Learn more about what ACEP is doing for you. Here is a short video by Dr. Paul Kivela discussing current issues important to emergency physicians.
It is easy to dismiss advocacy as simply “politics” or efforts best left to lobbyists. However, as emergency physicians, you practice advocacy every day. Every time you stand up on behalf of a vulnerable patient, or struggle to obtain the resources you need to provide quality emergency care for your community you are acting as an advocate.
Unfortunately, the challenges that we must face in order to provide high quality care for our patients goes beyond our local emergency departments and hospitals. Laws such as EMTALA, HIPAA and the Affordable Care Act impact our practice on a daily basis. As emergency physicians, we must work together to insure that safe and high quality emergency care continues to be available to our patients – wherever and whenever we are needed!
Listed below are brief descriptions of important issues that both MOCEP and ACEP are working on. This list is not an all-inclusive list, but rather a brief background on more commonly discussed issues. Under the “Our Policies” page, you will find Missouri specific issues that have been debated and our stance.
As part of this, hospitals and therefore the physicians working there needed to meet certain requirements. From MOCEP’s perspective, maintaining board certification in Emergency Medicine should accomplish the continuing educational requirement. When the system was being designed, we did understand that certain physicians, generally higher up in the administration, might have more stringent CME requirements. We believe this is where things went wrong and legislation was misinterpreted.
Somehow the Department of Health and Human Services decided that all EM physicians would be required to have 10 hours annually in stroke, STEMI, and trauma. Once again, we do not believe that was the original intent of the legislation. In addition, thirty hours of CME on just these 3 disease processes would not leave EM physicians with time to review or update themselves on any other subjects. In essence, this requirement could actually make care worse. Missouri only requires 25 hours a year of CME for licensing. In addition, we also did not believe this was the best use of an EM providers time as there is generally not 30 hours worth of new material needing to be reviewed on these 3 topics every year.
As such, MOCEP attempted to discuss this with the Department of Health and Human Services numerous times. Each time we left the meeting feeling as if we made progress only to see nothing change. Last year we were successful in passing legislation that took TCD requirements out of the purview of the Department of Health and Human Services and placed them under the Board of Healing Arts. MOCEP is currently working with other organizations to develop regulations that make sense and are satisfactory to all those involved. Our goals to minimize CME requirements for board-certified physicians need to be balanced with making sure those physicians not certified in emergency medicine are receiving the proper amount of continuing education.
Medicaid patients are generally as sick as other patients are when they seek emergency care. The majority of these patients (ages 21 to 64) seek emergency care with the symptoms of urgent or more serious medical conditions, according to a report from the Center for Studying Health Systems Change. According to this report, many assessments of “unnecessary” use of emergency care incorrectly look at patients’ final diagnoses, instead of patients’ symptoms and why they are seeking emergency care. If a patient thinks they have broken their ankle but it turns out to be a bad sprain, they still made the right choice by seeking emergency care.
A recent survey found seven in 10 Americans oppose health plan efforts to deny payments for ER visits. Eighty-five percent of respondents with regular medical providers who sought emergency care said they could not have waited to see their regular providers.
Cuts would increase the burden on emergency departments, threatening their ability to meet the emergency care needs of everyone. Emergency departments are required by federal law to provide medical care regardless of whether a person can pay. Reductions would have a double impact on state Medicaid programs because they receive matching federal dollars. Many states have taken advantage of federal program waivers to change coverage and/or eligibility requirements in the wake of continuing state budget deficits.
Cuts could affect community health centers (CHCs), which derive more than one-third of their total revenue from Medicaid. This could reduce CHCs capacity in a given area and increase use of the emergency department for patients who have no other place to get care.
When other physicians refuse to accept Medicaid patients because reimbursements are so low, patients often have no choice but to turn to emergency departments for care, often after their illnesses become acute. Thirty-one percent of physicians polled by the National Center for Health Statistics expressed an unwillingness to take on new Medicaid patients, compared with 17 percent who didn’t want to accept new Medicare patients and 18 percent who said they weren’t going to accept new privately insured patients. The survey also found that “small practices and, to a certain extent, primary care physicians – had lower-than-average acceptance rates of new Medicaid patients.”
Emergency medical care for all patients — insured and uninsured alike — is just 2 percent of all health care spending in the United States.
In response to budget crises, state Medicaid officials in many states have been using the “Billings algorithm” to deny coverage for emergency department visits based on final diagnosis discharge codes, rather than the symptoms that brought the patients to the emergency department. For example, a patient with chest pain, a possible indicator of a heart attack, may be discharged with a diagnosis of heartburn, a non-urgent condition. It applies 20-20 hindsight to health care and in the ER that is bad medicine.
For more information: ACEP Medicaid Fact Sheet
MOCEP does realize the importance in cutting costs. However, we want to do that in a manner that improves patient care and does not alienate patients. To that extent, MOCEP is working with other organizations on a proposal that would do just that called MMERP. It is aimed at the superutilizers. In essence, we would build a medical home for these patients where they could get the care that they need. To do this, EDs around the state would incorporate EDIE or a similar program. EDIE is a program that would automatically flag charts in the electronic health record. By simply clicking on an icon, the ED provider could see recent testing, notes, and medications for these patients. Instead of repeating large work-ups that had just been completed, the provider could make sure nothing new was occurring and then redirect the patient back to their established care plan. MMERP would save money by assisting physicians in foregoing large and expensive ED evaluations and getting these patients into a medical home which will improve their care. This proposal is still in the early stages but we believe it will improve care while making it more efficient. References to MMERP have already begun to replace LANE in the current budget.
We believe EMTALA is a good thing and believe most EM physicians are honored that they will treat any patient in need, something unique to our specialty. However, we also realize this puts us at substantial risk as often we are forced to make critical decisions on patients we have little to no pre-existing relationship with very little information. In addition, consultants are often hesitant to evaluate or treat our patients, as they do not want that extra risk which may come with minimal reimbursement. MOCEP is advocating for current legislation that would place all care delivered by emergency providers or their consultants under federal protection. Essentially, we would be treated just like providers at federal health care centers are treated if they are sued. We believe this would be good for us and our patients as it would better protect us and, hopefully, make it easier for us to get on-call providers to treat our patients.Main Points
Additionally, a hospital must report any time it has reason to believe it may have received an individual who has been transferred in an unstable condition in violation of EMTALA.
In addition, the transfer of unstable patients must be “appropriate” under the law, such that (1) the transferring hospital must provide ongoing care within it capability until transfer to minimize transfer risks, (2) provide copies of medical records, (3) must confirm that the receiving facility has space and qualified personnel to treat the condition and has agreed to accept the transfer, and (4) the transfer must be made with qualified personnel and appropriate medical equipment.
A receiving facility, having suffered financial loss as a result of another hospital’s violation of EMTALA, can bring suit to recover damages.
An adverse outcome does not necessarily indicate there is an EMTALA violation; however, a violation can be cited even without an adverse outcome. There is no violation if a patient refuses examination &/or treatment unless there is evidence of coercion.
Some health insurance plans retrospectively deny claims for emergency departments visits, based on a patient’s final diagnosis, rather than the presenting symptoms (e.g., when chest pain turns out not to be a heart attack). These practices endanger the health of patients and threaten to undermine the emergency care system by failing to financially support America’s health care safety net.
ACEP advocates for a national prudent layperson emergency care standard that provides coverage based on a patient’s presenting symptoms, rather than the final diagnosis. In addition, health insurers should cover EMTALA-related services up to the point an emergency medical condition can be ruled out or resolved.
For more information: ACEP EMTALA Fact Sheet
For more information: Liability Reform Data to Support Reform and Rebut Opponent Arguments
We all have a critical role to play in health care reform. Join emergency medicine leaders from throughout the country in shaping that future at ACEP’s Leadership and Advocacy Conference. Thought-provoking, inspiring and challenging sessions by nationally recognized speakers and key decision makers will provide you the inside information and skills you need to maximize your impact as an emergency medicine leader and advocate. This meeting is generally held each spring in Washington, DC.
ACEP will schedule Capitol Hill visits for you with key legislators and staff through Soapbox Consulting, LLC. You will not need to contact your legislators’ office directly regarding your appointments. The conference continues to grow each year and is considered by many to be the best conference that ACEP organizes. In addition to meeting with Senators and Representatives, multiple lectures update attendees on changes in healthcare impacting emergency medicine. In 2017, we had a record 18 physicians representing the state of Missouri.Registration Fees & Conference Benefits
In addition to an exemplary educational experience, your conference registration fee includes 3 breakfasts, 2 luncheons, 2 receptions, transportation to Capitol Hill for visits with your legislators, and daily breaks which include refreshments. The per-registrant cost of food and beverages alone is nearly $500, making these nominal fees an exceptional bargain and member benefit.
For more information on registration: Leadership and Advocacy Conference
Learn more about what ACEP is doing for you. Here is a short video by Dr. Paul Kivela discussing current issues important to emergency physicians.
Take advantage of the opportunity to follow up with your legislators since attending the ACEP Leadership and Advocacy Conference in March or start a dialogue with your federal legislators on issues of importance to emergency medicine and patients.
We will start the day with an Advocacy Briefing session and shuttle buses will take participants directly to Capitol Hill. Transportation back to the hotel is on your own. ACEP staff will schedule your Hill visits in advance with the assistance of Soapbox Consulting. Participants will be matched by your home address to your U.S. Representative and two U.S. Senators. All participants will attend meetings in groups and all members from a particular state will meet with their U.S. Senators together. Participants will receive their schedule at the training and will be provided with briefing materials to “leave behind” with legislators and their staff. The materials will highlight the specialty of emergency medicine and issues of concern currently pending in Congress.
Fierce Healthcare (8/31, Minemyer, 146K) reports that just “3.3%” of visits to the emergency department (ED) “are truly ‘avoidable,’” researchers found after examining “data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011 that included more than 115,000 records representing 424 million emergency department visits.” The study’s conclusions “challenge the commonly held belief that many people visit the ER needlessly, said Rebecca Parker, MD, president of the American College of Emergency Physicians, in an announcement.” Dr. Parker said, “Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about ‘unnecessary’ ER visits are just that – myths.”
Anthem Blue Cross Blue Shield in Missouri recently notified emergency service providers that they would deny coverage for services already provided when Anthem decides the services were not for a true emergency. The reason is that they are trying to reduce inappropriate use of the emergency department. But, will some individuals delay or not seek important and life-saving care when they may really need it?
The Missouri Hospital Association, Missouri State Medical Association, Missouri Association of Osteopathic Physicians and Missouri College of Emergency Physicians believe this is unfair to individuals who have health insurance through Anthem, and puts patients at risk. Federal and state laws require coverage for emergency services for any symptom that leads a person possessing average knowledge of health and medicine to believe immediate care is required. Anthem’s policy expects patients to diagnose their own condition and make a clinical decision that could be the difference between life and death.
We need your help. MOCEP has worked with the groups listed above to create a webpage for providers and patients to share their stories. We encourage you to submit your stories, and if you hear from a patient that an ED visit was denied, please encourage them to submit their story. It is important that we gather this data to provide fair coverage for our patients.
MOCEP has been working with national and state medical groups to protect Missouri patients and their emergency care coverage. The May announcement by Anthem Blue Cross/Blue Shield (BCBS) stating they would no longer cover a list of nearly 2,000 diagnosis they consider to be non-emergent is a clear violation of the national prudent layperson standard.
MOCEP members have been distributing Letters to the Editor and working with local media to help spread the word of what we believe to be a violation of the Prudent Layperson Standard. Recent coverage includes:
ACEP ACTION ALERT – VOTE “NO” on the BCRA
On Monday, the Congressional Budget Office (CBO) released its estimate that the BCRA would lead to 22 million more uninsured Americans in 10 years and not immediately help reduce premiums, which led to even more concern and uncertainty for Republican members.
ACEP launched its Action Alert in opposition to the BCRA proposal on Monday. Nearly 1000 ACEP members have already taken action to urge their U.S. Senators to oppose the bill in its current draft. The BCRA would make sweeping changes to the health care system that directly contradict ACEP’s health care reform principles and would lead to a significant reduction in health care coverage for Americans, erode patient protections, such as coverage for emergency services, as well as endanger patient safety and public health. Please keep the pressure on while Senators are back home during the 4th of July recess.
The Division of Emergency Medicine at the Washington University School of Medicine is hosting the inaugural Larry Lewis Health Symposium in Saint Louis on August 22nd. The topic will be about the Opioid Crises, the Emergency Department, and the Public Health Perspective. Featured speakers include Dr. Corey Waller of the Camden Coalition; Dr. Randall Williams, the director of DHHS in Missouri; Representative Holly Rehder, responsible for PDMP legislation that passed the Missouri House of Representatives; Rachel Winograd PhD, the director of a large grant to improve access to opioid use disorder treatment. We hope that other hospital and public officials will be in the audience to discuss the medical response to this issue. Please see the flier below for more information. Registration is free.
HB29 passed the House and was well received in the Senate Committee. The bill would have made powdered alcohol legislated just like any alcoholic product. However, it did not pass for a good reason, which is odd to admit. The Senate said they did not want to pass the bill because it did not go far enough, and wants to pass a stronger ban next year. They were genuine about their sentiment, and believe the support next year will be stronger for a flat out ban, at least via the internet, and then access only in retail for those 21 and older.