As a former president of the Virginia College of Emergency Physicians I (we ER docs) have gone down the path of using the retro scope to limit services of all kinds.  The PEND program comes to mind where patient visit payment was reduced to force the patients to seek out their primary care doctor (who was not available) and actually pay the ER physician less than an office visit if the visit (which already occurred) was deemed "unnecessary".   An infant with a fever deserves a workup and frankly will get a workup regardless of what those medical and non-medical managers think.  We are emergency physicians and we always strive to do the right thing for any patient coming through our door.  If your mother has dizziness, falls to the ground in the mall and cannot walk how will you get her to the hospital?  Maybe EMS is unnecessary?  Call the primary care office but they will not be able to take care of her because of the onset, location, lack of access to imaging or testing among other things.  Do the primary doctors take great care of their patients, yes they do.  However, the human body does not abide by a schedule for when issues arise, thus the system that is currently in place.  Poll all the medical specialties and they will support having an emergency department with competent providers available.  It is the safety net.  Call all those primary care providers offices and 99% of the messages on their phones will instruct the patient to go to the ER  or call 911 if they feel they are having an issue.   Good luck to all the patients out there that you feel do not have a medical condition worth looking into.  We have been down this path before and it seems efforts could be better spent on other societal issues.  Those who do not learn from history are doomed to repeat it. 

Mark Sochor, MD, MS, FACEP

Vice-Chair for Research, Department of Emergency Medicine

University of Virginia