
(15:00):
of understand Dave Treiger'spoint of maybe this is the time
that we have to kind of bandtogether and speak out and do it
in a way that's safe, thatdoesn't jeopardize patient care,
but really highlights tohospitals and to the public who
ultimately we need their voicesto stand up and say, yes, we
need to do better in order toaffect change.
Speaker 1 (15:16):
I don't know if you watched the Pit.
Speaker 2 (15:18):
Ooh, I love it.
Speaker 1 (15:20):
Excellent.
I'm so glad To the writers ofthe Pit.
I'm going off to to thewriters' room here in a little
while.
What would you ask them to do?
What message would you likethem to give to the general
public as part of what is reallya public health show?
It's entertaining, but it'salso a lot about what's wrong
with emergency medicine rightnow.
(15:40):
What would you have them say tothe millions of people that
watch every episode?
Speaker 2 (15:45):
First of all, thank you for doing that show and for
all the writers.
I think it has really helped usbe seen as emergency physicians
and help the public tounderstand many of the
challenges that we face day today.
I think the example that wetalked about of financing most
of the public doesn't realizehow emergency care is funded or,
in this case, not funded, andhow this unfunded mandate is
(16:07):
causing boarding, is causingthis backup of staffing.
And if we could explain topeople that the vast majority of
patients don't actually pay thecost of care and that emergency
physicians are required by lawand we are proud to do so, but
we can't continue to seeeveryone everywhere every time
(16:28):
without financing it andultimately that's going to cause
more boarding and crowding andgiving them that example of the
majority of patients don't paythe cost of care.
How would any other businessmaintain their operations and
keep their doors open iftwo-thirds of their customers
got free labor or free goods?
So we need to fundamentallyaddress how we do this and until
(16:51):
we really get to that rootcause, there's going to be
boarding, there's going to beviolence, there's going to be
more consolidation and I thinkyou just did a great job on the
pit of kind of examples aboutpatient satisfaction scores and
boarding times and having theircontract at risk.
You know, this report reallyhighlights that the people who
are most at risk are those likeDr Ravi's.
(17:12):
It's the independent groups thatare staffing emergency
departments that this system isreally making it a big concern
that that may not be a viablepractice anymore in the future,
that you may have to be a largemega group in order to be able
to fairly negotiate withinsurers and if we don't have a
system that disrupts thatconsolidation, that business
(17:35):
model of independent practice,it may not be financially viable
.
And that is a big concern andshould be a concern for
physicians, for patients, forthe public of recognizing that
competition in the workplace isa good thing.
We want to be able to drivepatient satisfaction to really
address quality.
But without having thoseguardrails and that financial
(17:55):
guarantee in place, we're goingto see more consolidation and I
think that concern that many ofus have as much as people don't
like big corporate groups.
Well, what if the insurancecompanies own us right groups?
Well, what if the insurancecompanies own us right?
If we see consolidation?
Where now the insurancecompanies whose whole business
model is to deny care to notcover costs.
Now, own physicians like thatshould terrify everybody because
(18:19):
ultimately, their goals are indirect conflict of ours of
providing patient care, ofcovering expenses, of covering
access.
That that could be where we'reheaded if this is not addressed.
Speaker 1 (18:32):
As always, a huge shout out to Joe Sachs, who made
the first season of the Pit sogood, so medically accurate and
brought up so many of thesethings.
We all in emergency medicineshould tap him on the back and
say thanks, joe, for letting usbe seen.
He did such an amazing job onthat first season and I'm hoping
the second season is going tobe just as good.
Thanks to Dr Schmitz and thankyou all for listening and we'll
(18:54):
continue these discussions andif you've got any suggestions of
people you'd like me tointerview, let me know.
I'm a little more timeconstrained right now because of
the pit, but let's cue some ofthese smart people up and get
them on the show.
Talk to you soon, herbert out.
ask you to say that again who are you?
Speaker 2 (00:03):
and what do you do?
Hi Mel, I'm Jillian Schmitz, Iam a professor at the Uniformed
Services University and Icurrently am the vice chair of
education at the Naval MedicalCenter, San Diego.
Speaker 1 (00:15):
And you've had a sort of an interesting career.
Tell us that you're not activemilitary.
Your husband is, but youstarted and ran a residency for
like 11 years.
Speaker 2 (00:23):
Yeah, so I've been in academics all of my career and
I helped start a civilianresidency program in San Antonio
back in 2011.
And we were there for a numberof years.
And then, because my husbandwas active duty military, I got
interested in military medicineand working with our military
residents, and so I worked for anumber of years at Brook Army
(00:46):
Medical Center, which is acombined Army Air Force
emergency medicine residencyprogram, and we just moved to
San Diego about 18 months ago.
So now I'm with the Navyresidents at a four-year program
in San Diego.
Speaker 1 (01:00):
And you were also the president of ACIP.
Was it 2020 or 2021?
Speaker 2 (01:04):
2021.
So I've been very interested inhealth policy and advocacy and
that's sort of my way ofcombating burnout is trying to
get involved and trying to makea difference and finding
solutions to some of thesevexing problems that face the
specialty.
Speaker 1 (01:19):
So you have some history with emergency medicine
at the highest level.
So this RAND study came out.
I talked to Al Cicchetti andPeter Vecelio, dave Schreiger,
and they're a little older thanyou and I in their 70s so they
were able to talk about whatemergency medicine was like
practicing in the mid 80s.
It was a really interestingconversation, but I wanted to
(01:39):
get your take, having recentlybeen the president of ASEP,
about what you think are thetake-home points from this RAND
study.
Speaker 2 (01:46):
I think the take-home points to me is the really
fundamental question of ishealthcare a right or is it a
privilege?
And we are a littleschizophrenic in our country in
how we address that.
That for years we've beenfeeling like it is a right and
you've heard several USpresidents say well, if you need
healthcare, you go to the ER.
They'll take care of youanywhere, anytime, anyplace, and
(02:08):
that is our privilege and ourhonor of emergency physicians to
do that.
But we've been funding it as ifit's a privilege and those two
tenants are really incompatibleat best and really you know at
this point you know incompatible.
And we've said for decades thatwe are the safety net of
healthcare in the United States.
But that safety net has becomeso frayed that we now have giant
(02:31):
holes in that safety net thatit's really loose threads.
We're seeing hospitals closing,physician groups consolidating
and I think all of the long-termaspects of boarding,
overcrowding, violence in theemergency department,
consolidation those are all theaftermath of really how we
finance healthcare and thisreport just a couple hundred
(02:54):
pages of light reading reallystrikes a chord of.
We need to figure out how topay for EMTALA and this unfunded
mandate that we've somehowsubsidized for the past couple
of decades is no longersustainable and if we don't find
a solution to this, healthcareand access to emergency care as
we know it will fall apart.
Speaker 1 (03:14):
There's a new dog in town, and when you were ASIP
president, you probably spentsome time talking to a lot of
Congress people and had a senseof where things might go.
Do you have a sense now wherethings might head now in terms
of our current administration?
Speaker 2 (03:28):
I don't think anyone knows the answer to that
question.
I do know that there isn'treally an appetite for providing
more funding for healthcare.
If anything, the government istrying to make cuts and there's
a couple of bills being proposedright now that would tie
Medicare to at least inflation,which would be a step up from
(03:50):
where we are now.
We'll have to see, you know,ultimately, if that passes
Congress.
But the problem and the way Ikind of oversimplify it for my
residents is you know, obviouslyevery emergency department has
their unique payer mixes.
But if you could take all 5,500emergency departments in the
country and put them into onebig pie chart and you look at
(04:10):
who comes to the ED and how isit paid for, over two-thirds of
our patients do not pay the costof care.
Let that sink in for a second.
How would any other businessstay open if, if two thirds or
nearly 70% of their customersdidn't pay for the cost of
services?
It's like if they've told youMel, you know you have to open
(04:32):
up a McDonald's and people arehungry and we want you to give
them free hamburgers.
We're not going to pay you forit, but you have to do it.
It's a mandate and if you don't, we're going to fine you for
tens of thousands of dollars.
The only way to make thatsustainable is to charge really
expensive milkshakes right tooffset and subsidize that cost,
(04:56):
and for years the way we've donethat is to charge essentially
the private payers.
So people like Brewcloth,spooshield, united, aetna would
help essentially pay that extracost of the uncompensated care
that we're providing.
But they're not doing thatanymore, right, they are coming
up with every sort of reason notto, and downcoding and delaying
payments, which ultimately wehave now this big gap of who's
(05:17):
paying for all thisuncompensated care, and we can't
.
The patients aren't paying it,the government's not paying it
and now the insurers aren'tpaying it, and so at some point,
how do we get this funded iskind of the fundamental question
.
But when we go to Congressevery year, you know they are
very reluctant to say, well,that's great.
You know, as they empty outtheir pockets, where is that
(05:39):
money going to come from?
You know who's going to pay forthat.
You know we can't even pay forMedicare Social Security as it
is right now.
Where is that funding going tocome from?
Speaker 1 (05:49):
That's a bleak picture.
I didn't realize it was 70%.
I thought it was like 50%, butnearly 70%.
It's crazy.
So where does this go?
Can you put on your sort ofwizard hat and say where do you
think this will be in one year,five years?
Because, I agree, I don't thinkthat there is any political
will to add funding at all.
(06:10):
I mean, all we're seeing isreducing funding, and I get it.
I'm a fiscal conservative inthat.
I think our debt is incrediblylarge and we need to fix it.
But is this the place to fix it?
So where do you think thingsare going?
Speaker 2 (06:22):
So this report kind of calls on state and local
agencies to help provide fundingfor things like substance abuse
, for a lot of the preparedness,and some of that makes sense to
me and I think when you look athow we fund fire departments
and police departments you knowit isn't necessarily just for
the calls they get, it's forpreparedness, right, being ready
in case something happens andrecognizing that we have to pay
(06:44):
for preparedness.
And I being ready in casesomething happens and
recognizing that we have to payfor preparedness and I think
COVID, you know, reallyhighlighted that that things
happen, that we are notanticipating and we have to be
ready no matter what.
And there is a cost of that.
And I think you could make acompelling argument for the
government to have some sort ofsubsidies to pay for that
emergency care.
But where I really see adifference is holding insurance
(07:05):
companies accountable.
When you look at how much theyare making billions of dollars
in profits, like not millions,literally billions, trillions
that they should be doing theirfair share.
And we passed some legislationto try and have some fairness in
the no Surprises Act and tryingto have patients taken out of
the middle.
But it is not really beingexecuted to the point where it
(07:27):
is holding insurance companiesaccountable and they continue to
kind of get away from payingtheir fair share.
And I think if the governmentcould at least put in some
guardrails that would reallyhold insurance companies
accountable and have them reallybe the person who helps fund
that safety net.
It would help provide somefinancial relief for emergency
(07:49):
departments.
Speaker 1 (07:50):
How are other countries dealing with this?
The entire Western world isaging.
More people are using theemergency departments.
On the one hand, it feels goodbecause your job's not going
away anytime soon, but it's allabout compensation.
So how is Canada doing it?
How is Australia?
How's?
Speaker 2 (08:06):
England Everyone pays a higher tax rate where you
have same and similar access tocare.
There are certainly pros ofthat model.
There's also some cons, where alot of places they have to wait
months, years to get a hipreplaced.
So there's advantages anddisadvantages.
A lot of companies have, orcountries have, a two-tiered
(08:29):
system where there is a publicoption and there's a private
option, where some healthcare issubsidized by the government
and then if you want to pay foradditional services or premiums,
that those are available.
There's a lot of differentoptions that have been put out
there.
I think politically it has beendifficult, as we've had
discussions on Medicare for allif that's something our country
(08:51):
could support how that wouldaffect Medicare and Medicaid.
But when Medicare was enactedright, there weren't as many
people who were 65 and older and, as we've seen, that baby
boomer generation now get intotheir 70s, 80s, 90s and patients
are becoming sicker.
They're consuming moreresources.
We don't have the funds tocontinue supplementing it the
(09:15):
way that we have.
But politically nobody wants totake anything away from seniors
.
So how do you thread thatneedle and how do we continue to
fund it?
I've seen over the last 10 yearsa shift, I think, in physicians
, where 20 years ago, talkingabout Medicare for all or having
some kind of public system wasuntenable.
(09:36):
I'm hearing more and more atthe AMA and other organizations
about really advocating for this, and I think part of it is
recognizing that we can'tcontinue what we're doing, that
it's not sustainable and that weneed to have a better system.
In particular, the way thatinsurance companies and this
vertical consolidation thatwe've seen is changing the
(09:57):
landscape of healthcare, I thinkis concerning people and
recognizing that we have to dosomething different.
Speaker 1 (10:03):
The numbers when you look at the summary of the RAND
report, all in the wrongdirection.
The complexity of patients isgoing up, the age of the
patients is going up and thepayments are going down.
There's only one outcome forthat if things don't change, and
that is the collapse of thesystem.
And what we're seeing is, Ithink, that collapse right now,
with boarding and other thingsgoing on.
Where it's interesting becausePeter Fogelio said we've had
(10:26):
this crisis for 40 years Now.
He was talking about this inthe 80s and there was some
really strong discussion betweenthose guys, but I've never seen
it this bad.
I've been here for 33, 34 yearsand I've worked at UCLA.
When I first got here and itlooked completely different than
it does today, the residentstoday have 60, 80 patients
(10:49):
waiting.
They are doing hallway medicine.
We didn't do any of that when Idid my residency in the early
90s.
That wasn't a thing.
Speaker 2 (11:00):
So it is worse, and I hear that from almost everybody
.
Yeah, I think boarding has beenaround a long time but to the
point now where the majority ofpatients we're seeing are
actually in the waiting room isbecoming the norm and that's
frightening and that's dangerous.
And yet we've had so manystudies showing that increases
mortality that this is obviouslybad for patient satisfaction.
It's high risk management butit continues because of the
financial structures thathospitals aren't staffing half
(11:23):
of the floors upstairs, we don'thave enough nurses and people
are trying to figure out how dothey cut staffing in the
emergency department to savecosts when, if anything, you
should be investing and havingmore staffing so we can get to
these patients.
And it really is infuriating.
But I think this is all atrickle-down effect of how we
pay for health care and if wegot paid, if we could even keep
(11:44):
up with just inflation, thatwould help subsidize some of
those costs.
That would allow us to be moreproactive.
This report also calls for anincreased primary care net right
of recognizing that some ofwhat we do in the emergency
department is not just emergencycare but acute, unscheduled
care and having a system thatwould better take care of those
patients where they have amedical home and a place to go
(12:06):
where we can be both primarycare, emergency care,
preparedness, like there'slimits to what we can do in an
eight-hour shift, like there'slimits to what we can do in an
eight hour shift.
And until we fundamentallyrecognize that and pay for it
and set up a structure thatsupports that with more
coordinated care, it's going tocontinue to be a challenge for
us in the emergency department.
Speaker 1 (12:23):
So there was a suggestion, two suggestions from
the prior panel, and one ofthem came from Dave Schroeger
said the only way we're going tofix this problem is if we go on
strike that we keep year afteryear, decade after decade, just
solving the problem.
Nobody's going to listen.
This isn't going to get fixeduntil there is basically a we
(12:43):
unionize as physicians and go ona national strike and say we
can't do this anymore.
So that was one radicalsuggestion.
And then Al Cicchetti was onthe other side.
Like I can't do that.
I'm an ER doc, I'm in there,I'm seeing patients If they're
sick.
I can't not do that.
So where do you stand with?
We're at a bad place.
(13:04):
Is it time for radicalsolutions like Dave Shredarigo
is suggesting, or is that justgoing to fail because ER docs
are just going to go to work andlook after people, because
that's what we do going to go towork and look after people?
Speaker 2 (13:12):
because that's what we do.
What a great question.
We were actually just talkingabout this yesterday.
There's a resolution in the AMAand their code of ethics of
what do physicians do aboutunionization?
What do we do about striking?
And fundamentally it seems likethat is a contraintroduction to
what we do with our Hippocraticoath that we guarantee that
we're going to take care ofpatients and that by striking,
(13:33):
by definition you're puttingpatients potentially at harm.
But there are ways you can setit up.
Where you have other people,you make sure you have coverage,
that there's no gaps wherepeople can make a stand, and
we've really ASAP has lookedinto this of what are the
benefits and the cons ofunionization, of striking, as
we're seeing that more and moreacross our specialty over the
(13:54):
last couple of years, of tryingto have a collective voice and
collective bargaining to improveour workplace environment, and
in some places it can be veryeffective.
I think one of the thingspeople have to understand is not
everybody can strike and noteverybody can unionize.
So, by definition, if you arean independent group and you
have ownership in your practice,you can't be part of a union.
(14:15):
So there's limits on if you'rehospital employed, depending on
your employment structure, ofwhether you are allowed to be in
a union really limitspotentially what you can do.
But I do think there is a rolefor collective bargaining, of
really making this more of apublic issue.
Clearly, the legislators are nothearing how desperate the
(14:35):
situation is, and I think thiswas the intent of the RAND
report was to the audience.
Is not emergency physiciansright?
We all know that boarding,crowding, violence this is our
everyday life.
The audience here is really awake up call to legislators of
like this situation is gettingdire and we need to address it
now.
But if this doesn't work and ifpolicy is not working, I kind
(15:00):
of understand Dave Treiger'spoint of maybe this is the time
that we have to kind of bandtogether and speak out and do it
in a way that's safe, thatdoesn't jeopardize patient care,
but really highlights tohospitals and to the public who
ultimately we need their voicesto stand up and say, yes, we
need to do better in order toaffect change.
Speaker 1 (15:16):
I don't know if you watched the Pit.
Speaker 2 (15:18):
Ooh, I love it.
Speaker 1 (15:20):
Excellent.
I'm so glad To the writers ofthe Pit.
I'm going off to to thewriters' room here in a little
while.
What would you ask them to do?
What message would you likethem to give to the general
public as part of what is reallya public health show?
It's entertaining, but it'salso a lot about what's wrong
with emergency medicine rightnow.
(15:40):
What would you have them say tothe millions of people that
watch every episode?
Speaker 2 (15:45):
First of all, thank you for doing that show and for
all the writers.
I think it has really helped usbe seen as emergency physicians
and help the public tounderstand many of the
challenges that we face day today.
I think the example that wetalked about of financing most
of the public doesn't realizehow emergency care is funded or,
in this case, not funded, andhow this unfunded mandate is
(16:07):
causing boarding, is causingthis backup of staffing.
And if we could explain topeople that the vast majority of
patients don't actually pay thecost of care and that emergency
physicians are required by lawand we are proud to do so, but
we can't continue to seeeveryone everywhere every time
(16:28):
without financing it andultimately that's going to cause
more boarding and crowding andgiving them that example of the
majority of patients don't paythe cost of care.
How would any other businessmaintain their operations and
keep their doors open iftwo-thirds of their customers
got free labor or free goods?
So we need to fundamentallyaddress how we do this and until
(16:51):
we really get to that rootcause, there's going to be
boarding, there's going to beviolence, there's going to be
more consolidation and I thinkyou just did a great job on the
pit of kind of examples aboutpatient satisfaction scores and
boarding times and having theircontract at risk.
You know, this report reallyhighlights that the people who
are most at risk are those likeDr Ravi's.
(17:12):
It's the independent groups thatare staffing emergency
departments that this system isreally making it a big concern
that that may not be a viablepractice anymore in the future,
that you may have to be a largemega group in order to be able
to fairly negotiate withinsurers and if we don't have a
system that disrupts thatconsolidation, that business
(17:35):
model of independent practice,it may not be financially viable
.
And that is a big concern andshould be a concern for
physicians, for patients, forthe public of recognizing that
competition in the workplace isa good thing.
We want to be able to drivepatient satisfaction to really
address quality.
But without having thoseguardrails and that financial
(17:55):
guarantee in place, we're goingto see more consolidation and I
think that concern that many ofus have as much as people don't
like big corporate groups.
Well, what if the insurancecompanies own us right groups?
Well, what if the insurancecompanies own us right?
If we see consolidation?
Where now the insurancecompanies whose whole business
model is to deny care to notcover costs.
Now, own physicians like thatshould terrify everybody because
(18:19):
ultimately, their goals are indirect conflict of ours of
providing patient care, ofcovering expenses, of covering
access.
That that could be where we'reheaded if this is not addressed.
Speaker 1 (18:32):
As always, a huge shout out to Joe Sachs, who made
the first season of the Pit sogood, so medically accurate and
brought up so many of thesethings.
We all in emergency medicineshould tap him on the back and
say thanks, joe, for letting usbe seen.
He did such an amazing job onthat first season and I'm hoping
the second season is going tobe just as good.
Thanks to Dr Schmitz and thankyou all for listening and we'll
(18:54):
continue these discussions andif you've got any suggestions of
people you'd like me tointerview, let me know.
I'm a little more timeconstrained right now because of
the pit, but let's cue some ofthese smart people up and get
them on the show.
Talk to you soon, herbert out.
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