Posted by Guest Blogger on Fri, Dec 04, 2009 @ 05:00 PM
By Wesley A. Curry, M.D.
I'm not the first healthcare professional to point out that this country already has variants of a "public option" in health care. The Senate's latest rendition will hopefully reverse a trend and not further burden hospitals and ER physicians with more uncompensated care. But the fact is any new program will be the "fifth" public option since 1965. And each one has ultimately increased the economic challenges on the emergency care system.
The existing public option variants are Medicare and Medicaid, both established in 1965 and both obviously financed by tax payer revenue. Another is the Health Maintenance Organization Act of 1973, which gives HMOs certain economic advantages including the ability to force non participating physicians and hospitals to accept lower reimbursement for treatment of HMO patients. Lastly there's the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986, an unfunded mandate that ensures public access to emergency services regardless of the individual's ability to pay.
Medicare and Medicaid patients are becoming less desirable to healthcare providers because of decreasing reimbursement rates (legislated decreases or because rates have failed to keep up with inflation). That means more people are coming to hospitals under the mandates of EMTALA. The problem is, it remains unfunded and is the "last resort" for people without health care. Their default option then becomes the hospital ER.
Emergency care providers and hospitals can ill afford to have another "public option" that does not adequately reimburse primary care physicians and specialists. Increasingly hospitals have had to make up the difference and provide financial support for emergency care providers and on call physicians. Some hospitals have closed and the number of emergency rooms has dropped nationwide as the average reimbursement continues to decrease for patients in emergency rooms.
A fifth public option is a good thing for the country - but only if more people get access to primary care. The covered services must be limited and tort reform needs to be included, because whatever form the public option takes, the benefits won't be equivalent to the best commercial insurance plans which are quite expensive in comparison. With more people covered by medical insurance, the rise in cost will be mitigated if the hospitals and health care providers don't have to factor in significant losses from uninsured and underinsured patients. There is no free lunch and no free health care. I would appreciate hearing your thoughts and comments.
Posted by Guest Blogger on Fri, Dec 04, 2009 @ 02:08 PM
By Joel A. Stettner, M.D.
I have always enjoyed my 36 years in emergency medicine, and have had a stimulating parallel administrative career as well. But I now feel more than a little frustrated with what is happening in the ER and beyond.
We seem to be in an environment that does not recognize our contributions. Instead, we're hammered on a daily basis with new bureaucratic requirements, that have us looking over our shoulders for surprise inspectors on fishing expeditions, giving us little or no relief for the liability that we are required to shoulder, and increasingly devaluing our services through opaque and often unfair reimbursement policies. Let me explain...and ventilate.
I believe our specialty has always tried to wear the proverbial white hat, seeing all comers (even before EMTALA) and doing our best to effectively resolve the myriad of medical and social problems that present to us. Early on, we fought hard to establish our specialty, and then to win the often-begrudging respect of our medical staff colleagues. My concern is that our practices are now wrongly viewed as some of the most costly and inefficient, and politicians and insurers regularly batter us for this.
Of course, since EMTALA, we're federally mandated to provide care...with no assured funding, no relief from liability, and no ability to take a charitable contribution deduction or a write-off for the vast amounts of free care we provide. Don't our white hats bring any recognition other than demands for cheaper and faster care and higher patient satisfaction scores?
And those JCAHO inspections, with diligent searches for dust, unchecked boxes on our charts, and unintentional technical errors...does no good deed go unpunished? Please don't misunderstand; I support the enforcement of reasonable rules and regulations. But do the current hoop-jumping requirements make good sense?
Well, of course it's not all bad. Although we lost balance billing in California, and our state emergency services fund evaporated, we still collect from many payers, and, with luck, Medicare will give us a bit more next year. An ending recession and health care reform might also lead to more insurance coverage for our patients.
Should we try to fix some of this? Please let me know, and share your ideas as to what might work. We built the specialty; shouldn't we do all we can to protect and enhance it, for the ultimate benefit of our patients, which is where we got started?