Posts Tagged emergency care
Sandra Schneider, MD, FACEP, ACEP Past President
I would like to personally invite you to become a member of the Emergency Medicine Practice Research Network – EM-PRN. Becoming a member is simple; just click on this link and answer a brief survey. It will take less than five minutes. We want to know if you are seeing patients with chronic pain, we want to know if you are experiencing medication shortages and how you are coping. We want to know how you practice. YOUR ANSWERS will provide ACEP with essential information for our advocacy in Washington and improving emergency care. To stay a member, all you need TO DO is to agree that you will complete 3-4 surveys, five minutes or less, each year.
Membership at this time is only open to ACEP members, residents, attendings and life members. Sorry, we cannot as yet accommodate non-members or medical students. Many other specialities have built practice research networks. Pediatrics has had one for more than a decade. They started small, like us. They have found that getting data from physicians on the front lines is often very different than getting it from inner city, teaching hospitals. Once you join EM-PRN, you will be able to do much more than just give opinions to survey questions. We want to submit ideas for research projects and survey questions that YOU would be interested in. Our group will pick the more interesting and the most popular IDEAS for the next survey. So you not only will be providing answers, you’ll be designing the questions.
Right now and for the next few years, EM-PRN will be largely surveys. Eventually, we will likely want to grow to collect some data. For example, IN THE FUTURE we might want to monitor the number of patients seen with chronic pain in emergency departments. You would simply count the actual number of patients you see during a single shift (no names, no identifiers) and submit it to ACEP.
We could then monitor this number over time to see if it is increasing, decreasing or staying the same. The members of EM-PRN will help direct what research projects we consider and will be acknowledged on any publication. Members will also receive the results of any project ahead of publication. So in the time it has taken you to read this Blog, YOU could contribute to advancing our knowledge of the real practice of emergency medicine. Join now.
ACEP, the National Stroke Association, and Genentech have partnered to develop a FREE stroke education course for EMS professionals. The course covers the basics of stroke, pre-hospital assessment, stroke systems of care, and case studies.
EMS educators may also download the slides and use them in their EMS education.
Access the course today at www.EMS4Stroke.com.
Trying to define the market value of someone’s professional services is difficult when those services are typically paid at vastly different rates, depending on the payer, especially when the party paying is usually not the direct recipient of the service. So when an emergency physician provides clinical services to a patient, how are those services valued by different payers, and what does that say about the reasonable market value of those services?
For example, let’s say that you come to the emergency department with an acute asthma attack: you can’t breath well, and your inhaler hasn’t helped to break the attack. A pretty straight-forward case, really: your ER doc does a history and physical exam, orders up some oxygen and a few respiratory therapy treatments, some steroids, perhaps an IV to rehydrate you and get access in case your condition worsens and you need IV meds, and returns to re-evaluate you every 15 minuets to make sure the treatments are working. Two hours later, you are able to go home with a script for three days of Prednisone and a refill for your Ventolin inhaler as the one you have is running low. You get instructions on how to care for yourself at home, when to see your primary care doctor, and what you should do if the wheezing comes on again despite the treatment. Chances are, you will likely get a charge for this service from the physician for 99284 level care for around $320, give or take, if you live, let’s say, in central California.
If you didn’t have insurance, you would be expected to pay the full charge. Unfortunately, many patients can’t afford to pay; or could afford to pay but are just irresponsible, and don’t pay anything. If the patient pays nothing, the emergency physician may be able to recover about $45 from California’s EMS Fund, a tobacco settlement funded program that pays on average about 15% of the emergency physician’s fee.
However, if you were uninsured with a family income at or below 350% of the federal poverty level; or you are insured and have incurred high medical costs (greater than 10% of family income over the prior 12 months) with a family income at or below 350% of federal poverty, and you submitted a request for a discount; you would (by virtue of California law) only have to pay 50% of median billed charges of a nationally recognized database of physician charges, probably around $150.
If you were covered by your County’s new Low Income Health Program (a family of 4 making less than $41,000/year), the county may pay the emergency physician about 30% of the Medicaid rate, or a whopping $21.
If you were covered by California’s Medi-Cal program, one of the lowest paying Medicaid programs in the country: $68.
If you were covered by Medicare: the federal program would pay about $125.
If you had HMO coverage, but had to go to a closer out-of-network ER, your HMO would pay the ER doc between $140 and $250.
If you had PPO coverage, the plan would pay between $175 and $240, minus any co-insurance payment, and you would have to pay the rest up to the $320 charge.
So, for a $320 emergency physician service, the emergency physician might receive anywhere from the full $320 down to $21, and about 10% of the time – nothing. The average emergency physician in California provides about $140,000 a year in unreimbursed care.
Of course, in order to provide these services, the emergency physician has to spend $10 to pay for malpractice insurance, $30 for billing services, and additional costs for other overhead amounting to a total of about $55 for every ED patient treated (even if the payment is $0)
So, what’s the real market value for an emergency physician’s services? I would argue that it is the full amount that the emergency physician charges, as long as these charges aren’t significantly higher than what other emergency physicians in the same area charge, but then I just paid a heating technician $175 for 10 minutes of maintenance on our furnace. Others would argue differently, but their estimate would be based on their particular agenda: protecting those living in poverty, reducing costs for the employer, dealing with government budget deficits, or making higher profits for the insurer. Unfortunately, none of these advocates actually provides emergency care to anyone.
By the way, if you were suffering from a heart attack or serious injury, and the emergency physician (and his team) actually saved your life (it happens hundreds of times every day), the emergency physician’s charge would be around $800 to (rarely) $2000. So, what’s the real market value of YOUR life?
This post also appears on the blog The Fickle Finger www.ficklefinger.net/blog/
In a widely read article in the January 2011 issue of The New Yorker by Atul Gawande that details the efforts of Dr. Jeffrey Brennerto improve care to a number of high-cost patients in Camden, NJ; Dr. Brenner was quoted as saying “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise.” This observation has often been quoted by any number of health care policy wonks, health plan advocates, and politicians in efforts to justify their particular distaste for ‘unnecessary’ ER care. Like many such generalizations, Dr. Brenner’s comments are often taken out of context or misinterpreted, and in some cases have been used to denigrate the care provided in ERs, or the patients that rely on the ER. Dr. Brenner was referring to “failures of prevention and of timely, effective care” in the rest of the health care system, and I cannot disagree with him that ERs are often called upon to address these failures. Nonetheless, my antipathy for Dr. Brenner’s observation is that it is glib, and too easy to misconstrue.
Emergency Departments provide such a broad scope of services, and play so many roles in health care, that it is rather short-sighted to view ER visits as the if they were almost inevitably the result of misuse, abuse, inattention, inappropriate delay, or a failure of prevention. If someone falls off a ladder and breaks their leg, that obviously is not a failure of the health care system, unless of course you plan to hold the health care system responsible for poor ladder design. Likewise, not all heart attacks or strokes can be prevented by good primary care, Lipitor, aspirin, and exercise; and not all pneumonias represent a failure to immunize or prescribe controller inhalers for asthma. The reasons why the number of ER visits have grown so rapidly go way beyond the fact that the health care system often fails us; or that the ER is open 24/7; or the EMTALA mandate to treat everyone regardless of insurance status or ability to pay.
ERs have become the diagnostic centers of the health care system; and many patients are sent to the ER by their doctor specifically because of the broad array of diagnostic services available, ER physician expertise as ‘diagnosticologists’, the ready availability of specialist expertise, and the efficiency of ER workups. It would not surprise me if more than a third of all cancers in the chest and abdomen are first detected in the course of an ER visit. In addition, the ER fills many roles that, if they had to be met by other health care providers and venues, would render those providers or venues overwhelmed, even more inefficient, and often just unavailable. Imagine if primary care doctors, or even urgent care centers, had to repair all lacerations, or treat all kidney stones, or manage every alcoholic who drank himself into a stupor. Think what it would cost if those offices and facilities had to stay open until 2 am to accommodate those who were not able to get their care during office hours. You don’t have to imagine closing every ER in the country to realize that ER care is not just some regrettable but necessary safety net established to manage the failures of the health care system. Just watch what happens when the last ER in a community closes: you will find that ERs represent what is often the best of what the health care system offers: timeliness, efficiency, effectiveness, scope, availability, responsiveness, surge capacity, compassion, and decisiveness; and this will be sorely missed by the residents of that community.
The tendency of many to misconstrue comments like those of Dr. Brenner is reflected in a host of similar aspersions cast on the ER. Jane Stevens also wrote an article about Dr. Brenner, and about a similar effort to reduce costs through an ER diversion program in Bend, Oregon, designed to help patients who frequently landed on the doorstep of the ER to get access to other, more appropriate places to get the things they needed, some health care related, but often focused on social service needs. The title of this article was “Improve health, lower health care costs by reducing emergency room visits”, implying that simply by blocking the door to our ERs, we could solve what is wrong with health care. At least, this is how many readers were likely to interpret the message. Taken to an extreme, this is the kind of message that leads policy makers and legislators to believe that if they just stopped paying for ER visits, they could keep everyone healthy AND solve their budget crises.
Dr. Brenner’s linkage of ER visits to failure has also become insinuated into even the most thoughtful discussions about health care reform. Brad Wright wrote a post in the Kevin MD blog that pointed out the mistaken belief by many that universal health insurance would lead to a reduction in ER use. He noted that “people go to the emergency room for a host of reasons that have nothing to do with their insurance status. Among these reasons are low health literacy, a health care system that is often complicated to navigate and inaccessible for people who can’t get off work during typical business hours, and a lack of continuity of care that arises for a host of reasons. Waiting to be seen in the ER is no picnic, but for many people it is a more easily understood process than trying to get a referral to a specialist from their primary care physician–assuming they even have one.” As I have noted above, this accounts for just a fraction of the reasons why patients use the ER. Mr. Wright notes that consequently, reduced ER use should NOT be considered a measure of the success of health reform.
I believe that ER use is an indicator of many things, some reflecting the failures of our health care system and our social safety net; others reflecting great advances in acute care, resuscitation, and diagnostic services; and still others reflecting our society’s need for, and desire for, efficiency, availability, and timeliness of care. You can’t hope to cover all of these attributes in a single, facile observation, no matter how well intended.
This post also appears in The Fickle Finger.
State governments have fallen into deep budget deficit holes, as we all know, and state legislators and policy makers are casting about for ways to dig themselves out. Many are climbing over the backs of those least able to fend for themselves in this troubled economy, since the poor have little clout and even less representation, now that the Supreme Court has given corporations and unions carte blanche to finance political campaigns up the political wazoo. Therefor, it should come as no surprise that the budgets of State Medicaid programs all across the nation are taking a big hit, and Medicaid policies intended to protect access to care for the indigent are being bent all out of shape, if not violated outright, in the process. Unfortunately, access to emergency care is getting the lion’s share of the attention in this cost-saving, budget slashing, attack on Medicaid, and this effort is rending holes in the emergency care safety net.
From the East Coast to California, State Medicaid Departments and policy makers have decided to target the ‘unnecessary use of the emergency department’ by Medicaid enrollees as the easiest way to eliminate waste and excessive costs in the Medicaid program, even though there are many far better opportunities to save money and reduce unnecessary expenditures in Medicaid and in health care in general. No doubt, ED care is relatively more expensive than UCCs and clinics and PCP offices for non-urgent medical services, and no doubt, many Medicaid patients could potentially receive this care in other, more appropriate venues, if these venues weren’t already failing miserably when it comes to providing adequate access for unscheduled non-emergency care to Medicaid enrollees. To many people, a cursory look at the efforts to get these non-emergency patients out of the ED might seem not only reasonable, but compelling, in the face of massive State budget shortfalls. Thus, you now see all sorts of policies aimed at limiting access to the ED, some designed to dissuade Medicaid patients from even considering a visit to the ED, others designed to retroactively deny coverage, or payment, for these services, despite the adverse consequences such policies will inevitably have on these patients, their families, and everyone else who might need emergency care. It seems to those of us who understand the implications of such policies the epitome of penny wise, pound stupidity.
California’s Medi-Cal program now intends to impose a $50 copay on ED visits in order to discourage ED use. Texas Medicaid will reduce payment on ER claims by 40% if the final diagnosis is not on their ‘emergency diagnoses list’, and Virginia likewise reduces payment for Level 3 visits using a similar approved list. In Illinois, a very rigid set of criteria are used to deny coverage under the prudent layperson standard, and in Oregon and other states, like Colorado, emergency physicians are paid a $10-20 ‘screening fee’ when the final diagnosis is not on the list of approved medical emergencies. Recently, In Washington State, Medicaid program directors have decided to implement what may be the epitome of bad medical policy by refusing to reimburse providers when the patient uses the ED more than three times in a year for non-emergency problems like hypoglycemic coma or pseudomonal pneumonia or sepsis. The process that WA used to derive this list of unapproved diagnoses, and meet their budget savings target, would be laughable if it weren’t so inane (see this blog )
These policies all have one thing in common; they entail little direct political risk for policy-makers. They rely on the EMTALA obligation of emergency care providers to ensure that patients who seek care from the ED, whether because they are seriously ill or injured or simply because there is no where else they can get any kind of care, will likely not be turned away. It won’t matter if the Medicaid enrollee can’t afford the $50 co-pay, or has to make a fourth visit to the ED in a year for another acute exacerbation of a chronic illness, or fails to pay the ED bill when the State declines to cover the visit, or is relying on the ED for psychiatric care because they can’t get into a treatment program, or makes an ‘imprudent’ decision to use the ED because they are concerned their chest pain might be an MI rather than esophagitis. Nearly all of these patients will be evaluated and treated for their medical emergency and even in most cases for their non-emergency condition, or at least be afforded a referral to an alternative venue once screened. This is not just because of EMTALA, but also because emergency physicians are, in almost every instance, compassionate providers who understand that they are the last, best, and often only hope for many of these patients – the safety net for the safety net.
The States that have adopted these budget-saving strategies also rely on another political reality to justify what otherwise might seem to be a fairly callous approach to the economically disadvantaged: all of these policies effectively dump the financial responsibility for caring for these patients on to the backs of hospitals and emergency care providers. The bet is that voters and taxpayers won’t care if the Medicaid programs in their state take advantage of EMTALA obligated providers in order to ease the burden on state budgets. Despite increasing hospital and ED closures, shortages of emergency physicians, and disappearing ED on-call specialists; the assumption seems to be that emergency care will always be there when needed even if these providers have to work for free. Somehow, EMTALA has suspended the laws of supply and demand.
Medicaid policies designed to reduce payment for ED care also have in common the decision to sidestep the prudent layperson standard that CMS imposed on Medicaid Managed Care organizations under section 1932(b)(2)(B)(ii) of the Social Security Act. Though many states have adopted this standard for Medicaid Fee-for-Service programs, others argue that prudent layperson does not apply to their Medicaid FFS program, and that they are not required to pay for medical screening exams when the final diagnosis does not substantiate an emergency medical condition, even though many of these same states have their own version of an EMTALA mandate on the books. Ultimately, this debate may need to be resolved in courts, where emergency care providers will hopefully be protected from abusive payment practices that effectively result in theft of their services.
The oddest aspect of these state payment policies is that they seem to be founded on the principle that the best way to punish Medicaid patients for using the ED inappropriately for health care services, and change this behavior, is to refuse to pay hospitals and emergency physicians for providing these services. The fact that these policies will adversely impact access to emergency care for everyone, rich and poor, seems to escape just about everyone.
You are about to endotracheally intubate a patient. As you struggle to elevate the laryngoscope more anteriorly, has your left hand ever trembled while trying to see the vocal cords? Before you say, “I think the cords are too anterior, hand me the [insert your favorite backup airway adjunct]“, let’s focus on some basics.
How can you gain significantly more laryngoscope lift strength? You can do more left arm bicep/tricep exercises, or…
Trick of the Trade
Hold the laryngoscope handle as close to the blade as possible.
Grabbing part of the blade helps to stabilize against the “waggling” of the handle. Furthermore, it is easier to pull exactly along the long-axis of the handle at this grip point. I would avoid holding the laryngoscope handle as shown in the image above. Is the physician intubating or holding a fragile cup of tea?
The most stabilizing larngyoscope grip
which provides maximal lift strength.
For other airway Tricks of the Trade, take a look an older post.
Last night the U.S. House of Representatives passed a health reform bill, H.R. 3962. Emergency physicians are divided in their thoughts about the consequences of this legislation, as is the house of medicine and the country in general. However, there are many aspects of the bill that are positive for emergency patients and for emergency physicians.
Some of these include:
- Inclusion of emergency services as part of an essential health benefits package
- Statutory authorization of ECCC (Emergency Care Coordination Center) and ECCC Council of Emergency Medicine
- Health and Human services annual report to Congress on ECCC activities, with focus on emergency department crowding, boarding and delays in ED care following presentation
- Emergency care/trauma regionalization pilot project grants
- Trauma stabilization grants
- Health and Human Services incentive payments to states that establish medical liability reforms (Certificate of Merit/early offer)
- Health and Human Services demo project to reimburse private psychiatric hospitals that provide EMTALA services to Medicaid beneficiaries
The American College of Emergency Physicians has worked diligently to represent emergency physicians and emergency patients throughout this volatile process. As the process continues toward final legislation, ACEP will continue to focus on the needs of emergency patients, future emergency patients, and the physicians who care for them.
Starting 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.
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.