Outgoing ACEP President Reflects on Reform

No Comments
Nick Jouriles never thought he’d be the ACEP president. “Not in my wildest dreams,” he said in a recent interview. But this month will mark the end of his tenure at that very position.
After an IM residency at Dartmouth and an EM residency in Denver, Dr. Jouriles went back to his home in Cleveland to practice EM at Case Western University. But his only EM-trained colleagues were in Columbus, at Ohio ACEP. So he began there to work his way up the “food chain” to the national ACEP board and eventually its top spot.

When asked what his goals were when he took over the helm, Jouriles said he felt the specialty was fractured and needed healing. He saw health care reform on the horizon and felt it was vital that we speak with one voice. The specialty needed to “play together,” he said, “and I’ve been blessed in my career in that I play well with everybody.” By “working side by side” with academicians and community EPs Jouriles feels he has helped the specialty to get “better focused.”

“I’ve tried to get residency directors, private practitioners, SAEM and others to stand up, pick up the phone” and call their congressional representatives.


When pressed on the specifics of what ACEP advocates for in Washington, Dr. Jouriles admitted that the College has no platform or single unified voice. “We support insurance coverage for every American,” he said. Further, he explained that ACEP supported the concept of the ‘prudent layperson’ standard for insurance coverage of a trip to the emergency department. And ACEP supports funding for EMTALA-mandated care. But on the issue of liability reform, he admitted that ACEP and even the larger community of physicians has been very unsuccessful in garnering meaningful congressional support. While noting some success at the state levels, particularly Georgia, Texas, and California, where caps on awards for pain and suffering have been enacted, Dr. Jouriles noted that there has been no progress at the national level. He attributed this failure to the fact that physicians historically don’t give a lot of money to lobbyists. “In DC, money talks,” he said. And physicians, on average, give about $7 a year to political candidates, while trial lawyers give thousands.

Dr. Jouriles reported that President Obama received cheers from the physician audience at the recent meeting of the AMA when he stated that “liability reform is an option.” The president was then booed when he immediately back pedaled, stating that he did not support limits on awards for pain and suffering.

When asked about his concerns related to the possibility of congress passing a health care reform bill, Dr Jouriles called it “carefully orchestrated theater.” Some good might come out it if most patients will be insured, he said. Most EDs have 50% or less collection rates, which amounts to, on average, about $120,000 per year in free care from every EP. “So anything is better than nothing,” he said. He admitted though that his conclusion was based on the assumption that any insurance would pay more than people would pay on their own, a conclusion that was challenged by a study published in the Annals of Emergency Medicine.


The main source of hope for any health care legislation is that it would include funding for EMTALA mandated care. This change might provide a “break in boarding” seen in so many EDs. Dr. Jouriles said that uninsured patients board in the ED while insured patients go to their beds. “This might force hospitals to rethink their business models.” But he also admitted that if funding is inadequate, it might actually make boarding worse.

Dr. Jouriles also voiced concerns over flat fee reimbursement to hospitals for episodic care. The track record over the last twenty years, he said, is that hospitals will get paid and emergency physicians will be the last to get paid.

According to Dr. Jouriles, Congress has perpetuated an assumption that one of the major factors in the rising cost of health care is the uninsured using high cost emergency departments. And health care reformers assume that if patients are only directed to their primary care physicians, instead of the ED, there will be major savings. This assumption, he says, is inaccurate as well as irrelevant. He points out that only 20% of patients are uninsured. And a CDC study found that only 15% of patients presenting to an ED will not need care within the next 24 hours. Moreover, he points out that emergency medicine only accounts for 3% of all health costs. So if 15% of those 20% who don’t really need emergency care went to their primary care physicians it would only lower health care spending a fraction of a percent.

Despite his multiple concerns over the challenges that face emergency physicians from health care reform, Dr Jouriles admitted that congress and the president are not listening to representatives of emergency physicians. Neither the president nor congress has solicited the testimony of anyone from ACEP. And ACEP for its part has no formal platform or agenda that it is trying to put forward proactively. Rather, “when the time comes” Dr. Jouriles anticipates that emergency physicians will speak up with a united voice. But after September Dr Jouriles will have to leave that job to another.


Leave A Reply