Breaking News from Capitol Hill

......the House of Representatives just passed a defense bill that places a hold on the 21% Medicare payment cuts scheduled to take place on January 1, 2010. The bill will hold Medicare payments to physicians at the current rate until March.

.....The so-called “Medicare buy in” that would have allowed persons aged 55 – 64 to enroll in Medicare is dead, having lasted a mere six days. Senator Joe Lieberman (I-CN) is credited with altering the proposed Senate health reform legislation (HR3590) with his announcement Sunday that he would not support a bill that contains the public option or the Medicare buy-in.

.....The President met with key Democratic leaders yesterday to urge them to pass health reform legislation. The Senate has a self-imposed Christmas deadline to successfully pass health legislation.

.....The Senate voted yesterday to reject an amendment by Senator Byron Dorgan (D-ND) that would have allowed the importation of drugs from foreign countries. A compromise bill by Senator Frank Lautenberg (D-NJ) would have allowed the importation of drugs from Canada and other foreign countries if federal health authorities declared them safe. The compromise bill failed in a 56-43 vote.

....and lastly, the Senate also defeated motion to send the reform bill back to the Senate Finance Committee.

Personal thoughts on DC's latest

Just want to share a few thoughts with you ......

First - Take a deep breath.

Next - Remember the reason that health reform is being debated. The present system is NOT SUSTAINABLE. The status quo is not an option because the status quo cannot continue unchanged. The most generous optimists project that government sponsored health programs will be completely depleted by 2017.

As for what is going on in D.C., here are the latest options being discussed, along with my personal (editorial) comments:

1.) Include persons between 55 and 64 in the Medicare program.

Does this include everyone between the ages of 55 and 64, or just those who cannot obtain employer-sponsored coverage?

Does this mean that reimbursement will be at Medicare rates or at another rate?

2.) Private insurers would be required to spend 90% of premiums on clinical services and programs to improve care.

The obvious answer to this for insurers is to increase premiums so that the bottom line remains the same.

3.) The Office of Personnel Management, which currently oversees health policies for federal employees, would manage a new system of national health plans available in every state to people who do not receive coverage through their employer.

Absent from this discussion is the personal mandate. As I see it, there is no way increase the risk pool. In addition, there would need to be a considerable ramp-up of the OPM.

4.) The Office of Personnel Management would be empowered to negotiate rates with insurers.

OK. This is better than the House bill? This "renames" the public option and puts it squarely in the Executive sector, beyond the control of the Legislative Branch. Hmmmm..

5.) Buried in there somewhere is a "trigger" for the public option.

I am unable to verify the existence of this "trigger," so will refrain from comment.

This is a piecemeal approach to a public option, and much like Frankenstein, may exceed the expectations of the creators.

Lastly - What happens next is that CBO will have to score the various options. (Insiders say that several different combinations were sent for scoring.) That may take a week. In the meantime, Reid is looking for cloture on the manager's amendment, which includes compromises he has worked on for the past 10 days. Other cloture votes will be required subsequently. More concerning to me than all the above is the rumor that if the Senate is unable to reach an agreement by the end of the year, the Democrats would push for bypassing a conference bill and call for a direct endorsement of the House bill.

Just a few thoughts to help you sleep tonight,

Angela (Angela F. Gardner, MD, FACEP)

PS Discussions continue on an amendment that would allow direct importation of drugs from countries approved by the FDA. Obviously Pharma opposes.......but the savings could be immense.

Long term prognosis for emergency care

This is a link to an article in Congressional Quarterly this week, written by Rebecca Adams. It is a fairly impartial assessment of the emergency department environments and the unanticipated consequences of health reform legislation.

http://www.cqpolitics.com/wmspage.cfm?docID=weeklyreport-000003259823

Help with Health Care Reform

http://www.youtube.com/emergencycareforyou

Here's how you can help with health care reform.

Senate Stall

Tuesday in the Senate each political party offered an amendment to the chamber’s health reform bill. A partisan floor discussion ensued, delaying actual votes on the amendments. Two-and-a-half days after discussion of the bill began, not a single vote has been taken. One amendment addresses the need for better women’s health screening services and the other eliminates billions of dollars of spending in Medicare cuts.

This is D.C. politics at it’s best. The Republican strategy seems to be to draw out the discussions as long as possible, knowing that the longer the stall, the less chance that any form of health care reform will pass. The Democrats are working on a strategy to overcome the Republican parliamentary tricks. Sen. Tom Harkin (D-IA) confirmed in Roll Call today that one idea under consideration is the motion to table the Republican amendments, this requires only 51 votes instead of the 60 votes needed for cloture.

On this third day of debate without a single vote taken, frustration is mounting in the Chamber as well as among those whose lives and livelihoods are affected by the outcome.

Texas Recognizes ABPS Certification

Texas Recognizes ABPS Certification

This was posted on thecentralline.org recently. Just an FYI for interested readers.

Senate Begins Debate On Health Reform

The Senate began debate this afternoon on the Senate version of the health care reform legislation. Opening statements came from Majority Leader Harry Reid (D-NV) and Minority Leader Mitch McConnell (R-KY). The debate is expected to heat up tomorrow as the parties offer alternating amendments. Rumor on the Hill is that Reid will conduct much of the work for consensus on the bill in the privacy of his office. According to American Health Line (11/30/09) four moderate members of the Democratic Party have been requested to attend private meetings to discuss the public option - Sens. Mary Landrieu (D-LA), Joseph Lieberman (I-CT), Blanche Lincoln (D-AR), and Ben Nelson (D-NE).

Of interest to emergency physicians is an amendment proposed by Sen. Charles Schumer (D-NY) that would add 2,000 residency positions to the current cohort of 100,000. Although it is unclear from the amendment which specialties would benefit from the additional training positions, physicians have conveyed their concern to lawmakers that health reform legislation will increase the demand for medical care.

Separating reality from rhetoric is always a major task in Washington D.C., and the debate over health care in America has only made that task more difficult. What IS apparent, however, is that the White House has decided to weigh-in with its own public relations campaign. The following is a video featuring Vice President Joe Biden and the presidents of the American Association of Family Physicians and the American Nurses Association. You tell me.....reality or rhetoric?

http://www.youtube.com/watch?v=Ek8mkIt-IJo

Health Care Reform Turkey?

The U.S. Department of Agriculture estimates 46 million turkeys will be consumed during the Thanksgiving holiday this year. Imagine that......46 million golden-brown birds will be served to hungry, thankful families in a feast that commemorates the survival of the settlers who landed in New England in 1621. Afterward, people will indulge in a tryptophan induced trance to watch football or plan for the sales tomorrow. Even people who worked today, as I did, managed to celebrate a little of the holiday by sharing a meal with their work family.

It just so happens that the number of Americans who do not have health insurance is just over 46 million. This is a coincidence, and certainly no reflection on the turkeys.

Just imagine, though, that through some bizarre quirk of fate every family that had Thanksgiving turkey today suddenly had no insurance, and everyone who had other plans suddenly had insurance. Through no fault of your own, your family now has no insurance. You will have difficulty making a doctor's appointment unless you are financially able to put up a substantial deposit. If you have emergency surgery, you could have to come up more than $10,000 on very short notice. You may have to sell your house to finance treatment of your cancer.

On a sober note, you will receive fewer health care services, even if you offer to pay for them. You will get less care, later in your illness, than if you had health insurance. Frankly, you won't live quite as long or quite as well as if you had health insurance. All because you chose turkey today.

Now I realize that this scenario is farfetched and is a depressing thought for Thanksgiving day, but the fact that the number of uninsured Americans is equal to the number of turkeys that sacrifice their lives for Thanksgiving was just too ironic to overlook.

Perhaps President Obama could pardon someone without insurance in the Rose Garden next year along with the turkey.............

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.