An emergency physician’s wish for tort reform.

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By Marty Ogle MD

As an emergency physician and part of a national emergency physician partnership - I keep hoping for the best in regards to tort reform. If only pigs could fly.

As you likely know, Tort reform refers to proposed changes in the system that would reduce tort litigation or damages. "Tort" is a system for compensating wrongs and harm done by one party to another's person, property or other protected interests. Sounds pretty logical, but of course, as in many things in the U.S., tort reform is a contentious political issue.

Nowhere is this more apparent than with healthcare tort reform as it relates to eliminating the "friction" in the system that wastes dollars. These wasted dollars are most often diverted to lawyers, malpractice insurance companies, etc.

Aside from billing costs - which could ultimately be reduced by requiring one standard billing form/procedure for ALL payors- medical malpractice coverage is the single largest expense in an emergency medicine practice. And yet, tort reform appears to be off the table - hmmm, I wonder if it's because most members of the U.S Congress and Senate are lawyers...nah!!!

So what to do? You can certainly let your representatives know that tort reform needs to be back on the table; that true, cost-effective healthcare reform can't happen without it. It may seem like our government isn't listening. Or they're listening to the wrong people. But if enough of us raise our voices, funny things can happen.  Like real, honest tort reform?

Here are two excellent links: 

http://www.calacep.org/advocacy/  (Advocacy Section)

http://www.acep.org/   (Advocacy Section)

I look forward to your comments.  

Here's to a positive year for emergency medicine.

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This first blog of the New Year focuses on some of the interesting stories you may have missed over the past few days. In the coming weeks, we'll be touching on the relevant and timely issues that affect emergency medicine and the emergency physicians and PAs who work so diligently to make a difference. So visit often.

We begin where we left off - with Healthcare Reform. Right before Christmas the Senate approved its healthcare reform bill. And now the complicated process lies ahead to reconcile this bill with the House bill, which was approved last month. An article 10 issues that Congress will need to resolve in final reform bill, published in HealthLeaders Media, outlines the work still needed to be done.

An interesting story from the Daily Mail in Great Britain on the National Health Service's dictum of a maximum four hour wait time for patients needing emergency treatment. According to their records, a "vast majority" of patients are seen within 3 hours. However it was revealed that hospitals have been fudging the figures. Truth or politics? It's causing quite a heated debate. 

Just this past week, a list of the top ten "overblown healthcare stories" of the past decade was posted in the Healthcare Economist. Not surprisingly the H1N1 pandemic was number one. Coming in at number four is the notion that uninsured patients cause ED overcrowding. An interesting read to be sure.

This story from the Los Angeles Times highlights a unique Chicago-area doc who is both trauma surgeon and SWAT team member. If you think your day is stressful -- read this!

And finally, an article posted on the Wall Street Journal reminds us that the Congressional stimulus bill passed back in February allows for docs and hospitals that make "meaningful use" of electronic medical records to receive big bonus payments from Medicare and Medicaid. The government released details last week on how to qualify for the money. Read the facts in How to Get $20 Billion for Using Electronic Medical Records.

As always, this page welcomes your comments and observations.

A note on National Physician Assistant Week – October 6 thru 12.

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By Ellis Weeker, M.D. 

As an emergency physician, I know the importance of an emergency department staffed with hard working, conscientious, and skilled Physician Assistants.

That's why in recognition of National Physician Assistant Week, I, along with my emergency physician Partners at CEP America would like to acknowledge the very significant contributions PAs have made - and continue to make - in our organization.  

I speak for my fellow Partners who join me in recognizing our Physician Assistants as valuable healthcare professionals and colleagues who play a vital role in providing the highest-quality care in our EDs. We couldn't do what we do without them.

So on the occasion of National Physician Assistant Week, I want to acknowledge our PAs for being the best PAs we have ever worked with - and to thank them for their continued hard work, commitment, and dedication.  Please join me in recognizing their important contributions.

Health care reform and patient satisfaction.

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By Jay Kaplan, M.D.

There's no question that in the current discussions on health care reform, pay for performance will play a central role.  Pay for care rendered is going to be replaced by pay for quality rendered. Value-Based Purchasing, the federal government's new name for pay for performance, will be tied to Core Measures for inpatient clinical quality and PQRI for outpatient clinical quality. 

Non-government insurers will follow suit, since the outcome is reduced payment to providers. CMS is already withholding payment to hospitals in some cases, and talking about reduced reimbursement for Medicare patients who return for re-admission within 30 days of discharge.  Bundled payments are also being contemplated.

A few years ago, the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) was created to measure the patient experience across all hospitals.  Right now, in order for hospitals to get their full Medicare market basket update yearly, they participate and publicly report their "scores".  Soon they will have to be at the 50^th percentile or have improved from the previous reporting period in order to be fully updated/reimbursed.

The three questions currently being asked about physicians are:

During your hospital stay, did doctors:

1. Treat you with courtesy and respect?
2. Listen carefully to you ?
3. Explain things in a way you could understand? 

In the early stages of nationwide implementation is the Clinician & Group Consumer Assessment of HealthCare Providers and Systems (CGCAHPS), which asks similar questions about physicians in the outpatient setting. Insurers in Massachusetts are already talking about tying outpatient reimbursement to CGCAHPS results. And don't think that we in the ED are not on the radar screen.

Now for a key point - CMS and the federal government now consider HCAHPS and CGCAHPS to be "quality" metrics. So as much as some of us would like to separate service excellence from clinical quality we and our hospitals will be paid for quality however that is defined. This means service becomes an issue with real fiscal consequences.

Rather than bellyache about an unfair system, we will need to focus on improving patient satisfaction. The good news is we can benefit from the focus on "quality", and in fact, an argument can be made that great patient satisfaction is built upon creating a great place for staff to work and for physicians to practice medicine. 

It's an approach that can work - in fact I've seen it work all over the US.

The Facts about Health Care Reform in the ER

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By Marty Ogle, M.D.

Last week, I was reading TIME magazine's online version and came across a short piece on US Emergency Departments and how overcrowded they are. "Dog bites man", right? We all know EDs are crowded. This is NOT breaking news.

But when they spoke of the causes of ED crowding, I was impressed to see they were at least partially right about the causes: insured patients not able to get into their Primary Care Physician and sick ED patients being "boarded" in the ED for hours or days due to insufficient in-patient bed capacity.

Where the author went off track, unfortunately, was the conclusion that hospital administrators do not want to invest in the ED and instead invest in tools for high margin elective surgeries. In fact, most hospital administrators I speak with agree that Emergency Services is a profitable part of their operations. In addition, at many hospitals, the ED accounts for 50% or more of all in-patient admissions.

I am reminded that 75-90% of the patients seen in the ED are sent home. So a savvy administrator who invests in ED capacity is probably getting the most bang for the buck. The other piece to this ED capacity/crowding is what some refer to as "virtual capacity." In essence, real capacity can be altered depending upon how smoothly the place runs. Clearly, a well-functioning ED can contribute to the financial success of the hospital overall.

Finally, the author goes on to say that the impending Health Care Reform - and the possibility that healthcare coverage would be universal - will have negative effects on EDs by throwing more patients into an already overburdened Emergency Care system. I would argue that with broader coverage, patients should have greater choices and might look to other sources of care than the ED. As always, the devil is in the details. It should be quite a ride. Please let me know your thoughts.