H.R. 3962 Passed....What Now For Emergency Medicine?

Last night the U.S. House of Representatives passed a health reform bill, H.R. 3962. Emergency physicians are divided in their thoughts about the consequences of this legislation, as is the house of medicine and the country in general. However, there are many aspects of the bill that are positive for emergency patients and for emergency physicians.

Some of these include:

*Inclusion of emergency services as part of an essential health benefits package

*Statutory authorization of ECCC (Emergency Care Coordination Center) and ECCC Council of Emergency Medicine.

*Health and Human services annual report to Congress on ECCC activities, with focus on emergency department crowding, boarding and delays in ED care following presentation.

*Emergency care/trauma regionalization pilot project grants.

*Trauma stabilization grants.

*Health and Human Services incentive payments to states that establish medical liability reforms (Certificate of Merit/early offer)

*Health and Human Services demo project to reimburse private psychiatric hospitals that provide EMTALA services to Medicaid beneficiaries.

The American College of Emergency Physicians has worked diligently to represent emergency physicians and emergency patients throughout this volatile process. As the process continues toward final legislation, ACEP will continue to focus on the needs of emergency patients, future emergency patients, and the physicians who care for them.

Please Help Us Fix the SGR

Starting this week, the Senate will take a series of critical votes on a bill, the Medicare Physicians Fairness Act of 2009 (S.1776), to abolish the flawed formula used to determine Medicare reimbursement rates. This bill is critically important to all physicians, but especially to emergency physicians who will undoubtedly see a significant increase in Medicare patients if the payment cuts are enacted.

Under the current system, physicians are scheduled to receive drastic cuts to Medicare payments starting next year. Congress understands that the scheduled cuts would devastate access to care for seniors so each year they "patch" the system by voting at the last minute to cancel the funding cut. However, even though the cut is not enacted, the total accumulated debt for physician reimbursement under Medicare continues to grow. Picture it as a credit card with a huge balance and a high interest rate. Congress "forgives" a payment on the debt each year, but that amount is added to the balance, and interest continues to add up. Without action by Congress, physicians are scheduled to take a 21 percent reduction in reimbursement for Medicare patients next year, with cuts totaling 40 percent in future years.

Having health insurance coverage is not the same thing as having access to medical care. All seniors over age 65 are entitled to insurance under the Medicare program. Increasingly, however, primary care physicians and other specialists are refusing to take new Medicare
patients because of low reimbursement rates. It's not that those doctors lack compassion, it's that many lose money on Medicare patients and a 40 percent cut in payments would make it impossible for them to continue to treat those individuals.

With an aging population, emergency departments already anticipate an increased volume of seniors needing care. If, however, Congress does not fix the flawed Medicare formula, that increase could be catastrophic. Seniors unable to find doctors accepting Medicare may have no choice but to seek care in emergency departments, which the Institute of Medicine already calls "dangerously overcrowded."

Passage of this bill would help to prevent more crowding in emergency departments, provide a reasonable level of compensation to emergency physicians, and help attract on-call specialists. This is a non-partisan issue. Republicans and Democrats claim to care equally about ensuring
access to care for seniors. If our elected representatives are sincere in these views, they will take a principled stand on this issue and support S.1776 now.

You can help assure passage of this critical legislation. Contact your two U.S. Senators now and tell them to support S. 1776. Here's how:

* Call 1-800-833-6354 to be automatically connected to your two Senators. Urge them to support all procedural motions and final passage of S.1776.

* Go to ACEP's Advocacy Center: www.acep.org and send an e-mail urging your Senators to support S. 1776.

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An Open Letter from America’s Emergency Physicians

As physicians seeing patients on the front lines of emergency care, we see people who are ravaged by untreated disease; help worried mothers on weekends with sick children, unable to access a system that’s open 9 to 5, weekdays only; and treat the victims of heart attack, stroke and injuries whose very lives depend on our care.

The role of emergency medicine has been badly misrepresented during the health care reform debate. The American College of Emergency Physicians supports comprehensive reform, including universal coverage. But it is vitally important that reform legislation not be based on erroneous perceptions, but instead address the critical problems harming emergency patients. It is time to debunk the myths, focus on the real problems and outline solutions to ensure that health care reform will protect and enhance everyone’s access to quality, timely emergency care.

Myth: Emergency medical care is expensive and inefficient. Reducing emergency care will “bend the cost curve” on our nation’s rising health care costs.

Fact: The 120 million annual visits made to emergency departments account for only 3% of all health care spending. In addition, emergency departments are equipped with state-of- the-art diagnostic equipment and highly trained physicians who can draw on many hospital resources quickly, providing coordinated, efficient patient care. The fixed costs of being open 24/7 are high, but the variable costs for seeing patients in the emergency department are the same as anywhere else care is provided.

Myth: Emergency departments are crowded with patients seeking non-urgent care.

Fact: Only 12.1% of emergency patients have non-urgent conditions that could wait 2 to 24 hours for medical care, according to the Centers for Disease Control and Prevention (CDC). While this percentage may be slightly higher in some hospitals, the reality is that crowded conditions and longer wait times are primarily caused by patients being “boarded,” or forced to stay in the emergency department – often on gurneys lining the hallways - long after they have been seen and admitted to the hospital.

Myth: Your local emergency department will always be there when you need it.

Fact: Hundreds of emergency departments have closed nationwide because of an overburdened emergency care system. Those remaining must accommodate an average increase of 3 million more patient visits each year. Every 60 seconds emergency care is delayed when an ambulance is diverted to a distant hospital because a nearer one is unable to accept more patients. In addition, 75% of emergency department directors report significant problems getting needed on-call specialists, such as neurosurgeons and orthopedists, to provide vital on-call services to emergency patients.

Myth: The need for emergency care will decrease when health care reform is enacted.

Fact: With a growing and aging population, our role in providing care to the sick and injured any time day or night, and our front line responsibility in responding to natural and man-made disasters, will be in even greater demand in the future. Since enacting its niversal health care legislation, Massachusetts has experienced an increase in emergency department patients. Emergency medicine is an essential community service that is vitally important to our nation’s health care system.

To help ensure our country has a strong emergency care system, the American College of Emergency Physicians supports comprehensive health care reform that includes:

• Every person in America must have meaningful and affordable health insurance coverage provided through a combination of employer and individually mandated insurance. It should be means-tested, allowing those in need to receive coverage or financial support to buy insurance. A combination of private sector and governmental solutions may be needed to achieve universal coverage. America is experiencing a dramatically rising tide of uninsured and underinsured patients. Emergency physicians are the only doctors in the country required by federal law to treat all patients regardless of their ability to pay. It is a responsibility we embrace proudly, but many emergency departments and physician groups are closing under the burden of uncompensated care.
• Health care costs must be reduced. Significant medical liability reform is needed to eliminate unnecessary, expensive tests known as “defensive medicine.” Liability reform can also help increase the availability of critically needed on-call specialists. Widespread adoption of electronic health records could substantially cut costs and improve patient care if there were complete integration of data between the emergency department and other medical settings. Administrative and overhead costs must be reduced.
• Quality and patient safety must be improved by eliminating the practice of “boarding” admitted patients in emergency department hallways until they are transferred to an in-patient hospital bed. This can be achieved by establishing quality standards that define how quickly admitted patients are moved to their appropriate care settings, with such information reported and available to the public.
• A national surge capacity plan must be developed and resources provided to prepare our nation’s hospital emergency departments for public health crises such as the H1N1 pandemic, a terrorist attack or other catastrophes.

With so much at stake, America can no longer ignore the crisis in its emergency medical care system or make health reform decisions based on myths. Go to www.acep.org/realities for information on protecting your access to quality, timely emergency care.

We must act now.

Nick Jouriles, MD, FACEP

President
American College of Emergency Physicians

Is Tort Reform Coming?

Health and Human Services Secretary Kathleen Sebelius announced today that the federal government will provide $25 million in grants to states and health care systems that study ways to reduce the costs associated with medical malpractice lawsuits. The program will begin in 30 days and will announce funding winners early next year. The grants will be awarded for studies that examine such practices as “early apology” and restitution, although Sebelius promises to consider a broad range of ideas during the selection process.

The goal of the program is to reduce the costs associated with medical lawsuits and thereby decrease the amount spent on professional liability insurance. Ultimately, these measures aim to prevent physicians from conducting unnecessary or redundant tests in order to avoid malpractice claims.

Today’s announcement follows on the heels of President Obama’s health reform speech to Congress, in which he promised to address the issue of professional liability in health care. It is a significant shift from his previous refusal to consider any type of federal tort reform, and may represent a conciliatory nod to conservatives.

In my humble opinion, this is only a gesture, and while the spirit of it is appreciated, it is unlikely to influence physician behavior any time in the near future. The problem with conducting research in the area of malpractice litigation is that it takes many years for a case to come to conclusion, so meaningful data won’t be available for nearly a decade. By then, Obama’s health reform debates will be a thing of the past.

It is FEAR of lawsuits that drives physicians to practice defensive medicine. As long as lawyers look at malpractice suits as the price a physician pays for doing business and physicians look at malpractice suits as a threat to livelihood, identity and soul, the fear of lawsuits will continue to fuel the practice of defensive medicine.

Here's What Is Happening in D.C. Today

Senate Majority Leader Harry Reid (D-NV) and House Speaker Nancy Pelosi (D-CA) will join President Obama and Vice President Biden in a discussion of the fall congressional agenda.

Senator Chuck Grassley (R-IA) addresses the Senate, covering the next steps for health reform legislation. (Pictured here, with me.)

Representative Chris Van Hollen (D-MD) outlines the Democratic Party’s plan to move forward with health care reform.

Senator Baucus releases the details of the "Gang of Six" health reform proposals.

White House Responds to Health Care Reform Questions

In the wake of the recent media coverage of health care reform, the White House has produced several videos addressing common questions. They can be found at http://www.whitehouse.gov/realitycheck/.

The first set of videos addresses a wide scope of topics and debunks some of those common myths:

CEA Chair Christina Romer details how health insurance reform will impact small businesses.

Domestic Policy Council Director Melody Barnes tackles a nasty rumor about euthanasia and clearly describes how reform helps families.

Matt Flavin, the White House's Director of Veterans and Wounded Warrior Policy, clears the air about Veteran's benefits.

Kavita Patel, M.D., a doctor serving in the White House's Office of Public Engagement, explains that health care rationing is happening right now and how reform gives control back to patients and doctors.

Robert Kocher, M.D., a doctor serving on the National Economic Council, debunks the myth that health insurance reform will be financed by cutting Medicare benefits.

In a video first released last week, Linda Douglass from the White House Health Reform Office addresses fears about the end of our private insurance system and reiterates that if you like your current plan you can keep it.

There is also a handy FAQ about health insurance reform.

I suggest that you check some of these out, if for no other reason than to hear what the White House perceives as the most significant issues. In addition, the website has a place for you to comment directly with your concerns about health care reform. Now is your chance to make your voice heard.

Obama's address to the AMA

In the wake of President Obama’s remarks to the American Medical Association on Monday, it seems that everyone has an opinion about what should be done with the healthcare system in America.  Unfortunately, there is no consensus , even within the house of medicine.  The president was very clear about his intent, and very little of it surprised those in the audience.  The president led with a condemnation of the status quo, complete with touching stories of patients struggling with tragic circumstances, both medical and economic.  His arguments were the standards in the healthcare debate – providing medical care is too expensive, too complicated, and too poor in quality to continue.  He did stop short of blaming the current state of affairs entirely upon the physicians, perhaps in deference to the audience.

 

President Obama followed his indictment of the status quo with a description of elements of the reform package that he has long championed:  the electronic health record, comparative effectiveness research, dissolution of healthcare disparities, and universal coverage.  He assured the audience that anyone partaking of a private health insurance plan who was satisfied with that plan would be able to keep it.  However, as he stated long ago on the campaign trail, he supports a government-supported public plan, now called the Health Insurance Exchange.  The president believes that a public option would provide an alternative for Americans who currently cannot obtain affordable health insurance.  He also stated that the public plan would provide “healthy competition” for private insurers. 

 

There were two things that I noticed today that were a change from the president’s usual discourse on health system delivery.  First, he stated today that all Americans would be required to purchase health insurance of some kind.  In the past, especially during his campaign, he only espoused a requirement  for insurance for children.  Secondly, he stated that he is opposed to caps on damages recovered in malpractice litigation, but that he is “open to consideration of” any number of other methods to  appease physician concern over professional liability.  He said that he has drawn criticism from members of his party over his willingness to consider any changes to the tort system. 

 

No doubt the president is looking to trade vague, lukewarm promises to consider changes in the tort system for some Republican support of his health system reform plans.  Will it be enough?

Tap Water Medicine?

"Tap Water Healthcare" is a term coined by Dr. Arthur Kellerman, MD, FACEP, Professor and Associate Dean for Health Policy, Emory School of Medicine.  It is the concept of a basic health plan that is the equivalent of community tap water.  The goal of community water treatment plants is to provide safe drinking water for the entire community.  In recent years, many have decried the taste of mass purified water, the low standards for solutes, and the lack of easy portability.  For these reasons, many people prefer to purchase bottled water.  Some even prefer fancy bottled waters from "natural" springs, from foreign countries, or with special additives like flavor or bubbles.  

     As the debate over health care proceeds, is it possible to develop basic health coverage that resembles tap water - available, inexpensive, and safe?

Representative Cuellar Signs On HR 1188

Gordon Wheeler and I met with Representative Henry Cuellar (D-TX) this morning, and he agreed to become a co-sponsor of HR 1188.  Representative Cuellar is actively involved in the current healthcare reform efforts, and was very receptive to our comments about the importance of emergency medicine in the lives of all Americans.  Thank you, Representative Cuellar, for your support. 

Swine flu

The American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) today issued a joint statement about the cases of swine flu in the United States and offered recommendations to the public about when to seek emergency care.

Saying the nation’s emergency departments are on the front lines of any public health emergency, the two organizations urged the public to apply the “prudent layperson standard” to any illness or injury: If the average prudent person would think you have the symptoms of a medical emergency, then you need to seek emergency care.

“Emergency physicians and nurses are specially trained to assess your symptoms and treat you, and if you have any doubts about your medical condition, we are there for you,” said Dr. Nick Jouriles, president of ACEP.  “While news reports about the swine flu may have raised alarm, remember there are still very few actual cases of the illness in the United States.  And if you have no symptoms, then you do not need to seek emergency care.  If you do not have a fever or cough, it is extremely unlikely that you have the swine flu.”

Emergency physicians and nurses in different parts of the country are seeing people who do not have symptoms, but are simply seeking information and reassurance that they are not ill, which both organizations say is understandable, given the widespread news coverage.  To help people understand this disease and get the information they need, the Centers for Disease Control and Prevention (CDC) is maintaining up-to-date web pages about the symptoms of swine flu and when to seek immediate medical care (www.cdc.gov/swineflu).

“If you have symptoms that would not ordinarily take you to the emergency department but are considering going because you are afraid you have swine flu, you probably do not need to go,” said Bill Briggs, RN, president of ENA.  “Remember that many illnesses – not just swine flu – are transmitted in public places and very often the best way to avoid the spread of disease is to stay home until your symptoms subside.”

In the current push for health care reform, policymakers must recognize the unique role that emergency physicians and emergency nurses play, especially in times of crisis.  Emergency departments are the nation’s safety net, a point driven home this week with the threat of pandemic swine flu filling ERs with patients fearing they are infected.  The safety net is under extraordinary stress in the best of times, never mind the worst.

“Even those ‘worried well’ who have primary care physicians are being directed to the emergency department because of our specialized expertise,” said Dr. Jouriles.  “We stand on the front lines of any disaster and when all other doors are closed, our doors are always open.  That is why true health care reform must strengthen America’s health care safety net – emergency departments.’

ACEP is a national medical specialty society representing emergency medicine with more than 27,000 members. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. 

ENA is the only professional nursing association dedicated to defining the future of emergency nursing and emergency care through advocacy, expertise, innovation and leadership.  Founded in 1970, ENA serves as the voice of 37,000 members and their patients through research, publications, professional development, injury prevention and patient education.  Additional information is available at ENA’s website www.ena.org.

Swine Flu Outbreak

The United States has seven confirmed cases of Swine Influenza A/H1N1, five in California and two in Texas, and nine suspect cases.  All of the seven confirmed cases had mild Influenza-Like Illness (ILI).  No deaths have been reported. 

 

Mexico reports three separate event locations – Mexicali, San Luis Potosi, and the Federal District of Mexico.  The government of Mexico began surveillance of ILI March 18, 2009.  Since then, 854 cases of pneumonia have been reported in Mexico City, with 59 deaths.  San Luis Potosi, in central Mexico, reports 24 cases of ILI, with three deaths.  Mexicali, near the border with the United States, has had four cases of ILI, with no deaths.  The majority of these cases have been in healthy young adults.

 

Of the Mexican cases, 18 are confirmed Swine Influenza A/H1N1.  Twelve of the 18 are identical to the Swine Influenza A/H1N1 viruses isolated from the patients with confirmed cases in California.  Swine flu viruses do not normally infect humans.  However, sporadic human infections have occurred in persons with direct exposure to pigs and in health care workers caring for persons with swine flu.  The Centers for Disease Control and Prevention (CDC) report 12 cases of human infection with swine flu between December 2005 and February 2009. 

 

The Swine Influenza A/H1N1 viruses isolated in this outbreak appear to be a strain not previously detected in pigs or humans, although these reports are preliminary.  Because there is reported spread of an animal virus in humans, and because of the geographical spread of multiple community outbreaks, these events are of concern, and the CDC is working to further characterize the viruses and provide guidance for treatment and prevention.

 

The symptoms of swine flu in humans are expected to be similar to the symptoms of seasonal human influenza, and include fever, malaise, lack of appetite, and coughing.  Some patients with the swine flu have reported runny nose, sore throat, nausea, vomiting, and diarrhea.  The H1N1 swine flu viruses are antigenically different from human H1N1 viruses, and vaccines for the human seasonal flu are not expected to provide protection from the swine flu viruses. 

 

To diagnose swine influenza A infection, a respiratory specimen must be collected and sent to the CDC for testing.  The specimen must be collected in the first 3-4 days of the illness, when the virus is shedding.  Testing may require an additional 3-4 days.  The CDC has not yet made recommendations for treating patients with an antiviral medication while the testing is pending, although these recommendations are expected later today. 

 

There are four different antiviral medications available for use in the United States for influenza:  amantadine, rimantadine, oseltamivir and zanamivir.  The most recent swine influenza viruses isolated from humans are resistant to amantadine and rimantadine.  At this time, the CDC recommends the use of oseltamivir or zanamivir for the treatment of infection with swine influenza viruses. 

 

The outbreak of “swine flu” in North America is a growing cause of concern in the World Health Organization (WHO) and in scientists worldwide concerned with pandemic prevention.  Recent improvements in pandemic preparedness may be tested by this emerging threat.   

 

 

 

Gardner's Gate: HAPPY 100TH EPISODE!

Gardner's Gate: HAPPY 100TH EPISODE!

HAPPY 100TH EPISODE!

This is my 100^th blog for the American College of Emergency Physicians.  For television shows, the 100^th episode is a cause for celebration.  One hundred broadcast episodes means that the show is a success for everyone involved, the producers, the sponsors, the actors, AND the writers. 

 

I began this “blogging” project in November of 2006, as the first official “blogger” for the American College of Emergency Physicians.  It was my idea that the leadership of the college should investigate ways to reach out to younger physicians using newer technologies and communication media.  Having a blog seemed so hip, so young, so whatever-the-word-of-the-moment is.

 

It has been a learning experience.  I learned how to host a blog.  I learned to write without an editor.  I learned that writing without an editor means everyone feels entitled to offer advice on your writing, both style and substance.  I learned that the harshest critics did not want to criticize me in the “comment” section, where others could see, but wished to make their views known via email.  I learned that being a blogger for an organization means that everyone has your email address.

 

I learned that producing three to five hundred coherent, intelligent-sounding words that will live in cyberspace forever on a consistent basis is a challenge not unlike rearing children - tedious, relentless, and unimaginably joyful.

 

I learned the distinct joy of trying on, trying out, and wearing out new technologies.  I have “pages” on every social network imaginable. I facebook, myspace, pulse/plaxo, link-in and now, I tweet on twitter.  (Writing without an editor also allows me to create brand-spanking-new verbs.)  I have thousands of friends-of-friends.  I actually believe that epidemiologists could learn a thing or two about communicable diseases from observing the spread of information through social networking devices.  I have even appeared on youtube more than once, and more than Mom watched it........or else Mom spent most of the last few months clicking and reclicking.

 

So, to my several hundred loyal readers, my occasional readers, and even my first-time readers, I say thank you.  Thank you for the chance to learn, to grow, to express myself, and to be a part of something much, much larger than myself.  Thank you for allowing me just another mature adult trying to stay connected to a rapidly changing world.  Most of all, thank you for birthing the inevitable result of 100 hundred successful episodes.......a spin-off!

 

ACEP now has bloggers from all walks of the (emergency physician) profession expressing themselves on The Central Line.  Check it out now at thecentralline.org.

 

.....and stay tuned for next season’s premiere.

 

 

 

Disclaimer:  Because I do believe in telling the truth, I have to admit that The Central Line is not my project.  It was lovingly crafted by very skillful ACEP staffers, and is written by a host of VERY talented emergency medicine professionals.  They are allowing me to link to the site and to claim credit for the idea because THIS IS MY BLOG AND THEY CAN’T STOP ME!  Seriously, they are allowing me to post to The Central Line during the debut at the Legislative and Advocacy Conference in Washington D.C. this week.  Check it out......and thanks for stopping by.     

Health Reform must include emergency medicine

ACEP members will demand that emergency medicine be addressed during health care reform.

Nearly 400 emergency physicians from across the country will be converging on the nation's capital April 19-22 to advocate for greater patient access to lifesaving emergency medical treatment. As part of their visit, these medical specialty leaders will meet with key policy and lawmakers on Capitol Hill to educate them about the nation's emergency care crisis, which was recently documented in ACEP's National Report Card on the State of Emergency Care.  The report, issued in December, assigned the nation an overall grade of C- for its support of emergency care and a D- in access to emergency care. 

Emergency physicians will urge their elected officials to hold hearings on and enact the Access to Emergency Medical Services Act (H.R. 1188 and S. 468), a bill that outlines measures to strengthen access to emergency care for patients. The meetings are part of the 2009 Leadership and Advocacy Conference of the American College of Emergency Physicians (ACEP), a key component of which is to urge members of Congress and the administration to include an array of critical emergency care issues in the discussions of health care reforms.

Invited conference speakers include former Clinton Administration senior health care advisor Chris Jennings, Rep. Pete Stark (D-Calif.), political pundit Charlie Cook, executive director of Families USA Ron Pollack and executive vice president for government affairs of the U.S. Chamber of Commerce R. Bruce Josten (final confirmations pending)