So what will health care reform mean to Emergency Medicine?

By Ellis Weeker, M.D.

Well it's actually happened.  We now have "healthcare reform". After a seemingly endless and wildly partisan debate, President Obama has signed into law an historic healthcare reform package. But even a week later, as an emergency physician, I'm still not sure what it all means. However, one thing is true for all of us - physicians, nurses, physician assistants, nurse practioners, administrators and patients - there will be change.

For those of you trying to sort out what it all means, I recently came across an article in Healthleadersmedia.com that does a good job of highlighting how the healthcare reform provisions kick in over ten years.  

As we still deal with the seemingly never-ending arguments in this country about the bill, it's interesting to get an outsider's opinion of what our country is about to do with its healthcare system. This article in Germany's Spiegel Online presents the argument that what's good for the US (healthcare reform) may not be positive for the president or for the rest of the world.

So the questions are: what does it mean to Emergency Medicine? How will it affect how I practice my medicine? And what's going to happen with reimbursements?"    

The obvious is there will be more people with medical insurance seeking health care. Emergency physicians know what that means. There will be more people chasing down an already inadequate supply of primary care physicians. So there will be more patients coming to the only other game in town-emergency departments.

With those increased patients will come even more government regulations and expectations of performance. Very likely much of the reimbursement will be tied to performance measures of some kind and there will be increased government scrutiny of billing practices. Expect lots of audits to reduce fraud and abuse.

As there is no money allocated for illegal immigrants, these patients will continue to come to our emergency departments. The worry is there will be a reduction in the money available from cost shifting to pay for those patients. We will see an increase in the use of physician extenders-PAs and NPs. The final question is whether this is the beginning of better days or the beginning of more frustration with government intrusion. Most likely it will be a little of both.

Change is never easy. And something as far-reaching as healthcare reform is the most monumental piece of legislation since the sixties. In the end, I am hopeful that the "good" will far outweigh the "bad".  It's time to move the country forward. We have debated our ethical responsibilities to our fellow citizens long enough.

What are your thoughts and fears on the healthcare reform bill? 

 

Health Care Reform: the second act

By Joel A. Stettner MD

So what's wrong with America's Affordable Health Care Choices Act of 2009, aside from a none-too-catchy title? Although we're still very much in the early stages of Act Two (which follows Act One's "Debate and Discussion" and precedes Act Three's "The Realities of Implementation"), it seems clear that we may have a few issues worth consideration.

First, and perhaps most important, is the apparent near-fatal condition of our national political process. It's apparently been replaced by intransigent partisanship, highlighted by offensive if not downright abusive language coupled with extremist behavior.

I frankly don't understand how positions can be so far apart such that no affirmative votes are cast by the opposition political parties, while families are threatened because of a legislator's partisan vote. I'm not sure if our Founding Fathers ever thought we'd get to this point - in spite of their strong disagreements as our democratic form of government was established. There are a multitude of problematic issues that must be addressed by Congress and I don't see how sudden cooperation and a willingness to compromise for the greater good are likely to materialize any time soon. This is very worrisome.

Second is the bill itself. Finding an accurate summary, and understanding the implications, is difficult if not impossible. Obviously all of us in the health care industry (and in my case, emergency medicine) will be impacted. But figuring out exactly how remains a difficult challenge.

Although there are many purportedly complete analyses of the bill's provisions, the interpretations seem to vary widely. And as an emergency physician, I'm not sure how to judge what will happen to my practice. More patients who think they have coverage but may not so much? More patients on Medicaid with less revenue per patient to be collected? More primary care in the ER (beginning with the EMTALA-mandated MSE) since the shortage of practitioners in that field remains severe? More demands from the hospital for cost control coupled with higher Press Ganey scores? Or something we haven't yet thought of? And with no tort reform? Please!

So what should we call Act two of our health care reform play? Perhaps "Trials and Tribulations" would be appropriate. After all, lawsuits have already been filed...and we know who always wins once the legal system becomes involved.

So if you've got the health care reform bill figured out, please fill me in. Or if you have strong feelings either way about the legislation, I would love to hear those as well.

 

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

By Marty Ogle, M.D.

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.

Healthcare reform: A brave new world of new - or old ideas?

By John Ruffner

The ink is barely dry on the new Healthcare Reform bill. But after more than a year of very polarizing comment and debate from every special interest group on the planet (and some groups who are apparently not from planet Earth), it's now time for those of us in emergency medicine who will actually have to work with the reforms, to start hammering out the details of implementation.

A number of industry leaders, policy makers, practitioners and academics are focusing on how the market/industry will restructure to meet the national plan.  Some of the ideas are new - but many are old concepts reborn.  Either way, none of the ideas are likely to take effect for at least four to five years. 

In the end, the objective is to form organizations of sufficient scale clinically, technologically and financially to assume global risk for all services to their market.  If this sounds a bit familiar, it's probably because we actually already have a working model of this approach called "Kaiser Permanente".

Over the next few years, we will all become familiar with the terms "Accountable Care Organizations" (ACO) and "Medical Homes" as these are some of the models currently being piloted.  The national policy objective for growing these structures is to bend the cost curve and slow the rate of increase on overall healthcare costs.  Early results from the pilots and other prior existing operations like Group Health and Mayo Clinic, demonstrate actual quality improvements with lower costs.

At this point, there are a number of unresolved issues still being hammered out - the two most important of which are (in my opinion):

1. The cost and quality leaders (Kaiser, et al) are for the most part, primary care driven.  There are not enough primary care physicians to duplicate this model across the country.  And, there's not likely to be enough for a decade. So what happens?
2. The diversity of markets such as the greater Los Angeles metro area (approximately 13 million) as opposed to places like the State of Vermont (600,000).  With its diverse population and just as diverse healthcare provider industry, Los Angeles will clearly not find a "one size fits all" solution, and there are many other metro areas in the same boat.

Stay tuned. It's going to be a brave new world of new policies and ideas. I'm betting that the good will far outweigh the bad. How about you?

Emergency medicine gets a bum rap. Again.

By Marty Ogle, M.D.

As an emergency physician, I'm always interested in reading articles that purport to tell me how I should feel about the current state of emergency medicine. I recently came across such an article in Slate that poses the question: "Are Most Emergency Room Visits Really Unnecessary?"  

The article brings up the old argument of how "unnecessary" emergency department visits for minor conditions, such as colds, headaches, stubbed toes, etc., are clogging every ER in America. After all, people coming into the ER with a sore throat and no insurance are surely bleeding the system dry, right? How else can you explain the current crisis of our healthcare system? If these people would just get insurance or stay home, everything would be fine and insurance premiums would plummet.

However, having worked ER shifts for many years, I can tell you that I've seen and treated everything from major trauma cases, to patients suffering from bug bites. While some cases are obviously more life threatening than others, I have a hard time defining what is an "unnecessary" ER visit and what isn't.

I simply don't think the idea holds water that keeping patients out of the ER who don't have non-life threatening cases - or those without insurance - is the way to save the healthcare system significant dollars. 

In the end, the article generally debunks the "unnecessary visit" position, but somehow I don't feel entirely vindicated. What I believe is not being discussed is that emergency care (from the EMS call...to the ambulance ride...to the ER doc charges...to the fees charged by the hospital emergency facility...) make up less than 5 cents of the healthcare "dollar." If you cut emergency care by 50% you've saved a whopping 2.5 cents. Yet in reality, since the emergency department is still open, the ER doc and nurse are still on duty, and the ambulance and paramedics are still sitting there waiting to respond, the true cost has not changed.

No matter what the politicians and pundits say, our current system (ER safety net for all, 24/7) is working and is not why the healthcare system needs reform. Those who think they can save bushel baskets full of money by barring the door to the ER need to step back and evaluate the very real cost of providing unscheduled care while still maintaining the fixed costs of 24/7 emergency treatment that Americans want.

Anyone else think emergency medicine get's a bum rap?  I'd love to hear your comments. 

In addition, ACEP offers an excellent online portal for you to express your opinions to Congress regarding emergency medicine issues.

Who's managing your medical practice?

By Michael Harrington, CEO, MedAmerica

As the healthcare reform debate continues, the overall complexity of our country's healthcare system seems almost overwhelming. Many healthcare organizations, physician groups, administrators and physicians are frustrated and unsettled by the pending sea change in how the government will fund and support our myriad healthcare programs.

Navigating the healthcare maze is challenging enough. But with total healthcare spending predicted to reach a staggering 20% of the entire US economy by 2017, and with per person healthcare expenditures looking to double during the same period, physicians and medical professionals will be hard pressed to spend quality time with their patients - adding to increased concerns about healthcare quality and safety. 

That's why I firmly believe that the importance of a qualified, third party practice management organization has never been greater. To illustrate my point, I've identified the top 5 benefits a practice management organization can offer to health administrators and physician groups:

• Deep understanding of your business - The strength of a practice management organization is that you are working with a team of experienced professionals who understand the healthcare industry. You'll work with people who truly know and understand your business, and will treat you like a partner.
• Efficient and cost effective - Because a group offers comprehensive management specialties under one roof, you'll be able to take advantage of an array of management solutions without having to shop around to several consultants or smaller firms. This "one-stop shopping" approach increases overall efficiency and cost effectiveness.
• Collaboration - Collaboration ensures open lines of communication and a healthy sharing of ideas that lead to high-performance solutions that work for your practice. A practice management organization should be completely in sync with your unique needs.
• Technology - The benefits of a larger practice management organization include Information Technology services that are right for your needs, vs. a cookie cutter approach that may not serve your best interests. Looking toward the future, technology will be playing an ever greater role in maintaining a successful practice.
• Financials - having access to a full scope of financial, billing, reporting, benefits administration, etc. enhances the profitability of your practice. The best practice management firms offer these capabilities and take the burden off of you and your practice to keep up with ever-changing State or Federal mandates.

The bottom line is the healthcare industry isn't going to get any less complicated. The right healthcare practice management organization can really make a difference in running a successful practice. And as I like to say, it allows doctors to do what they do best - practice medicine!

Have any opinions on practice management groups?  I'd love to hear them!

Are ER doc's emergency medicine concerns being heard?

As the healthcare reform behemoth continues to limp forward, now's the time for ER physicians to turn up the heat on their elected representatives. 

No matter your opinions on the pros and cons of healthcare reform, emergency medicine - and emergency physicians, administrators, PAs and NPs - will be affected one way or another.  

It's obvious that Congress listens to the loudest voices, so this isn't the time to wait on the sidelines.

ACEP offers an excellent online portal for advocates to address issues with Congress regarding emergency medicine.  If you feel strongly about the future direction of your profession, it's worth a few minutes of your time to ensure that your voice is heard - especially as we near healthcare legislation crunch time.

Do you have successful advocacy stories? If so, please share them - and let us know how you accomplished your goals.

Seven secrets of the emergency room, Medicare, and much more.

From time to time, this blog pauses to look at some of the healthcare and emergency medicine issues buzzing around the web. The past few days have offered some interesting topics to chew on.

We'll start with this breaking news: The Senate voted 62-36 Wednesday to approve a $138 billion bill that would temporarily prevent Medicare payment cuts to doctors as well as extend federal Medicaid assistance and COBRA premium subsidies.

"This week's bill helps those who have been hit the hardest. Among other things, we're going to extend unemployment benefits to those looking for work, cut taxes for families and businesses, and protect Medicaid so low-income families can afford healthcare," Senate Majority Leader Harry Reid (D-Nev.) said in a written statement. The bill now heads back to the House. You can visit modernphysician.com to read the entire story.

And now onto the healthcare reform debate...

President Obama took to the road this week to make the case for a health-care overhaul that still awaits an uncertain fate in Congress. This story originally published in the Washington Post, outlines the White House's strategy of using health insurance company rate increases to rekindle the fire for reform.

If you're wondering what the president is saying out there, you can read excerpts of Mr. Obama's speech, as well as view a brief video here.

And of course in politics, every action has a reaction. To counter the White House's health care efforts, hundreds of business groups have launched a multimillion-dollar ad campaign designed to stop health care legislation and fire back at the president's efforts to win support for a plan Obama says would expand insurance coverage to 31 million people.

On another topic, it's been just about a year since H1N1 arrived in the U.S.  A story in today's Health Leaders Media, "One Year Later: What Have We Learned From H1N1?" does a good job of assessing how our healthcare system responded to the frenzy - and poses the question as to whether our country is prepared for the next pandemic. 

We're all getting older. And now it appears more hospitals across the country are expecting to offer geriatric emergency departments as the nation's 76 million baby boomers reach their senior years. These sites are staffed by doctors and nurses with geriatrics training care. But will they remain viable with Medicare cuts to physician payments, or will hospitals use them to draw in patients for more profitable procedures? St. Joseph's Regional Medical Center in Paterson New Jersey has become one of the first hospitals in the nation to open a geriatric emergency department. It seems to be working well - you can read about it here.

If you work in emergency medicine, you know the ins and outs of life in the ER. The New York Times has posted an interesting article on the "seven secrets of the emergency room".  Perhaps you recognize them - or maybe you have some secrets of your own you'd like to share??

Have a comment?  Please feel free to share!

Does Patient Centered Care add to ER Overcrowding?

By Prentice Tom, MD

In a recent issue of Health Affairs, (28, 4, 2009: w555-w565), Dr. Don Berwick makes an argument for Patient Centered Care, where physicians rely on patients to make informed decisions regarding diagnosis and treatment plans.  He states:

"Evidence-based medicine sometimes must take a back seat. First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. Should patient ‘wants' override professional judgment about whether an MRI is needed?  My answer is, basically, ‘Yes.'  On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase ‘a fully informed patient.'"

I agree with the concept that it is critically important to have patients involved in their care and be part of the decision making process. And as physicians, we need to strongly encourage patients to take an active role in their health maintenance and disease management.  Over the last twenty plus years of practice, I have found that by informing and educating patients and their families regarding their medical condition, diagnostic and treatment options, and by seeking their input regarding their health goals and their expectations, I am much better able to serve and care for my patients.

Still, there are times - especially in the emergency department - when this approach may not be in the patient's best interest, nor the best interests of overall patient care.  Unfortunately, in the emergency department, where time and resources may be severely limited, the emergency physician may be required to provide care in a manner that most efficiently utilizes resources and maximizes patient outcome, even though the patient may want a test that is not necessary for treatment or the physician may not have had the opportunity to fully explain his/her decision.

In a physician's office, clinic, or in-patient ward, care that's truly patient-centered considers patients' cultural traditions, personal preferences and values, family situations, and lifestyles.  But in the emergency department where beds are scarce, resources are limited and the patient has no prior relationship with the physician, we need to balance patient education and demand for limited resources with overall patient flow, and the type of patient-centered care that Dr. Berwick describes may not be the best solution.

It is likely that every emergency physician can recall seeing a patient similar to the one that Dr. Berwick describes:  Doctor, I have a headache, and I want an MRI.  Access to an MRI can take multiple hours in a busy hospital, and even explaining why we can't offer such testing can take many minutes.  In principle, I agree with Dr. Berwick.   But in a system where the patient may not bear any financial responsibility, and where resources and time are limited, Such a practice may not always be in the best interests of overall patient care.  I only wished I lived in a world where emergency physicians had the time and resource availability to provide patient centered care to all our patients.

I would appreciate your thoughts or experiences with Patient Centered Care in the emergency department.