Okay don't hate me for asking this question, but I am a third-year medical student who is very interested in emergency medicine and is pretty dead set on going into it.
I just love the pace, diagnosing first, the variety of problems, the need to perform at your best at the most stressful/urgent time in a patients care, and the patient interaction.
I just wanted to know what people in this specific profession feel that direct impact of the ACA on emergency medicine is.
More patients? Less pay? Better job opportunities? Less primary care problems?
Yes, probably not, maybe, no.
There's a lot that we don't know about how the ACA is going to impact things (especially with the mandatory Medicaid expansion being blocked) but if you look at systems that have implemented mandatory insurance there are trends that arise:
1) Insured people consume more health-care than their un-insured counterparts.
2) There is no flood of new primary care doctors to meet this demand. PCPs have long been trying to maximize revenue by maximizing volume and there's essentially no surge capacity left in the system (unless the new insurance paid high enough rates to reverse the trend towards concierge medicine, which they don't).
3) These newly insured pts without the ability to access primary care services for anything other than scheduled months-in-advance check-ups will utilize the ED for things they wouldn't have without insurance.
4) For actual emergencies, we'll come out ahead since the costs of an ED stay will zero out (or at least come quite close) the deductible and so the uninsured appy, TIA, etc. will be bringing in more revenue than when they were self pay. For the primary care stuff, it will be essentially the same scenario as it is now (at least in states without Medicaid expansion) since the majority of the newly insured are going to have huge deductibles for anything that's not preventive primary care.
5) Urgent cares will handle some of the PCP overflow, but the average NP is going to refer to the ED significantly more than the average MD (not sure the magnitude of the effect but it's worth mentioning).
6) Job opportunities are going to very locally, depending on how well the particular hospital systems in your area are at staying profitable.
7) We'll see more primary care issues because of 1,2,3, (and to a lesser extent) 5. Hospitals will continue trying to find reliable ways of diverting this business to a less expensive venue (screen-outs +/- referral to hospital owned UC/IM or FP office or nurse driven"medical home"), but at least at the moment the incentives for diversion aren't worth the effort for most systems.
Bonus:
The difference between being a good and great EP is two-fold:
1) Great EPs find the practice of emergency medicine intellectually interesting and cultivate and maintain that interest as their careers mature. Good EPs maintain competence but are just focused on executing their assigned tasks well. Good EPs probably notice a dozen things a day that could be done better but no longer (or never did) have the activation energy to work on improving them.
2) Great EPs care about their patients, all of them. When they talk about frequent flyers, there's a sadness in their faces that the rest of us don't have. They call back the patients they sent home to see how they're doing. They follow the course of patients upstairs. They want to do the right thing for the patient because it will make the patient better, not because it means they're less likely to get sued or get yelled at by another physician.
Unrelated tangent: The 2nd part was actually easier when the paternalistic model of medicine was the standard. It's a lot easier to care about someone if you're taking responsibility for their choices.
