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 @ 04:58 PM
By Christy Palombo, RN
Seems like every day there's a new challenge concerning H1N1. For those of us in emergency medicine, it's important to take note. Is the hysteria starting? Are ER's about to be hit by an onslaught? Are people listening to us and staying home if they're ill?
On Thursday, an article published in the Washington Post stated that people may be able to spread swine flu even after their symptoms have subsided.
This comes from a recent study of Air Force cadets who came down with the flu this summer. It was found that a large number of the cadets were still "shedding" the virus more than 24 hours after their fever and other symptoms had disappeared. You can read the full report here: American Journal of Preventive Medicine
These findings bring into question whether people are listening to what we've been telling them, most importantly, staying home if they have flu-like symptoms (such as fever, sore throat, cough, etc.) instead of going to work or school and spreading the virus to others. If transmission is still possible after symptoms have gone, it could be bad news if individuals are returning to work or school too soon.
Because of swine flu vaccine production delays, the government has backed off initial estimates that as many as 120 million vaccine doses would be available by mid-October. As of last week, only 11 million doses had been shipped to health departments, doctor's offices and other providers across the country, according to the CDC.
All of which means, unless current behavior patterns change, there will be a lot of sick people heading for their local ER. My view is that medical professionals and the media need to get the word out to individuals and employers that staying home if you feel sick is the best medicine. It's clear that there will always be those who try to power through whatever illness they have, but it's also clear that the H1N1 pandemic is not business as usual. Behaviors need to be modified, and we need to make sure that message is getting out to the public. That's what I'm attempting to do here.
I welcome your thoughts and ideas on the topic - please ensure that your voice is heard!
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?
Posted by Guest Blogger on Fri, Dec 04, 2009 @ 12:45 PM
By Chris Hannan
As a healthcare marketing professional, "better communication" and "technology" are certainly terms that I use every day. As a proponent of finding and leveraging better ways to communicate, I'm intrigued by how the latest communications technologies are making their way into healthcare delivery - all the way to the OR in some cases.
It's fascinating but at the same time, I wonder if we're utilizing Twitter, Facebook, YouTube and the Web etc. in ways that make sense on a business and patient-care level.
Can a web site help solve overcrowding problems in an emergency department? Some hospitals are posting their emergency room wait times on a web page. While there are many benefits to keeping the public informed - what happens if a patient shows up and has to wait 5 minutes longer than the posted wait time - does this lead to improved quality care or a better patient experience- or more stress for all involved?
Another example of new technology in the OR comes to us from Des Moines Iowa, where a 70-year-old patient's children followed her hysterectomy and uterine prolapse surgery progress via Twitter. A hospital staffer sent more than 300 tweets over more than three hours from a computer just outside the operating room. Nearly 700 people followed them. Eight people tweeted questions to the staffer. Is this a good thing, or is it just that, thanks to Twitter, it's possible to tweet about virtually anything?
What do you think about these growing trends? What kinds of technologies do you see in your ER or hospital? Is it too much information? A fad that will pass? Or a prelude of things to come?
Posted by Guest Blogger on Thu, Dec 03, 2009 @ 11:18 AM
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!
Posted by Guest Blogger on Thu, Dec 03, 2009 @ 11:16 AM
By Nancy Carlson, RN, MBA.
One more thing this recession has done is to temporarily mask the symptoms of a problem that's two decades old. That is, with older nurses staying in the work force longer and delaying retirement - and other nurses who left and then came back due to recessionary times - the trend toward nursing vacancies appears to have been reversed.
But there's still a nursing shortage. In fact, CINHC projects California will have a shortfall of 108,000 nurses in California alone by 2020. So even with fewer openings, there's a real need to increase capacity to educate and prepare new nurses.
Today, the positions are being filled by experienced nurses back in the market due to the economy. The average age of an RN in California is over 47, so when they start retiring, the statewide shortage will jump. According to the California Institute for Nursing & Health Care (CINHC) 90% of RN's under the age of 55 are working, which tightens the market for new grads more than usual.
The good news is that educational capacity for RNs statewide has increased 55% since 2004, bringing younger nurses - including men - into the workforce. But despite these successes, we can't pull back in our efforts to overcome the nursing shortage.
Increasing funding for nursing-education programs is still very important. And we can't become complacent when looking at recent economic data that indicate we've solved the nursing shortage. With an aging population and continued growth in the demand for caregivers, the need for new nurse graduates is as great as ever.
So where can new graduates get the needed "first job" experience if hospitals are not hiring them? (At least until the economic tide shifts and baby boomer nurses retire).
There are nursing jobs available. Opportunities are growing in ambulatory and non-acute settings as care shifts away from hospitals. Apply for any open position, be persistent in calling employers and consider moving to states such as Texas or the Midwest with more demand. New graduates may not get their first choice of a job or location, but there are still openings.
What ideas do you have to encourage our new nurses? Should hospitals hire more staff than they really need (or can afford to have on the payroll)? What has YOUR hospital done to keep graduate nurses in the employment pipeline?
Posted by Guest Blogger on Wed, Dec 02, 2009 @ 02:13 PM
By Marty Ogle, M.D.
I find it pretty interesting that our representatives in Sacramento are spending their time trying to first push through a bill that would effectively delay an imminent closure of a district hospital ED and then abandon the bill and the effort to salvage the facility Oakland Tribune. It seems to me that they should consider facilitating activities to address inefficiencies and waste at the facility to make the hospital and the ED financially viable. The excuse that this is a district hospital and therefore it needn't operate efficiently is unacceptable.
There are ways to make what appears to be a financially unsound ED into one that contributes to the financial stability of the entire facility and improves service to the community. There would need to be commitment from the very top of the organization, including the five member Board of Directors, to make the changes to accomplish this, and I have seen this happen at much larger, more complex, and more challenged ED and hospitals.
It really comes down to leadership and decisiveness if this facility is going to continue to serve San Leandro. Attempting to pass bills in Sacramento to maintain the ailing status quo is not needed right now.
I welcome other opinions on this matter.
Posted by Guest Blogger on Wed, Dec 02, 2009 @ 01:10 PM
By Nancy Burghart-Hall
The Obama Administration stimulus plan would spend $22 billion in federal and state money to jumpstart Healthcare Information Technology (HIT). And that's only round one. One of the main goals of the HIT stimulus package is to incent providers to purchase and adopt Electronic Health Records (EHR) and to facilitate the exchange of health-related information.
Hospital-based physicians are specifically excluded from these incentives, meaning no money for ER providers even if you did fund your Emergency Department Information System (EDIS). So what does this mean for emergency doctors? There are implications, and I believe opportunities to consider.
Hospitals are eligible for incentive dollars. The base for hospitals is $2 million, and monies will begin to flow as early as 2011 for hospitals with systems in place in 2010. So if your hospital has not adopted an EHR yet, you will probably feel the push soon if not already as your Hospital facility implements a system or replaces an outdated one with a certified vendor product.
To obtain incentive dollars your hospital must show "meaningful use", a term still being defined by the Office of the National Coordinator for Healthcare Information Technology (ONC). However, there is a good chance the EDIS system in your Hospital will be key since it can demonstrate orders integration, patient discharge instructions, and prescriptions. These are all part of where we see the definition of meaningful use heading. If EDIS is not at the top of the list, it may be soon.
Physician adoption of Information Technology is also part of the HIT plan, and grants will be awarded starting January 2010. This may be an opportunity for emergency doctors to support your Hospitals by leading physician adoption efforts. At many of the CEP America sites, this has already been accomplished by talented and innovative Medical Directors and site leaders.
Another consideration is the availability of information. With the widespread implementation of EHRs, information will no longer be a differentiator. Payers, providers, and patients will have more information. With the looming ICD-10 transition information to support healthcare reform, efforts will be available to CMS. It will be important to have the information others have about you and be able to continue to manage to your own performance standards. If you currently do not obtain a copy of your EDIS charts, it will be important to add this as part of every systems implementation.
For those of us in HIT for the past 20 years, our time has come. This year at the Healthcare Information and Management Systems Society (HIMSS) conference there were over 200 new HIT products and 900 new exhibitors. This is my industry's response to the stimulus plan. The HIT industry is preparing for a new wave of activity. I believe one of the primary things we can do is communicate to our stakeholders what is reasonable and doable. I'm interested in hearing any comments or questions regarding the HIT stimulus plan and how you see it impacting your emergency room.
Posted by Guest Blogger on Wed, Dec 02, 2009 @ 12:47 PM
By Ted Kloth, M.D.
In this current climate of hospitals cutting back on expenditures or shutting their doors, the burden for emergency departments to generate and capture revenue has never been greater. In my view, the revenue in the ED is there - if you know where to find it.
The easiest hidden revenue would be to capture LWBS patients. No new marketing expenditures are needed and you don't need to attract more patients (many EDs are overwhelmed as it is). You just need to make sure you see the ones that show up to your ED. That's where the Rapid Medical Evaluation (RME) system has played such an important role of garnering hidden revenue. It's a system that enables patients to be seen by an appropriate provider, in an appropriate setting usually within 30 minutes of entering the ED. And not necessarily requiring a bed for each patient.
Because the admission rate of these LWBS patients is similar to the admission rates of those seen, the big bang for the hospital comes from the increased number of in-patients and hence the increased in-patient revenue. For a hospital with 50,000 annual visits, a decrease in LWBS would increase hospital revenue by about $2 million dollars per year for every 2% of LWBS patients that are captured. So if LWBS was decreased from 5% to 1% (a very achievable result in my experience) hospital revenue would increase by about $4 million dollars per year. Allowing those LWBS patients to leave your facility untreated is tantamount to giving your competitors a $4 million dollar annual stipend - money that should have been in your revenue stream, not in theirs.
The bottom line is that by utilizing RME, we're able to see more patients per ED bed, thereby increasing patient volume capabilities and generating more revenue for the hospital. I welcome your comments or questions.