Posts Tagged access

Senate to Consider Medicare Payment Fix – Make Sure Your Voice is Heard

Angela GardnerStarting this week, the Senate will take a series of critical votes on a bill, the Medicare Physicians Fairness Act of 2009 (S.1776), to abolish the flawed formula used to determine Medicare reimbursement rates. This bill is critically important to all physicians, but especially to emergency physicians who will undoubtedly see a significant increase in Medicare patients if scheduled payment cuts are enacted.

 Under the current system, physicians are scheduled to receive drastic cuts to Medicare payments starting next year. Congress understands that the scheduled cuts would devastate access to care for seniors so each year they “patch” the system by voting at the last minute to cancel the funding cut. However, even though the cut is not enacted, the total accumulated debt for physician reimbursement under Medicare continues to grow.  Picture it as a credit card with a huge balance and a high interest rate.  Congress “forgives” a payment on the debt each year, but that amount is added to the balance, and interest continues to add up.  Without action by Congress, physicians are scheduled to take a 21 percent reduction in reimbursement for Medicare patients next year, with cuts totaling 40 percent in future years. 

 Having health insurance coverage is not the same thing as having access to medical care.  All seniors over age 65 are entitled to insurance under the Medicare program.  Increasingly, however, primary care physicians and other specialists are refusing to take new Medicare patients because of low reimbursement rates. It’s not that those doctors lack compassion, it’s that many lose money on Medicare patients and a 40 percent cut in payments would make it impossible for them to continue to treat those individuals.

 With an aging population, emergency departments already anticipate an increased volume of seniors needing care.  If, however, Congress does not fix the flawed Medicare formula, that increase could be catastrophic.  Seniors unable to find doctors accepting Medicare may have no choice but to seek care in emergency departments, which the Institute of Medicine already calls “dangerously overcrowded.”

Passage of this bill would help to prevent more crowding in emergency departments, provide a reasonable level of compensation to emergency physicians, and help attract on-call specialists. This is a non-partisan issue. Republicans and Democrats claim to care equally about ensuring access to care for seniors. If our elected representatives are sincere in these views, they will take a principled stand on this issue and support S.1776 now.

You can help assure passage of this critical legislation. Contact your two U.S. Senators now and tell them to support S. 1776. Here’s how:

  • Call 1-800-833-6354 to be automatically connected to your two Senators. Urge them to support all procedural motions and final passage of S.1776.
  • Go to ACEP’s Advocacy Center  and send an e-mail urging your Senators to support S. 1776.

Now is the time to become involved. Pick up the phone and make that call.  And check back here often for updates. Working together the emergency physician community can make a difference.

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The Role of Emergency Physicians (and the ED) After Health Reform

In anticipation of the upcoming ACEP Council meeting, prospective counselors have been engaging in some email jib-jab on health reform on the council e-list.  Until recently, this discussion focused on the proposed shape and form of our new health care system:  much ado about something that emergency physicians (EPs) and ACEP will likely and unfortunately have limited impact.  However, the topic has now shifted a bit towards the question of the future role of EPs and the Emergency Department post health reform, something we ought to be able to impact, and which, though equally political, is an in-specialty debate really worth having.  Of course, the lack of a health reform crystal ball necessitates bald conjecture when it comes to imagining how our future health care system will evolve; and this complicates the debate considerably.  Nonetheless, given the Republican’s belief: ‘government can do no right, so let’s do as little as possible and declare victory over rabid socialism’, and the Democrats imperative: ‘we must to do something, even if it is the wrong thing, so we can declare victory over heartless capitalism’; one can make a reasoned guess about the likely provisions of health reform legislation and move on from there.  To wit: something like 90-95% of citizens (and very few undocumented aliens) will have some form of health insurance (I wish they would stop calling it health care – insurance is not care); there will be higher deductibles and co-insurance payments to deter utilization; the ‘medical home’ concept will be promoted to control costs; the private health insurance industry will be a bit more tightly regulated (but still very profitable); likewise the drug industry; doctors and hospitals will take a hit (perhaps not the primary care docs); states will be given leeway to experiment with Medicaid; Medicare Managed Care plans will take a hit (they deserve it) though capitation in general will persist; some effort will be made to control cost and utilization through outcome based payment rather than task based payment; and there will be no real malpractice tort reform.

So where does that leave the role of the EP and the ED in the new health care paradigm?  If you listen to the debate in Congress and in the media, the ED has become the poster-child for the type of unnecessary and cost-ineffective health care services that characterize the worst aspects of the current health care system.  ACEP can hardly get a word in edgewise in hearings on health reform in D.C. and elsewhere.  When the ED is discussed by legislators, you rarely hear anything about what EDs and EPs do right, what we contribute to improving the health of the population, how important we are for surge response, how under-funded the emergency care safety net is, how we are the finger in the dyke.  Common sense would say that ignoring the role(s) of the ED and EP in discussions of health reform is at best imprudent, at worst, (I hate to use the word, post-Gates-gate) stupid. However, I think we can only blame ourselves if we fail to get on the radar screen – and to do so; we must go beyond moaning and groaning to providing answers and solutions. We aren’t there yet.  Solely for the purposes of promoting this discussion, I will try to delve a bit deeper into a few relevant topics, some of which have started to appear on the Council’s e-list:  cost containment, care coordination, appropriate ED utilization, error prevention and pay for performance, health promotion, and surge response in a post-reform health care system

Cost Containment
Let’s face it, ED care is expensive.  If there is one thing driving health reform today, it is the looming financial disaster that will befall the US if we don’t find ways to rein in the cost of health care.  If we don’t like being the poster child for the problem, EPs have to be part of the solution.  Granted, cost-shifting to cover the care of the uninsured might diminish post health reform; but EDs will still be the provider of first resort for the remaining uninsured, and it will be hard for hospitals to roll back ED charges even if most patients have coverage.  Perhaps having readily accessible EMRs will allow us to cut down on unnecessary and redundant testing; but as mentioned, don’t look to tort reform to mediate patient demand for the ‘definitive’ diagnostic workup.  Cost containment in the ED will require (first) a change in the incentives that pay more for doing more, something that is really at the heart of the entire health care problem and thus will get short shrift in D.C.  Payment reform, particularly for inpatient hospital services under Medicare, is already changing the way hospitals perceive the impact of the EP on their revenue stream.  It will also require a lot of hard work on our part – to collect the data (thus the push to resurrect ACEP’s Emergency Department Data Institute), derive best practices that incorporate cost containment strategies while maintaining good outcomes and patient satisfaction, and implement these strategies in everyday practice, not just for EPs, but for the entire ED team.

Care Coordination
Every time I hear about the Medical Home I have to laugh.  When it comes to the costs of health care, the hospital is really where the big dollars are spent; but when was the last time you saw a primary care doctor come in to coordinate the care of a sick patient in the hospital?  It happens, but not often any more (and I have to admire the docs that still do it).  If continuity of care and prior experience with the patient (the raison d’etre for the medical home) is so all-important, why isn’t it even more critical when the patient is in the ED or on their way to the OR or the ICU, and who is doing this coordination now?  Emergency physicians, that’s who, it’s what we do every day, and we are pretty damn good at it. Let’s be frank, the real push behind the Medical Home is the redistribution of payments to primary care providers through capitation, which in real practice has been less about managing care than it is about managing payments, managing investments, managing paperwork, and managing enrollment.  I’m all for paying primary care providers more so we can grow more of them to do the real work of improving and maintaining health. However, particularly for EPs and on-call specialists who work under the EMTALA obligation, capitated payments to managed care medical groups is an invitation for primary care docs to stick it to their specialist colleagues and put their patients on the hook for the underpaid claims.  Groups like Kaiser may be able to delegate acute care work and reimbursement within their organization in a fair and appropriate way, and perhaps that is where health reform must ultimately lead to be successful; but in the interim, most ‘managed care’ organizations will continue to pay lip service to the concept of care coordination, especially when patients are really sick.

For many medically valid and financially sound reasons, the ED has become the hub of the acute care wheel and the epicenter of diagnostic evaluation.  EPs are the primary diagnosticians and principle coordinators of episodic and high-resource care for those who need to access the most expensive health care services. We have more experience with a wider range of specialists, imaging and testing services, ancillary providers and programs, social services, and, of course, patients, than any other physician.  Why, then, would legislators not insist on hearing from us about health care reform?  EDs aren’t inappropriately expensive, they are necessarily expensive;  and the success of health reform will depend as much or more on the way the ED of the future operates and the skill of the EP in managing, distributing, accessing, and even denying access to some of the most expensive services and care the system has to offer.  Even so, the cost of the EP’s services is relatively meager.  Failure to integrate the ED hub and EPs into health reform, and the wheel of acute care will simply spin disconnectedly.

Appropriate ED Utilization
Few would argue that the ED is an appropriate place to dispense primary and preventative care services (with perhaps exceptions like tetanus immunization), but the debate as to whether the minimal marginal expense rationale for providing urgent care in the ED is valid is a very important debate to have.  When you analyze the ‘true cost’ of ED care for lower acuity patients, you can’t simply compare acuity adjusted charges; you have to look at all the costs, and who bears them. What is the cost of having to lose a full day of work running between the PCP’s office, the x-ray office, the lab, and back to the PCP’s office?  What is the added cost of going to the PCP’s office for early abdominal pain only to be referred to the ED for further testing?  What is the cost of delaying care and discouraging the ED visit with a high co-pay, only to have the appendix rupture or the TIA progress to stroke?  On the other hand, what is wrong with deferring care in the ED when more appropriate venues are readily available?  Do EPs tend to over test and over treat because we are used to seeing sicker patients?  I will tell you what’s wrong with deferral of care:  most of the time, there are no readily available alternative venues.  I’ll tell you what’s wrong with primary care in the ED:  we aren’t that good at it.  This particular issue (economic triage and deferral of care) calls out for great caution and careful implementation under health reform, rather than the knee-jerk reaction that is more likely to prevail.

There is also the question of the role of the ED in the care of the uninsured, and the underinsured.  Health reform will not cover everyone with insurance, but more importantly, it will leave many with inadequate insurance coverage.  These folks might have coverage, but they won’t have access, certainly not timely access.  EPs have long been purveyors of charity care, four times more than any other physician, upwards of $150,000 worth per year.  Unlike most providers and venues, we never limit the number of Medicare or Medicaid patients that we agree to treat. Is providing urgent or primary episodic care for the poor and underinsured an appropriate role for the EP and the ED post health reform?  Perhaps, perhaps not, but I don’t see many others stepping up to volunteer. Do you hear anyone talking about that question up on the Hill?  I doubt it.  Mr. President, Congress men and women: COVERAGE IS NOT CARE!!

Error Prevention and Pay for Performance
I am all for reducing medical errors, who isn’t? The ED is a great place to work on this issue – the climate for errors is ripe.  If error prevention is one of the mandates of health reform, why, we can all definitely get on board that train.  Give us systems to manage our patients more effectively and with greater safety, and errors in the ED will certainly diminish. Refuse to pay for ‘never events’ that we have little hope of preventing, however, and you will have lost us. The hardest thing to do in medicine is to meet unrealistic expectations.  If health reform were to result in payment only for services that make people better (don’t worry, it won’t); who would want to work in an environment like the ED, where the odds are stacked so heavily against us?  So how should EPs and EDs be reimbursed post health reform?  A recent story out of Vermont hyped the cost-effectiveness of a hospital that employs physicians.  Is this the appropriate new model for health reform? If so, say goodbye to the corporate bar on the practice of medicine, and one more layer of protection between the patient and the all-mighty bottom line.  Personally, I don’t think hospitals have to employ physicians to get them on board with cost-effective care:  they just have to stop having such a schizophrenic approach to hospital-medical staff relations.  Another health reform proposal involves global payment schemes, but giving hospitals all the money and letting the CEO decide how much to pay each physician and how hard to work them is not likely to improve those relations.  The payment machinations of managed care are not going away, they will just become more devious.  I am afraid we are in for some rather unpredictable changes in the way EPs are compensated under health reform, and my greatest fear is not that compensation will go down, but that it will become even more politicized, and even less rational.

Health Promotion
Here is where I believe the ED may have an expanded role under health reform.  There is a lot more that EPs and ED staff could do to derail bad habits, interdict social circumstances that undermine health, educate the ill informed, reinforce healthy choices, and generally promote wellness in the community.  However, since we are running up against the headwind of cost-containment in an ‘expensive’ venue; chances are few will be interested in paying for EDs and EPs to play in the health promotion sandbox.  Never mind that the only time stubborn smokers might finally be willing to quit smoking is when their T-waves look like tombstones, or that high schools quit teaching parenting skills in the 80’s. The best chance for this to happen would be if, in the process of bumping up primary care compensation, the cognitive skills of EPs also get boosted.

Surge Response
This one is really perplexing to me – how is it that in the aftermath of 9-11 and SARS, the ED’s role in disaster and pandemic response has gotten so little attention and financial support?  Getting ED Boarding legislation through Sacramento has been a real grind, and we can’t even talk about transfers to inpatient hallways without getting everyone in a snit.  How important will health care reform seem to the victims of the next Katrina, if surge response and the fragility of the ED safety net continue to be neglected in the halls of Congress during this great debate?  You think a scarcity of ventilators might be a problem if H1N1 gets nasty:  try finding bed space and nursing staff in the ED.  Actually, forget the big disasters for a minute, and think on the every day disasters, when ED overcrowding gets BAD, on-call docs disappear from the rosters, and no one gets the service they deserve.  How does that scenario, playing out in hundreds of EDs throughout the nation every day, comport with the objectives of health care reform in the US?  Can we really claim to be ‘fixing health care’ if we don’t fix that?!?   Considering the Massachusetts experience, providing ‘coverage’ for every citizen is only going to compound the problem of ED overcrowding, and diminish, not enhance, ED surge capacity.

ACEP, and the State chapters, have a lot to talk about in the next few weeks and months; let’s just hope that those intent on their own particular version of health care reform might take a few moments to listen between rounds of pugnacious advocacy.

Myles Riner, MD, FACEP

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A Review of Obama’s Speech to the AMA

The AMA Section Council on Emergency Medicine

The AMA Section Council on Emergency Medicine

ACEP President Nick Jouriles shares his thoughts on President Obama’s speech to the AMA House of Delegates yesterday

President Obama was warmly received by the physicians at the AMA Annual Meeting earlier today. Like many in the crowd, I went with mixed feelings. Our current system is not sustainable, we all know that. But would he actually speak specifically to some- even one – of the critical issues in emergency medicine today? What are his plans, how will our issues be addressed, and where do we go from here?

For starters, the President told us that he is not trying to create a state run plan. “When you hear the naysayers claim that I’m trying to bring about government-run health care, know this–they are not telling the truth,” Mr. Obama emphasized.

But his plan does have a public component and includes: an emphasis on preventative care, widespread use of electronic health records, and changes in the health insurance industry including a new “exchange” where individuals and businesses can purchase a health plan. That “exchange” includes a government option.

Like many in the audience I was wondering about President Obama’s emphasis on wasteful spending in health care. He does not lay the blame at the foot of physicians, but the constant drumbeat coming from his administration on this issue is unsettling. Can inefficiencies be wrung from the system? Can we streamline some of our processes? Can things be done differently? Yes, yes and yes. But to the tune of hundreds of billions of dollars? I don’t see it. Most emergency physicians don’t see it, and neither will most Americans.

But then, he brought up an issue we can all agree on. I am encouraged that he is open to changes in the medical liability system. That was a position I had not expected from this Administration, and although he does not take a strong position, it is a start. President Obama said, “[W]hile I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed, I do think we need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine, and encourage broader use of evidence-based guidelines. That’s how we can scale back the excessive defensive medicine reinforcing our current system of more treatment rather than better care.”

Like I said, a start.

We will also have to look long and hard at proposals affecting the physician payment system. In addressing the issue, Mr. Obama said, “We need to bundle payments so you aren’t paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead are paid for how you treat the overall disease.”

How that plays out for emergency medicine will be key, but given our 25 year history with EMTALA, where many hospitals receive extra funds for indigent care while we do not , his emphasis on this is not a good sign.

Finally, it was disappointing not to hear emergency medicine mentioned specifically. We saw how our emergency departments were affected with the “worried well” of H1N1. And the New York Times published my letter to the editor addressing that point. But the White House has hit the mute button for now- or until the next epidemic or natural disaster occurs- regarding the crisis in emergency medicine.

It was a good speech and a good start. It was great to be in the audience. Now it’s time for Congress to get down to business and find solutions that we can all believe in. And time for the nation’s emergency physicians to stand up and make our voice heard. Our patients need us.

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Health Care Reform Takes Center Stage

Rep. Bart Gordon at ACEP's Leadership and Advocacy Conference

Rep. Bart Gordon at ACEP's Leadership and Advocacy Conference

Democratic leaders in the House and Senate released their long-awaited health care reform plans on June 9. The House released an outline that three major committees will work off of, while Senator Edward Kennedy (D-MA) released a full bill. Senator Max Baucus (D-MT), the other leading architect of reform legislation is expected to put out a bill before the end of June.

One of the key provisions of the Kennedy plan is a requirement that every person in America have health insurance. The legislation also creates a government run insurance program that would compete directly with private insurance companies. But as emergency physicians know, access to health insurance does not always equate to access to health care. If the primary care docs do not accept new patients with government insurance because of low reimbursement rates, they will eventually present in the emergency department.

ACEP’s Washington office- headed by Gordon Wheeler – has been working with the House and Senate committees responsible for developing health care reform legislation with the goal of assuring that emergency medicine’s issues are being addressed. In addition, ACEP recently launched a letter writing campaign urging members to contact Congress and demand that emergency patients’ needs are included in health care reform.

 ACEP is having some success in bringing emergency medicine’s issues to the attention of Congress, Mr. Wheeler said, and Senator Kennedy’s bill, “The Affordable Health Choices Act,” includes several provisions important to the specialty, including:

  • Reauthorization of the emergency medical services for children program ($25 million in 2010, to $30.3 million in 2014)
  • Design and implementation of regionalized systems for emergency care
  • Competitive grants for regionalized systems for emergency care response
  • Support for emergency medicine research
  • Mental health assessments, crisis intervention, counseling, treatment, and referral to a continuum of services, including emergency psychiatric care¸ community support programs, inpatient care, and outpatient programs.

In addition, Rep. Bart Gordon (D-TN), House sponsor of the “Access to Emergency Medical Services Act of 2009″ (H.R. 1188) said recently that he would like to see language from that bill included in the House’s health care reform legislation. Rep. Gordon said that all of the bill’s provisions (listed below) should be considered:

  • The creation of a national bipartisan commission to examine factors that affect the delivery of care in emergency departments
  • The need for additional resources in support of emergency care delivery
  • The development of standards, guidelines and measures by the CMS to address boarding and ambulance diversion

Rep. Gordon is also encouraging the development of pilot programs to model effective and efficient trauma regionalization systems, especially in dealing with capacity and diversion issues. Rep. Gordon, a long time supporter of emergency medicine, is also concerned about emergency medicine workforce issues and reimbursement for emergency medical services. He recently sponsored “The Health Care Safety Net Enhancement Act of 2009″ (H.R. 1998), a bill that would improve access to emergency medical services and provide liability coverage for emergency physicians when providing care to EMTALA patients.

Rep Gordon is also the sponsor of “The Medicaid Emergency Psychiatric Care Demonstration Project Act of 2009,” (H.R. 1415) legislation that would fund a demonstration project that allows Medicaid to pay for emergency psych services at non-publicly owned or operated institutions. The goal of the project is to help alleviate the psych bed shortage and move patients out of the emergency department and into treatment.

Debate on the numerous bills being discussed is expected to begin in July. At this juncture, it is unclear what the final health care reform legislation will look like, or if comprehensive health care reform will be successful this time around. ACEP will continue to lobby for emergency medicine’s interests and seek solutions to the critical problems confronting the specialty. This blog will continue to keep you informed of ACEP’s progress.

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