The following is the second part of my interview with Dr Jouriles, in which we talk in a little more detail about the nuts and bolts of health care reform and the politics involved. I was impressed that Dr Jouriles was able to tackle some of the very nerdy questions, but I’ll admit that I’m disappointed that ACEP hasn’t taken a more proactive stance on the reforms. It seems to me that the time to get involved and to stake out some policy turf is before the final package is set in stone. If you wait until the end, you can only support or oppose, but being involved early lets you have a hand in crafting the legislation. On the other hand, it’s not clear that ACEP really has a dog in the fight over, say, the public option, and perhaps they are quite right in focusing their attention on the narrow interests of the Emergency Departments.
Dr. Yore: So what elements of healthcare reform does ACEP see as being the most critical to include in a final package?
Dr. Jouriles: Whenever the final package is it has to include coverage for everyone and emergency care has to be one of the priorities, where everyone gets emergency care is part of their package.
Dr. Yore: If universal coverage is enacted, many people have pointed out that does not necessarily equal access to care if the coverage isn’t meaningful or if the care resources aren’t available in the community. How do you see that impacting emergency care in the US?
Dr. Jouriles: Well the only model we have is from Massachusetts when two years ago they insured all the people who formerly did not have insurance. They found an increase in the number of ED visits. In the long-term I don’t think it’s going to affect the number of patients in the Emergency Department. I think we will continually see a gradual rise in the number of patients in the Emergency Department because the population is increasing and the population is aging which means more chronic diseases. What we find is the majority of people who are in the Emergency Department, 85 percent, have a medical emergency. They absolutely need to be there. The 10 or 15 percent that may or may not need to be there is discretionary. I don’t think that that’s going to change too much over time either. I think our numbers are going to continue to gradually increase over time with or without insurance, but what will happen is the experience will be better as more and more people have some kind of coverage. We’ll be able to provide better services for people.
Dr. Yore: For example, more access to on-call specialists?
Dr. Jouriles: Well not only that but more emergency physicians because we’ll have instead of each emergency physician contributing a third of their work for free, we’ll be able to recoup some of that. We’ll be able to hire more people and have a better system. Same thing with the hospitals we work in. Right now if the hospital is losing a third of their income to uninsured, if they are not losing that then maybe we’ll have better lab turnaround, better radiology turnaround, housekeepers; the things we don’t have today.
Dr. Yore: A public insurance option has emerged as a flashpoint between the right and the left. Does ACEP have a position on the public plan?
Dr. Jouriles: Well as of now we are not quite sure what people mean by this because it hasn’t been completely defined. We are open to the possibility of a public option. We don’t think that that’s necessarily a good idea or a bad idea. We’re willing to work with anyone if they’re going to make it work. Right now we are the de facto public provider of care and so a public option would actually help our members more than any other specialty. So we are willing to listen to any discussion about that.
Dr. Yore: The Tri-Com Bill, H.R. 3200, appears to be the framework many people are expecting to prevail as the final reform package. It contains among many other provisions a repeal of the Sustainable Growth Rate formula that is currently scheduling to require a 21 percent cut in physician reimbursement. Is this a potent incentive for the Physician Lobbies in general to support H.R. 3200?
Dr. Jouriles: Well the SGR was a flawed concept. That has to go away some way or another. I think the beauty of the discussion about healthcare reform is that everything is on the table including the SGR, which clearly isn’t working, just like most of Medicare these days isn’t working and a lot of things aren’t working. I don’t think the SGR specifically is a flashpoint for people who can sit back and think about things. I do know that every year when the SGR came up it was a beautiful thing for the AMA for Congress because the AMA would rally the troops and people would give lots of money and the lobbyists would make lots of money and politicians would have lots of attention. Then they put it off for another year instead of fixing it. I think that just getting that out completely will be a win for everybody.
Dr. Yore: One of the reforms that has been proposed regarding reimbursement has involved reimbursing for episodes of care and there has been discussion of bundling of payments, which I presume means bundling the payment for the hospital as well as perhaps for multiple physicians. Is this something that emergency physicians should be concerned about?
Dr. Jouriles: It is, for a couple of reasons. One is that even though there is no guarantee about who the bundled payment is going to go to, most people believe that it is going to go to the hospital. In situations where you have integrated practices like the Geisinger Model or maybe even the Mayo Clinic or where everyone is part of the same entity in terms of the physician, the hospital, even the insurer, then the bundled system works beautifully because internally you can work through the who did what and how people are going to get reimbursed for that. In the system where most of our members practice where the hospital and the physicians, the emergency physician, are all part of separate groups, then you are going to get a clash about who gets what and when and why. That’s going to be problematic. From an emergency medicine point of view, we have seen for years that under EMTALA, when a patient comes in who is uninsured, the emergency physician has never received a penny for that. On occasion, the hospital gets payments from either the federal government or the state government or the county government for uncompensated care. Rarely, you know there are a handful of places where that money trickles down to the physician; usually the hospital just keeps it. If that’s the track record of the money goes to the hospital, our members in particular are going to be in trouble.
Dr. Yore: I share that concern. Several professional organizations including the AMA and the American College of Surgeons have explicitly, or in the case of the American College of Physicians implicitly, endorsed H.R. 3200. Is ACEP considering a public endorsement of this bill?
Dr. Jouriles: Well, considering, yes. Will it happen? Probably not until it get fleshed out more and not until we see the end result. They are still jockeying so I think it’s too early to tell.
Dr. Yore: Are there circumstances you could see, from what we know now, where ACEP might oppose some of the reforms coming down?
Dr. Jouriles: Of course. I mean, since we don’t know what the final factor is, we don’t know what we’re going to support and what we’re going to oppose. We know what elements we’d like to see in there; we’ve been very clear about that. Who knows what strange turns Washington may take between now and then.
Dr. Yore: Are there any specific, for lack of a better word, deal breakers, that ACEP is concerned about?
Dr. Jouriles: I don’t think there are any real deal breakers. What we’d like to see is more funding for primary care, well we’d like more funding for emergency medicine. Primary care incentives for people to go into primary care because they are under-served. We don’t begrudge other people extra assets but we think that we’re just as deserving. In terms of specific deal breakers, fortunately, we’ve got some good friends in Congress: Maria Cantwell, Debbie Stabenow, Pete Sessions, Bart Gordon, who are pushing really hard for us. We have confidence in our friends that they are going to not put anything in there or allow anything in there that is going to be a deal breaker. I think we have enough political capital with our friends in Congress and with the public that there is not going to be anything egregious in there that is going to be a deal breaker.
Part Three can be read here.