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.”
What is Advocacy?
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!
What Are Some Examples of Legislative and Regulatory Issues?
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.
Time Critical Diagnosis (TCD)
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
- EMTALA [Emergency Medical Treatment and Labor Act] is a federal law that requires hospital emergency departments to medically screen every patient who seeks emergency care and to stabilize or transfer those with medical emergencies, regardless of health insurance status or ability to pay — this law has been an unfunded mandate since it was enacted in 1986.
- America’s emergency departments are under severe stress, facing soaring demands; many have closed because of uncompensated care due in part to the unfunded EMTALA mandate.
- Emergency physicians are dedicated to providing the highest quality emergency care to all.
- Emergency departments are essential to every community and must have adequate resources.
- ACEP advocates for recognition of uncompensated care as a practice expense for emergency physicians and for federal guidance in how fulfill the requirements of the EMTALA mandate in light of its significant burden on the nation’s emergency care system.
- EMTALA was enacted by Congress in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 U.S.C. §1395dd). Its original intent and goals are consistent with the mission of ACEP and the public trust held by emergency physicians.
- Originally referred to as the “anti-dumping” law, it was designed to prevent hospitals from refusing to see or transferring financially “undesirable” patients to public hospitals without, at a minimum, providing a medical screening examination and treatment to ensure they were stable for transfer. As a result, local and state governments began to abdicate responsibility for indigent care, shifting this public responsibility to all Medicare participating hospitals.
- Hospitals and physicians violating EMTALA are subject to civil monetary penalties ($50,000 per violation) and threat of Medicare decertification. Between March, 2008 and May, 2012, there were 35 EMTALA violations that netted a little more than $3 million.
- EMTALA has become the de facto national health care policy for the uninsured. It requires Medicare-participating hospitals with emergency departments to screen, stabilize and treat patients with emergency medical conditions in a non-discriminatory manner, regardless of ability to pay, insurance status, national origin, race, creed or color. Ninety-two percent of all hospitalizations for the uninsured are directly linked with an emergency department visit.
- The Institute of Medicine in 2006 recommended that the U.S. Department of Health and Human Services adopt regulatory changes to EMTALA and the Health Insurance Portability and Accountability Act (HIPAA) so the original goals of the laws are preserved.
- It remains to be seen how the implementation of health care reform may affect emergency departments and emergency patients. Evidence from Massachusetts indicates emergency visits will rise with increase in financial pressure due to cost saving measures imposed by health plans. EMTALA may have new found impact as the healthcare system adjusts to these new parameters.
- 1. Any individual who comes and requests examination or treatment of a medical condition must receive a medical screening examination to determine whether an emergency medical condition exists. This cannot be delayed to inquire about methods of payment or insurance coverage. Emergency departments also must post signs that notify patients and visitors of their rights to a medical screening examination and stabilizing treatment.
- 2. If an emergency medical condition exists, treatment must be provided until it is resolved or stabilized. If the hospital does not have the capability to stabilize the emergency medical condition, an “appropriate” transfer to another hospital must be done in accordance with the EMTALA provisions.
- 3. Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions.
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.
- Termination of the hospital or physician’s Medicare provider agreement.
- Hospital fines up to $50,000 per violation ($25,000 for a hospital with fewer than 100 beds).
- Physician fines $50,000 per violation, including on-call physicians.
- The hospital may be sued for personal injury in civil court under a “private cause of action”
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
Medical Liability Reform
- Between 1996 and 2001, the average liability award increased 107% (Jury Verdict Research, 2002)
- The average jury award is $3.9 million. 54% of all awards were for $1 million or more (Jury Verdict Research, 2002)
- On average, the cost of defending cases that physicians win is more than $90,000. (Physicians Insurers Association of America, 2003)
- In 2002, medical liability insurers paid out more in claims than they received in premiums. For every $1.00 received in premiums, they paid out $1.42 in claim costs. (AM Best Aggregates and Averages, 2003)
- Median insurer premiums, adjusted for inflation, increased 55.86% between 1996-2002. (NAIC)
- Median insurer losses incurred increased 139% from 1996-2001 (NAIC)
- 56% of Blue Cross/Blue Shield plans in crisis states report that physicians are leaving their practice, retiring or no longer performing higher risk procedures (Blue Cross/Blue Shield report, 2003)
- 26% of health care facilities have reacted to the liability crisis by cutting back on services and/or eliminating some patient care units. (American Hospital Association TrendWatch, 2002)
- Medical liability costs add $60 to $108 billion to the cost of health care each year, diverting health care dollars away from direct patient care and research. (US Department of Health and Human Services, July 2002)
- HHS also believes that excessive medical liability adds $47 billion annually to what the federal government pays for Medicare, Medicaid, SCHIP, VA health care and other government programs. (HHS Report: Confronting the New Health Care Crisis)
- The current tort system is highly inefficient in compensating injured parties, returning less than 50 cents on the dollar to the people it’s designed to help. (“US Tort Costs” Tillinghast-Towers Perrin, December 2003)
- A 2002 survey by Wirthlin Worldwide, Inc. showed that 72 percent of respondents, while favoring measures to allow full payment for lost wages and medical expenses in medical liability cases, support reasonable limits on “pain and suffering” awards. The same question has shown that 70% or more Americans have shared this view in 1992, 1995, 1999, and now 2000.
- Approximately 80 percent of Americans favor a law to limit the percentage that a personal injury lawyer can receive as a fee from any settlement or award.
- A study by Stephen Zuckerman et al. looked at several types of reforms and concluded that capping physician liability reduced premiums for general surgeons by 13% in the year following enactment of that reform and by 34% over the long term. Premiums for general practitioners and OB/GYNs were impacted similarly. (Effects of Tort Reforms and Other Factors on Medical Malpractice Insurance Premiums)
- In a different study by Kessler and McClellan, those researchers found “that malpractice reforms that directly reduce provider liability pressure lead to reductions of 5 to 9 percent in medical expenditures without substantial effects on mortality or medical complications. (Do Doctors Practice Defensive Medicine)
- The National Association of Insurance Commissioners states that while total premiums in the rest of the U.S. have risen 569%, California premiums have risen only 182% since 1976, after the passage of MICRA.
- The Agency for Healthcare Research and Quality found that by 2000, states with damage caps averaged 12 percent more physicians per capita than states without damage caps.
For more information: Liability Reform Data to Support Reform and Rebut Opponent Arguments
- AAMC analysis confirms likely significant shortage in coming years across a broad range of specialties
- Population growth, aging and medical advances are increasing demand
- Aging of physicians and work patterns of younger physicians will limit growth of supply
- Shortages are already apparent and competition for physicians is increasing
- MD and DO 1st year enrollment will rise by nearly 6,000 per year between 2002 and 2013
- GME is unlikely to keep pace. This will probably lead to a reduction in IMGs and limit the supply of physicians and a peaking of the physician to population ratio in the next few years
- The recession is slowing the growing shortage but health care reform will increase it
- Increasing physician supply has to be part of a mulch-faceted effort to assure access including increased use of non-physician clinicians and innovations in service delivery
- Continue to increase medical school enrollment
- Increase GME positions
- Assure that we are using our physicians wisely and effectively
- Increase use of teams including non-physician clinicians (This will require inter-disciplinary education and practice)
- Improve efficiency and effectiveness, including through evidence based medicine, comparative effectiveness studies, improved IT and EMR
- Design service delivery responsive to needs of younger and older physicians, such as flexible scheduling and part time work
ACEP Leadership and Advocacy Conference
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
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:
- An ER visit, a $12,000 bill – and the health insurer that wouldn’t pay
- Anthem expands its policy of punishing patients for “inappropriate” ER visits
- Doctors group speaks out against health insurer’s policy denying coverage of some ER visits, October 10, 2017
- Top Docs Radio Show Interview, September 19, 2017
- Healthcare Dive, August 8, 2017
- Fierce Healthcare, August 7, 2017
- AMA Wire, August 7, 2017
- St. Louis Post Dispatch, August 4, 2017
- St. Louis Public Radio
- St. Louis Post Dispatch
- Columbia Missourian
- Columbia Tribune
- ACEP/MOCEP News release
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.
Last week, the legislative session ended. Overall, we had a lot of success. Here are relevant bills that passed and failed.
Expert Witness Reform (HB 153) – This bill made it to the Governor’s desk early in session, and it has already been signed into law. It requires the state courts to shed the antiquated Frye standard for the admission of expert testimony in favor of the more widely accepted Daubert standard. The new standard requires a judge to determine not only if the testimony is widely accepted in the scientific community (where Frye ends), but also whether it is, in fact, reliable. A majority of the state and the federal courts have already accepted the Daubert standard.
Collateral Source (SB 31) – This bill changes the way damages are calculated in medical malpractice cases. Instead of being able to introduce evidence based on the amount that was billed, damages will now be restricted to what was actually paid
Advanced Directive Registry (SB 50) – This bill requires the Department of Health to establish a statewide database for the collection of advanced directives. Once operational, authorized physicians will be able to access the database when needed to further patient care.
Epipen Protocol (SB 139) – This bill allows certain entities, such as restaurants and amusement parks, to stock a supply of Epipens under a physician’s protocol.
Statewide Narcan Protocol (SB 501) – This language allows the director of the Department of Health, if they are a physician, to establish a statewide protocol for Narcan, making it easier to access the overdose antagonist.
Overdose Good Samaritan (SB 501) – This bill allows limited immunity from prosecution for any person, who in good faith, seeks medical assistance for themselves or another person experiencing an overdose.
Medical Student Burnout (SB 52) – The language of this bill creates a committee that will work with medical schools to research the prevalence and concerns surrounding medical student burnout and depression, and develop protocols to minimize the risk of suicide. If a study is undertaken, it must be submitted to the General Assembly and made available on medical school websites.
THOSE THAT DIDN’T PASS…NOT ALWAYS A BAD THING
PDMP – Yeah, the good version didn’t pass, again, but neither did the bad version
APRN Schedule II – This bill would have allowed advanced practice registered nurses to prescribe Schedule II controlled substances.
Helmet Repeal – This bill would have repealed the state’s motorcycle helmet requirement.
CDC Prescribing Guidelines – This attempt would have required physicians to abide by the Centers for Disease Control’s Prescribing Guidelines for opioids.
Predetermination of Benefits – This bill would have required insurance companies to respond in real time to patient requests for cost sharing information prior to the service being provided.
MOC/MOL – This bill would have restricted insurance companies and hospitals from considering maintenance of certification and maintenance of licensure in creating networks or staff privileges.
Texting While Driving – This bill would have included texting while driving to the criminal distracted driving law.
Emergency Physicians: Anthem Blue Cross Blue Shield Policy Violates Federal Law
WASHINGTON ¾ The American College of Emergency Physicians (ACEP) and its Missouri Chapter today said the list of medical diagnoses developed by the health insurance giant, Anthem Blue Cross/Blue Shield (BCBS), is a clear violation of the national prudent layperson standard, which is codified in federal law including the Affordable Care Act. It’s also law in more than 30 states.
On Thursday, ACEP Board member, Mark Rosenberg, DO, MBA, FACEP, and ACEP Congressional Affairs staff met with Sen. Cory Booker’s (D-NJ) office to promote solutions for the nationwide opioid epidemic. The focus of the discussion was the “Alternatives to Opioids” (ALTO) program and its three components (prevention, harm reduction, and detox and recovery) established by Dr. Rosenberg and his team at St. Joseph’s Healthcare System (Paterson, NJ). Dr. Rosenberg, ACEP and St. Joseph’s are advocating for ALTO to become a model, alternative approach to addressing the opioid crisis. Promoting collaborative legislative action with federal lawmakers is part of ACEP’s ongoing Leader Visit Program in Washington, DC