Are the answers to true health care reform all around us?

By David Birdsall MD

 

As an emergency physician and hospital Chief of Staff, I can honestly say that not since Medicare has there been such a boisterous and spirited debate regarding health care.

 

Until recently, when I was asked what we should do to fix health care, I took a thoughtful pause (at least that was the look I was going for) before opining ontort reform. “Just reign in the lawyers. That should take care of everything,” one colleague claimed.

 

While malpractice suits are a big problem, they’re just one of the symptoms of the 

very complex disease that is our national health care system. And just like a complex disease, we need multiple “specialists” to work together to cure it.

 

We in the U.S. claim to have the best health care in the world, yet only 40% of those polled were satisfied with their health care. Compare that to Denmark’s 91%, Austria’s 73%, and France’s 61% (France is rated the best health care in the world by many.) How do we judge success with that variance?

 

Yet, if we continue along our same path, Medicare will be bankrupt in six to eight years and we’ll continue to fall farther behind other industrialized nations.

 

So what should we do and what model should we follow? Should we look at France and Japan who provide health care using private insurance financed by employers and employees, and accomplished through tight regulation of cost and utilization? 

 

Or perhaps the U.K., which finances health care through large income and sales tax revenues.

 

We could look at Canada which uses a system where the payer and the insurer is the government and the providers are private.

 

Or what about Third World countries who make health care selfpay.

 

No matter the direction, I believe we should heed the standards employed by all the top health care systems around the world in the following areas:

 

1. Insurance companies should be “not for profit” with regard to basic medical care (U.S. insurance companies only pay 80 cents of each premium dollar on health care compared to 90-95 cents elsewhere. Why? Because these companies have to make a profit for shareholders.)

 

2. Costs and charges need to be contained and standardized. A CT exam at one hospital should cost the same at another. Clearly, this will require changes in our payment structure, which needs to be changed anyway.

 

3. Utilization needs to be curtailed. For many reasons we order more tests and perform more procedures than most other countries. Japan is the exception, but they have tight cost controls.

 

4. Quality of care should be high.

 

5. Preventative and primary care should be stressed (in the U.K., 60% of

all physicians are in primary care vs.35% in the U.S.).

 

6. Health care should be provided for all (regardless of employment status or pre-existing conditions) with all citizens contributing to that end. This means that everyone, except the

extremely poor, pays into the system in some form or fashion.

 

Health care reform in its current state is not the complete answer but it has gotten the ball rolling. The one thing that is clear is that physicians need to be intimately involved in whatever reforms or changes are made. We need to stick up for our patients, ourselves and our hospitals. Do you agree?

 

 

35 hour waits: now that's a real ED emergency.

By Marty Ogle MD 

In a recent LA TIMES article, it's reported that Los Angeles County health officials have launched an investigation into allegations that the emergency room at County-USC Medical Center is so crowded, patients wait an average of 35 hours to be seen -  sometimes without any vital signs being taken. Not 3.5 hours - 35 HOURS.

A spokesman disputed the claim of 35 hour waits at the hospital's emergency room, saying the average time is less than nine hours and varies depending on the patient's illness. As if an 8 ½ hour wait in the ED is somehow acceptable.

A complaint has been filed by a patient - by coincidence, a healthcare professional - who went to the ED for abdominal pain and witnessed what she described as "an institutional disregard for basic standards of care." The list is rather long and troubling.

In one of the more obvious statements I've heard in awhile, LA County Supervisor Mark Ridley-Thomas said that "If this could be substantiated, it would be hugely problematic because it would show systemic problems."

There is no place for 35 hour waits in the ED, no matter what the excuses about facility size, number of beds or increased patient throughput.  

If I could put on my County Supervisor's hat for a few moments, I would demand that performance metrics are put in place - not just at County-USC emergency department, but everywhere - to force real standards and improvement. They no longer have the excuse that their facility is old and outdated. They are no less overloaded than several surrounding busier County EDs (I happen to know, since the emergency physician partnership I'm part of manages these sites). These have average arrival to provider times of less than 30 minutes - NOT 35 hours!

Many of these surrounding County EDs I refer to are teaching hospitals, who deal with union issues, and have the same financial uncertainty that all County governments face. So, if it's not the size of the ED, and it's not the physical plant, and it's not the fact that they are a County ED, and it's not the fact that they deal with nursing and other unions, and it's not the fact that they have financial constraints, it must be, well, you get the idea. I think it's time for County-USC Medical Center to step up to the plate and acknowledge that their system is broken and do what it takes to fix it. Before you or someone you know ends up waiting 35 hours in their ED.

What are your thoughts on County-USC Medical Center's emergency department challenges? Have you had experiences with them? Please share your thoughts.

Payment cut approaching if Congress doesn't repeal the SGR!

Attention emergency physicians: not to sound like a broken record, but action on repeal of the flawed Sustainable Growth Rate (SGR) is still being swept under the rug.  Physicians will experience devastating cuts to their Medicare payments unless Congress intervenes before May 31.

Currently lawmakers are contemplating when to take up the matter. Based upon past history, any new bill will almost certainly not be hammered out until the 11^th hour. Resolving the problem now is the fiscally responsible course to take - relying on past methods of postponing the immediate crisis will only increase the cost of a permanent repeal.  

The U.S. Congress responds only when an interest group (us) makes it clear that we are paying attention and want action taken. Please take a minute to tell legislators that continuous last-minute legislation that momentarily prevents the cuts forces group practices to reduce services and makes it economically challenging to provide proper medical care.  

ACEP offers an excellent online portal for advocates to address issues with Congress regarding emergency medicine. In addition, you can use the AMA's toll-free grassroots hotline to voice your concerns at (800) 833-6354.

How is emergency medicine doing this week?

Seemingly, there is always something in the news that affects emergency physicians and emergency medicine in general. Here's a summary of some of the stories circulating this week's news venues... 

American's health coverage has changed during the Recession. Surprised?

A new study published in the May 2010 issue of the Employee Benefits Research Institute examines some surprising and not-so-surprising changes in health coverage among workers during the recession which began in December 2007. The study's findings include:

• After the 2001 recession, the percentage of the non-elderly population with employment-based coverage continued a downward trend until mid-2005, when it flattened out at or slightly above 60 percent through 2007. The percentage of uninsured also flattened out, remaining at about 12.5 percent through 2007.
• The unemployment rate was as low as 4.4 percent in May 2007. By July 2009 it had reached 9.4 percent.
• The percentage of the non-elderly population where employment-based coverage was 61.3 percent in May 2007 and by July 2009 it was down to 58.2 percent.
• The uninsured rate was 12.3 percent in May 2007, and by July 2009 it was up to 16.4 percent.

New government office created to oversee insurance overhaul. Good news or....

A story posted this week on KevinMD.com sheds light on how a little known government department could have a big role in reforming health insurance.  As reported by the  government, the Department of Health and Human Services recently announced that it has created an Office of Consumer Information and Insurance Oversight to assist with implementation of the newly passed health insurance reform law.

Among the responsibilities overseen by this Office and its Divisions will include administering new high-risk pools and their funding. Putting in place new rules governing the insurance market and the rules regarding the percentage of revenues that health insurers will be required to spend on medical care. The collection and maintenance of comparative pricing data for the HHS health insurance website. The development of rules governing state-based health insurance exchanges, and overseeing their operations.  All sounds good, but as with anything our government does, it remains to be seen what the final verdict will be.

Insurance companies are refusing to pay for early discharges. Or are they?

The April 2010 issue of Annals of Emergency Medicine includes an article that attempts to debunk the theory that insurance companies are refusing payment for patients who leave the emergency department against medical advice. The authors reviewed 104 AMA discharges in a suburban hospital emergency department and queried 19 insurance companies including HMOs, PPOs, Medicare, Medicaid, and worker's compensation. Out of 104 AMA discharges, every visit was fully reimbursed by the insurance companies. Surprised? You're likely not alone.

Are on call ED physicians being compensated?

Being on call at a hospital's emergency department has been the price physicians paid for admitting privileges. But an article appearing in Medscape Today states that in 2009, hospitals compensated 61% of physicians who covered EDs. This is according to a survey by the Medical Group Management Association (MGMA).

Neurosurgeons commanded the top daily on-call rate of $1671. Family physicians who didn't deliver babies were at the bottom, earning $100 per day. Most physicians were paid daily stipends for ED call coverage; others received annual, monthly, or weekend stipends.

These findings appear in the MGMA publication Medical Directorship and On-Call Compensation: 2010 Report Based on 2009 Data. This report reflects the survey responses of 2924 on-call providers in 319 medical groups.

Have a comment?  We'd love to hear your viewpoint!

Texting for wait times: the future for emergency departments?

As a follow up to a story that was posted to this page in April, there is now a short video that further discusses how California's Riverside Community Hospital's "Know Before You Go" text system is generating positive benefits in the emergency department.

To view the video, click here.

As the largest emergency department in Riverside County, averaging over 77,000 emergency patients annually, the hospital recently implemented the system and is reporting increased patient and emergency staff satisfaction levels. The text message program works using a technology that links the computer system in the emergency room with the texting abilities of cell phones.

While the national average wait time exceeds four hours, Riverside Community Hospital's wait times can be as low as just a few minutes.  Hospital administrators say the system not only cuts a person's wait time once they arrive at the ER, but also helps the hospital design ways to become more efficient.  

Of course, many emergency situations can't be predicted, and in a true medical emergency, patients should call 911 for assistance. But for situations where texting is an option, the system is clearly providing benefits across the board. Take a look at the video and judge for yourself.

Emergency physicians, honor yourselves!

By Joel Stettner MD 

As emergency physicians, we're often so wrapped up in the daily "doing" of emergency medicine that it can be difficult to step back and recognize the significant clinical and administrative accomplishments of our colleagues.  

Luckily ACEP, through its American College of Emergency Physicians Awards Program, does an excellent job of recognizing those ED physicians who have demonstrated the highest levels of leadership and excellence. The Program provides an opportunity to honor members for significant professional contributions as well as outstanding service to the College.

The ACEP Excellence in Health Policy Award is an example of how the program works. Each year, ACEP presents this award to a member who has made a significant contribution to achieving the College's health policy objectives, or who has demonstrated outstanding skills, talent, and commitment as an administrative or political leader.

I am pleased to report that a respected partner and colleague, Miles Riner, MD, was recently named the 2010 recipient of this award. Through his work on state and national regulatory and legislative issues, and as a member of the Board of Directors of the California chapter of ACEP (CAL/ACEP), Dr. Riner has been able to make a significant contribution as a powerful advocate for emergency physicians and the emergency care safety net. Recently retired from clinical work, Dr. Riner is continuing his efforts in support of health care policy advocacy at both state and national levels.

I'm honored to call him my friend and very pleased that his hard work and dedication to emergency medicine have been recognized.

All members of ACEP are eligible for one or more of the College's award programs. Our success as a specialty has always depended on our willingness to get and stay involved beyond clinical work. As busy as we are, it will always be important to take time to recognize the individuals who demonstrate true commitment and excellence in their work.

Have a comment?  Please share!

Why America’s “50 best hospitals” really aren’t

By Marty Ogle MD

What does an emergency physician do on his off hours? In my case, I sometimes like to read – and not just about emergency medicine. Recently an article in the April 2010 Annals of Internal Medicine caught my attention. The article examined the criteria that US News and World Report uses to determine the 50 best American hospitals – which, it seems, is based primarily on “reputation”.

After finishing the piece, I came to the conclusion that there’s apparently little or no objective criteria in the selection process such as mortality rates, size of a specific program, patient satisfaction, CMS Core measures, or the elements of the PQRI program. That, to me, is a real puzzler.

If you've read the U.S. News article, you may very well join me in asking if these are really the “Best” hospitals. Wouldn’t you expect part of the selection criterion to include how well they actually care for their patients?? Isn’t that what hospitals are supposed to do?

The Annals article concludes by stating that “The relative standings of the top 50 hospitals largely reflect the subjective reputations of those hospitals. Moreover, little relationship exists between subjective reputation and objective measures of hospital quality among the top 50 hospitals”. To which I say “Amen, brother”.

In an era of increasing scrutiny of outcomes and performance (for both providers and hospitals), I think this would somehow enter into the mix. Not only are objective criteria in the “real world” being looked at by payors, some performance metrics are being linked to reimbursement and I suspect this trend will only accelerate.

I know that US News and World Report needs to sell magazines and advertising space, and is skewed toward a “consumer” vs. medical industry audience. So the thinking among their editorial staff most likely is to portray the article as containing empirical content to increase curiosity and sales. Nothing wrong with that -- but let’s get real. Try labeling the selected facilities as the “50 Most Popular Hospitals in the US” for journalistic accuracy. They would likely still sell a lot of magazines. And at least their article would be accurate.

What are your thoughts on mislabeling hospital quality and performance?

What makes a successful democratic emergency physician group?

By Ellis Weeker MD 

For over 30 years, I've been a partner in a flourishing democratic emergency physician group. In fact, we're now the largest truly democratic physician group in the U.S. Our partnership is a relationship between member physicians characterized by mutual cooperation and responsibility, dedicated to achieving a common goal. In our case, that goal is to ensure that every partner is an equal owner - or on the way to becoming one - and provided with a maximal feeling of ownership and control over their medical practices.

From the beginning, we understood that there are many ways to define the term "democratic". Because of our unwavering belief in "shared ownership", our group has been based on mutual respect, local autonomy, organizational transparency and a relentless focus on providing the highest quality patient care. We even went so far as to develop a set of core values called our "Partnership Principles" that define many of the aspects of the culture.

But that doesn't mean it's been a cakewalk from Day 1. On the contrary, one of the strengths of our group is understanding that it is a living, breathing organism that can be inspected, altered, and improved as often as necessary.

An article written by Ronald A. Hellstern, MD, FACEP does a great job of outlining why democratic physician groups fail. But I'd like to use my experiences - and the experiences of our partnership - to convey what I believe are a few of the reasons why our democratic physician group did not fail.

Democracy - our leaders are elected or appointed to positions of responsibility and act as stewards of the partnership. They are elected for their willingness to serve the interests of the group.

Shared Ownership - As owners, our partners support each other, stay connected to their practices, and are part of something bigger than them.

Autonomy - practice sites have a great deal of local autonomy from the partnership and may develop various approaches to enhance their practices based on a majority rule vote.

Accountability - no one is above the partnership, and we all are held accountable for our decisions and behavior as partners.

Freedom of Speech - all partners are encouraged to voice their opinions and leaders are accessible to partners to answer questions or concerns.

Transparency - partners have the right to access information about the partnership, including financials.

Achieving and maintaining a successful democratic organization of over 1,000 emergency physicians isn't always easy.  It requires cooperation and agreement as well as patience and mutual respect for one another.  But most importantly, it requires a true understanding of the partnership's long term goals - and the intrinsic benefits to all concerned.

I look forward to your comments.

 

 

Increased availability of Primary Care Physicians: good for Emergency Services?

By Prentice Tom, MD 

What would life be like in the emergency department if patients had greater access to primary care physicians? A recent article in the Journal of Emergency Medicine, authored by K. Tranquada, et al, addresses that same question - and concludes with something that emergency physicians have known for years:  the demand for emergency services is not related to the availability of primary care physicians.

Over the past few years, there have been a number of studies that suggest a significant percentage of ED visits are "unnecessary" i.e. treatment could have been provided in a primary care clinic or office.  Emergency physicians have long understood lack of a primary care physician is not necessarily the reason that patients seek "non-emergent" care through the  ED, and that significant numbers of patients with non-emergent medical conditions, who have access to a primary care physician prefer to obtain their medical care through the emergency department. 

There may be a multitude of reasons why patients preferentially seek care through the ED, and if increasing the number of primary care physicians does not change patient behavior, than as emergency physicians, we need to ensure that the emergency department is able to efficiently provide care with a marginal cost similar to the marginal cost of providing care through a primary care setting. 

For episodic care, where diagnostic testing and labor resource expenditure are similar, this may already be true.  For conditions where the emergency department has much greater experience, it may be possible to provide even less urgent care at a lower cost than that provided in a primary care setting.  For example, an experienced mid-level provider may be able to treat minor trauma requiring laceration repair and evaluation for simple fractures faster and with less use of diagnostic tests than may a primary care physician. 

Instead of trying to screen patients out of the emergency department, the solution may be to learn to efficiently treat patients so that necessary medical care can be provided through a number of alternative venues that meet patient needs.

Agree or disagree? Please let me know your thoughts.

Health Care Reform: welcome but not done yet

By Wesley A. Curry MD

For all of the hand wringing and hyperbole, health care reform is ultimately about ensuring that the appropriate health care services are available in a timely manner to the people who need it.                            

As an emergency physician, my view on health care reform is that it has already happened in one area of the healthcare system, namely the emergency room.  With this new legislation, we now have an opportunity to take some of the burden off the "emergency" part of our health care system, which is long overdue.

The "reform" that I refer to was EMTALA (Emergency Medical Treatment and Active Labor Act), which was enacted in 1986 as part of the Social Security Act, and is included in the section of the U.S. Code which governs Medicare. EMTALA was passed as part of the Comprehensive Omnibus Budget Reconciliation Act (COBRA).  It remains the largest unfunded healthcare mandate ever enacted by the federal government.

Generally, EMTALA applies to a "participating hospital", with provisions applying to all patients (including those under managed care).  The hospital must have an emergency room (or service) to fall under the provision, but based on a broader interpretation by the courts and regulatory agencies, this law applies to all areas of the hospital - even offsite medical practices or clinics. It requires that all hospitals with emergency rooms evaluate everyone who presents to participating hospitals in order to determine that a serious, disabling, or life-threatening emergency does not exist.

Lest we forget, EMTALA happened because of egregious practices decades ago toward patients who had no medical insurance and were turned away - often suffering from serious conditions - from emergency rooms by hospitals and physicians.  While laudable, it has often applied a heavy burden on ERs.

One thing is clear however; we're about to experience a true sea-change that will define the future of health care in this country. During the next decade I believe that something will be built to radically change how people consume health care services and the way money flows within the healthcare portion of the economy. This development is long overdue, because now the question is not "whether" Health Care Reform will happen, but what it will look like a generation from now when the wrinkles have been ironed out.

History teaches us that this historic legislation is the beginning of a new phase in the long and tortuous process to achieve a more effective and equitable health care system for this country. Once implemented, it will provide much improved healthcare services to a significantly larger segment of our population.

Where do you stand on the issue?  Please send me your comments.