Emergency physicians: are you ready for a Medicare fee cut?

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Emergency physicians beware - as of this writing, the current freeze to the Medicare conversion factor is set to expire on March 31. But wait, haven't we been down this road before?  As a matter of fact, yes.  On March 17, the House of Representatives passed the Continuing Extension Act of 2010 (H.R. 4851) that included a provision that froze Medicare physician payments at their current level until April 30. The legislation also extends the therapy cap exception process through April 30. 

On March 10, the Senate approved the American Workers, State and Business Relief Act (H.R. 4213) of 2010 that included provisions to extend the current Medicare physician payment rates through the end of Sept. 2010 (a 6 month extension), the therapy cap exception process through the end of the year, and the current geographic practice cost index work floor through 2010. 

Further votes by the House and Senate on these expiring provisions are expected - but without further congressional action, the current freeze to the Medicare conversion factor still expires on March 31.  Currently the expectation is for the Senate to consider the 30 day/House extension and possibly take it to a vote as early as this week, though the Senate must also vote this week on the House passed reconciliation bill (H.R. 4872). Without permanent repeal of the sustainable growth rate (SGR) formula, we will be subjected to this Never Never land of temporary fixes - or even lapses - virtually forever. I urge you to contact your Senators and Representatives and ask them to support permanent repeal of the sustainable growth rate (SGR) formula once and for all.

Together, our voices are strong. Please take a moment to reach out.

Be an advocate: get to know your legislators.

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By Carlos Medina, M.D.

The old saying "if you want something bad enough just try harder" could have been coined around the topic of "advocacy". But what exactly does advocacy mean to us in the medical field? 

First of all, what we're talking about here is voicing your opinion about a particular piece of legislation that will affect what we do or where we practice - either negatively or positively.

Sounds easy enough, right? But in order to be a successful advocate for an important issue, you need to know how to monitor the legislative process and then how to gain access to your specific legislator(s) either in a letter or over the phone. Luckily, it doesn't have to be hard - especially if you follow a few simple rules.  And as we in California know first hand thanks to our recent budget woes, it really IS important to be an advocate for a position that will affect your livelihood, your hospital, and your community. And the more you write or call, the more likely legislators are to listen.

To write to your legislator, here are a few tips to follow:

• Get a grasp of the bill and your position
• Identify yourself, what you do, where you live
• Describe how the proposed legislation will affect  the community, patients and EDs
• Use local examples and refer to common interests
• Be timely and state when the bill is scheduled to be heard or voted on
• Stick to ONE subject. Be brief and to the point. Use short sentences and short paragraphs
• If calling, ask for the staffer who deals with Health Care. The key to a good relationship with the politician is through a good relationship with their staffers - they look to them for information/opinion

In addition, here are some useful links that should help you in the advocacy process:

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

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

http://www.legislature.ca.gov/ (Legislators and Districts)

Successful advocacy is important - and it's something we can all do! I'd love to hear your comments or ideas on this topic!

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.

Health Care Overhaul: Real Change?

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By Joel A. Stettner, M.D.

Like many of you, I continue to watch the ongoing Washington discussions on Health Care Reform with great interest. Perhaps what is most striking to me now is my feeling that an old phrase may still ring true: the more things change, the more they stay the same.

I don't mean to reject the notion of change in our system, which clearly is needed. Rather I am struck by the "politics and special interests as usual" approach that seems to have bogged down what admittedly is a complex undertaking. On the one hand, both Democrats and Republicans are holding onto their traditional and reliable positions concerning single payer and/or public option approaches, the need (or lack thereof) for medical liability reform, and the best (or least distasteful) way to fund the changes we need.

At the same time, key industry players seem to be hardening their approach, reflecting their tradition of protecting special interests. And there is risk of a new "scare tactics" campaign, raising issues around socialized medicine and pointing out how ineffectual alternative systems appear to be (Canada comes to mind, although the concept of no or badly delayed care and Canadian citizens coming across the border in droves for medical services turns out to be untrue when examined).

I cannot pretend to have good answers to the complexities of reform, but objective discussion, coupled with a long-term view towards the greater good, might help accelerate the process of finding solutions.

If you have a few minutes, check out a video created by an emergency physician in Portland, Oregon; it can be found at http://www.ourailinghealthcare.com/. I know that ER docs, like everyone else, have a point of view driven by their experiences and their needs. None-the-less, I thought this was a reasonably objective look at the problems we face, coupled with thoughtful observations about what might be worth considering as the debate goes on. What are your thoughts?

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.