‘An Opportunity to Come Together’: ACEP President Kang addresses Virginia emergency physicians
Reproductive health laws at the federal and state level.
Double-digit growth rates for nurse practitioners and physician assistants.
Chris Kang, MD, FACEP, the president of the American College of Emergency Physicians, addresses a room of about 150 emergency physicians, EM residents, students, and EM staffers at VACEP’s 53rd Annual CME Conference on February 18.
Reimbursement. ED boarding. Workplace violence.
“The bottom line is, we have a myriad of issues” and challenges facing emergency medicine, American College of Emergency Physicians President Christopher Kang, MD, FACEP told a gathering of emergency physicians in Virginia last weekend. “And yet just like every day when you show up to work, if you're with the right people, with the right team, with the right belief in what you're doing — bring it on.”
Kang, an emergency physician at Madigan Army Medical Center in Tacoma, Wash. and Providence St. Peter Hospital in nearby Olympia, addressed a group of emergency medicine providers at VACEP’s 53rd Annual CME Conference on February 18.
Noting he was an undergraduate history major, Kang said it’s important when considering fixes to present problems to remember the lessons of the past.
“Something old becomes new again, and some things repeat [themselves],” he said, noting many of today’s issues were exacerbated out of the pandemic. He explained that, in every pandemic in history, government policies were controversial, mortality and economic disruptions highlight inequalities, and some in society become isolated and push extreme narratives. “And in the end, for those that survive it, there's always a period of economic, social, medical and moral advances,” said Kang, who leads the nearly 37,000-member strong national organization.
Kang told physicians, residents and students in the room that there is an opportunity before emergency medicine to come together, evolve, and show the world how critical the specialty is to society. Even after the pandemic and other challenges, he said, “we’re still here.”
During the presentation, Kang pulled up a screen listing a number of issues facing emergency medicine, then led a “Choose Your Own Adventure” style approach, allowing physicians in the audience to pick topics to discuss.
Workforce woes
First up: Workforce, specifically surrounding an April 2021 ACEP report that “shook a lot of people up” by showing a likely oversupply of about 8,000 emergency physicians by 2030. He noted that, while 2020 hit a high mark of more than 3,600 applicants to emergency medicine residencies, the numbers today are closer to 2018 or 2019 figures, at around 3,400 annual applicants. In 2022, there were more than 270 emergency medicine residency programs, up from about 230 in 2018.
Another factor that changed since the report: Pandemic-related physician attrition has continued for longer than expected, increasing demand for emergency docs. Due heavily to COVID, Kang said, the expected surplus by 2030 could be half as much as initially projected.
““Despite the challenges, I’m working with you, you’re working with me, and whatever it is, we’ll face it together.””
Adjacent to the report, Kang explained the Accreditation Council for Graduate Medical Education (ACGME), which accredits all medical specialty residencies, is evaluating standards, training, and objectives for emergency medicine programs, along with the role of emergency physicians to ensure the specialty continues to address the needs of their patients and communities. Kang said the process will “set the bar” for EM residencies over the next 10 years, ensuring quality programs and graduates.
On scope of practice
Kang also touched on scope of practice for PAs and NPs, a hotly debated issue in emergency medicine. The two are among the fastest-growing healthcare jobs and often ranked on best-of jobs lists, due to less stringent training, high pay, and open positions nationwide.
While recognizing the value of NPs and PAs on an emergency medicine team, VACEP regularly opposes NP-backed Virginia legislation that would give them more independent practice with limited or no training (the current standard of 9,000 hours or five years of supervised training in Virginia remained this year, despite a bill that would have removed training before granting autonomy).
While acknowledging some of his peers may oppose his opinion, Kang said it should be left to individual emergency physicians, whom he and ACEP consider the leaders of emergency medicine teams, to decide how to best deploy NPs and PAs in their EDs.
“I personally believe that, if you are a leader, that means you have a responsibility to help your team,” Kang said. Physicians should have autonomy to evaluate the capabilities of PAs and NPs on the team, and use all available resources to ensure patients are appropriately evaluated and treated.
Kang also highlighted the importance of emergency medicine-specific training, citing a 2022 Stanford University study that showed NPs in the ED cost more money overall and result in worse outcomes, especially when dealing with complex patients.
On workplace violence
Kang turned to ED violence, and recognized Virginia emergency physicians for pushing a 2023 bill in the General Assembly, the first of its kind in the nation, to put trained security in every emergency department in the state.
While calling for more emergency medicine-specific training for NPs and PAs, Kang said decisions inside the ED over which roles can see, evaluate, or treat patients should be left to emergency physicians who are responsible for their teams.
Last year, ACEP joined the Emergency Nurses Association to push legislation directing OSHA to require employers to develop and implement workplace violence prevention plans, focused on the safety of health care workers and patients. He said Virginia’s bill, which requires a trained guard or off-duty officer to have de-escalation training and skills necessary to physically restrain unruly individuals, “will hopefully be a standard for a lot of states.”
Fighting for fair reimbursement
Kang also addressed the No Surprises Act, federal legislation that bans balance billing patients for out-of-network care and instead leaves that cost difference to insurers and physicians to settle. Under the act, if insurers and physicians cannot agree on the appropriate OON reimbursement rate, either party can escalate the matter to independent dispute resolution (IDR).
After the law passed, regulatory language tilted the IDR process in favor of insurance companies. Specifically, arbitrators were instructed to weigh the median in-network rate for a specific service in a specific geographic area — an artificially low, insurance company-dictated value — more heavily than other factors such as patient acuity or provider education and training.
In addition, because federal law (EMTALA) mandates emergency physicians see every patient regardless of ability to pay, health plans are less likely to keep emergency providers in-network — and then refuse to pay (or pay a fair rate) for OON care. Last year the government also increased the non-refundable price tag from $50 to $350 for initiating the IDR process, which Kang noted can be more than the total reimbursement owed and requested.
Kang questioned how insurance companies can post record profits, yet refuse to pay for care and implored the entire emergency medicine community “to come together and say, ‘This is wrong.’” ACEP is fighting the issue in federal courts.
Despite obstacles, Kang reminded everyone that emergency medicine, by its very nature, is a demanding, challenging job with the best-trained, highly educated and sought after physicians. And it’s the people, working together, who solve crises.
“When I show up to work, and I've been at my same workplace for 20 years, I’m in one of those very lucky places where people don't want to leave. When I drive to work, I look forward to it,” he said. “Despite the challenges that are there, I'm working with you, you're working with me, and whatever it is, we'll face it together.”
Disclaimer: Kang’s opinion and views expressed may not reflect the official policy or position of Madigan Army Medical Center, the Defense Health Agency, Department of Defense, or the U.S. government.
