Continuous Physician Staffing for Rural Emergency Departments
The feds and 48 states don't require EDs to have 24/7 physician staffing. The ACEP Council recommended action to require continuous ED physician presence. Will legislation follow or is this just talk?
Would lawyers be OK with law firms lacking lawyers? Would the National Football League make sense if teams did not field NFL players? Would a university be fulfilling its mission if it had no Ph.D.-level professors?
When it comes to life-or-death medical care, federal law and 48 state laws allow for emergency departments to not staff a physician. How is this legal?
When things don’t make sense, the answer is usually money. It is cheaper for EDs to staff non-physicians, so health systems, insurers, and the government are tempted to allow physician-less emergency departments.
Emergency medicine organizations are (belatedly) pushing back. The Indiana and Virginia Colleges of Emergency Physicians have led the successful passage of state laws that require a physician to be present 24/7 in every ED in their states. In contrast with health system bluster, no hospital has closed due to the requirement to staff a physician.
The September 2024 American College of Emergency Physicians (ACEP) Council voted for the following resolution to be sent to the ACEP Board of Directors:
RESOLUTION 27: Continuous Physician Staffing for Rural Emergency Departments
RESOLVED, That ACEP collaborate with the American Medical Association to advocate that the Centers for Medicare and Medicaid Services (CMS) modify the “Staff and Staffing Responsibilities” Conditions of Participation for critical access and rural emergency hospitals such that a qualified, state-licensed (MD/DO/MBBS) physician be immediately available for on-site care of emergency department patients at all times.
At the 2023 ACEP Council Meeting, the following resolution was passed:
RESOLUTION 42: On-site Physician Staffing in Emergency Departments
RESOLVED, That ACEP work with state chapters to encourage and support legislation promoting the minimum requirement of on-site and on-duty physicians in all emergency departments; and be it further
RESOLVED, That ACEP continue to promote that the gold standard for those physicians working in an emergency department is a board-certified/board-eligible emergency physician.
In response to the ACEP Council resolutions, W. Anthony Gerard, MD, FACEP, FAAFP - a leading physician advocate for improvements in rural acute care - wrote the following powerful post on the Rural Section engagED page, which we are sharing with Dr. Gerard’s permission.
The ACEP Council forwarded a resolution on advanced practice providers working solo in emergency medicine to the Board, and ACEP leadership will soon be discussing this at the American Medical Association (AMA). I want to emphasize a few points that are fundamental to our specialty.
If APPs are allowed to work solo in EDs, we are compromising on our gold standard for competence in emergency medicine and "leaving remote and rural communities behind."
Because we have not solved the rural ED workforce challenges, the marketplace has solved them with a "low-cost, low-quality solution." In 2020, we promised not to "leave rural and remote communities behind.” We have solutions we can still implement, but not if we allow this "cop-out."
EM was developed by PHYSICIANS in 1968 "in response to the need for physicians skilled in managing emergency patients."
When EM achieved specialty recognition in 1979, it was because there was a body of knowledge - emergency medicine - that takes physicians 3-4 years to master after 4 years of medical school. One of EM's most fundamental values is that every ED patient should be seen by a competent emergency PHYSICIAN.
Since the beginning, the gold standard has PHYSICIANS who are residency trained in EM. Until only recently, concerns about an emergency medicine workforce shortage persisted, and yet we never compromised on this. Despite a workforce shortage during these decades, we never ONCE deviated from this commitment to the gold standard.
APPs provide an important contribution to the EM workforce, but their training is a fraction of what physicians complete. Some can become highly competent emergency clinicians with experience, but allowing them to work solo severely tarnishes the gold standard.
Some small rural EDs, such as CAHs and REHs, have now become dependent on APPs to staff their EDs. However, allowing this to occur is an abandonment of our foundational commitment to the gold standard of an emergency physician in every ED and ignores the Institute of Medicine and ACEP Rural ED Taskforces’ recommendations.
Some have argued that "the horse is out of the barn" and that we cannot go back and propose that APPs should not work solo. They believe that some CAHs and REHs will close if required to be staffed with an on-site physician. But this is not based on evidence.
Using this argument to tarnish the gold standard is based on fear and removes the incentive to strive for the gold standard in ED staffing. Compromise may be needed in some remote regions, at least as an interim solution, but we must change this bad precedent. APPs should not work solo in emergency departments.
If we do not re-establish this as a gold standard, there is no incentive for rural hospital leadership to try to hire physicians. Given significant financial pressures, many rural EDs will "look for low-cost solutions" to the known problem of rural ED staffing and continue to hire APP's.
Decades ago, the IOM Report on EM proposed solutions to rural ED staffing issues that have not been fully implemented. The ACEP Rural ED Taskforce also proposed collaborative solutions. These are not easily achieved, but compromising on the gold standard does not provide an incentive to implement these. It allows a "cop-out" that puts cost above quality/ competence.
There are probably 40,000 practicing EM in the United States, and this number may be growing. The 2020 EM Workforce Taskforce, comprised of multiple EM organizations, emphasized that "no community (should be) left behind."
We are leaving remote and rural communities behind if we allow APPs to work solo.
The proposed resolution on this issue and the language proposed to AMA and CMS are not mandates or threats. They simply restate our fundamental commitments to a gold standard.
If we do not re-establish this as the gold standard, we are abandoning our fundamental commitment to the specialty and to our patients.
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W. Anthony Gerard, MD, FACEP, FAAFP
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Is the "Gold Standard" mentioned several times in the article "EM Residency Trained Physicians," or just "Physicians" (of any specialty) as mentioned elsewhere in the article? Much of EM is already practiced by non-EM residency trained physicians, typically IM or FM, so this distinction isn't trivial and the two are hardly interchangeable. Also, it would help if the author could point to outcome data to support the article's argument.
Good afternoon all!
I'm reading with interest the thoughtful posts & replies.
As a RT/BC EM physician of 31+ years, I've seen a spectacular transformation of Emergency Medicine
Long gone are the days where I had to "justify" my/our specialty to patients, professional colleagues, even to my own family members!
I also wish to celebrate and recognize our terrifically talented APP's. They are a tremendous "force multiplier" within the appropriate supervised ED settings.
I've also had a good share of working in several CAH's where I was continuously on call to an ED for up to 1 week, staying local but responding within < 10 mins to a call from the ED should I not be present.
My friend and fellow USAF Reservist EM physician started a staffing company based solely on CAH's across the US. He explained to me the specific funding the federal government provides to staff these rural/remote ED's full well knowing the challenges of finding/hiring docs in such remote areas.
This is a quick summary from Google AI on the question of physician funding for CAH's:
The federal government pays physicians in critical access hospitals (CAHs) in a few ways, including:
Standard Payment Method: Medicare pays CAHs 101% of reasonable costs for most outpatient services. Physicians or other qualified practitioners bill for their services under the Medicare Physician Fee Schedule (PFS).
Optional Payment Method: Medicare pays CAHs 115% of the allowable amount for outpatient services.
Method II Billing: Physicians and non-physician practitioners can reassign their billing rights to the CAH. Medicare pays the CAH for professional services using revenue codes (RC) 96X, 97X, or 98X.
CAHs are reimbursed differently than non-CAHs. For example, CAHs are paid based on the cost of providing services in most care settings, unlike other hospitals.
My concerns are -does the federal government no longer reimburse hospitals for physician coverage as the above indicates? If this is still true, I'm curious to how hospitals can justify NOT hiring physicians when the CAH's are reimbursed with the physician staffing model foremost in mind?
I also support the statement that a EM trained physician in the ER is the gold standard, fully understanding the realities of the economics of finding/retaining EM trained physicians. I guess the "silver standard" would be a non-EM trained physician but with demonstrable experience/skill to practice in such remote areas without much/any physical specialty back-up.
As far as "evidenced-based studies" regarding APP's staffing ED's, why following that logic is there not a push for APP's to perform surgery, or practice medical specialties in underserved areas? I'm sure the expectation from the public is that they have a right to be treated by a physician in a hospital/ED regardless of the setting if at all possible.
In closing, as an 25 yr Air Force veteran ED physician & flight surgeon, we had a saying when flying missions:
"Everyone want's to be in the right seat (Pilot or Aircraft Commander), but you must have the skills and training to sit there". What works for military aviation is very applicable to civilian medicine.
Physicians have a professional duty to care for our patients. Allow us to do so......
Doc BG