Emergency Medicine 2009:

Current Issues & Crises

Jennifer L. Wiler M.D., M.B.A.Councilor, ACEP Young Physicians Section Vice Chair, AMA Women Physicians CongressSpeaker, AMA Young Physicians Section EM Advisor, AMA RVS Updates Committee (RUC)Immediate Past-Vice Chair, Missouri State Medical Society YPS

Obama’s Domestic Agenda

1. Healthcare Reform2. Education3. Energy

Reasons for Healthcare Reform

• Problem:– Cost– Quality – Un/Under Insured– Access / Coordination

of Care

Healthcare Spending “Out of Control”

Est. by 2018: HC spending 1/5th total US economy

Government (taxpayer) pay >50% costs (Source: CMS)

Cost ≠ Quality; Variations by State

Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality

Relationship Between Quality of Care and Medicare Spending, by State, 2004  C

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How Does U.S.A. Compare?

Source: UC Atlas of Global Inequality.com

Source: JAMA Dec 24/31, 2009 300(24):2843

A Question of Value

Jobless & Uninsured Rates are Climbing

Aging Adult Population

www.princetoncme.com

Increasing System Demand Decreasing Capacity

Projected Workforce Shortage – Physicians

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html;

Physicians NOT Accepting Medicaid -- On the Rise

Modern Physician 11/06

Shortage of On Call Specialists

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html

Affecting nearly 75% of all hospitals

“I mean, people have access to healthcare in America. After all, you just

go to an emergency room.”

President Bush Cleveland Ohio June 10, 2007

Increasing ED Patient Volumes

“Hospital Ambulatory Medical Care Survey” 9/06 www.CDC.gov

1996-2006: Annual # of U.S. ED visits rose by 32% (90M to 119M) EDs decreased 5%

EMTALA …

• 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA)– a.k.a. Federally mandated

uncompensated care

The Result …Your ED Waiting Room Looks Like This

Source: www.boston.com

And It is Not Just Your ED...

% of Hospitals with ED At or Over Capacity

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html

Many ED’s Report Being On Diversion…

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; American Hospital Association, 2007 Survey of Hospital Leaders

500,000 Ambulance Diversions Qyr On average one every minute

Institute Of Medicine 2006“Hospital Based Emergency Care – At The Breaking Point”

• Many EDs and trauma centers are overcrowded.

• Emergency care is highly fragmented.

• Emergency care system is ill-prepared to handle a major disaster.

• EMS and EDs are not well equipped to handle pediatric care.

• Underfunded system.

www.iom.edu

EDs Have No Surge Capacity

Chairman Rep. Henry A. Waxman (D-CA)

ED Crowding/Boarding is Bad

• Worse Patient Outcomes – Sig increase serious complications (~6 vs. 3 %) in ACS pts 1

• Crowding Causes Deaths 2

– ~1/3rd ED sentinel events (serious injury/death) related to crowding 3

• Crowding / Boarding is Expensive– Increases total hospital LOS 4

– Increases LWTC & adverse outcomes 5

– Increases ambulance diversion 6

– Increases medical negligence claims 7

1. Pines JM, et al. ACEP SA 2007 Abstract; 2. Chalfin DB, et al. Crit Care Med. 2007; 35(6):1477-1483; 3. Joint Commission. Sentinel Event Alert, June 17, 2002; 4 Krochmal P, et al. Am J Emerg Med 1994;12(3):265-266.; Richardson B. Med J Aust. 2002; 177(9):492-495.; Liew D, et al. Med J Aust. 2003; 179(10):524-526.; 5. Richardson DB, et al. Confirmation of Association between overcrowding and adverse events in patients who do not wait to be seen. Acad Emerg Med. 2004; 11(5):462.3; 6. Burt CW, et al. National Center for Health Statistics, 20067. 4 ED Crowding: High Impact Solutions www.acep.com

ACEP’s National Report Card The State of EM 2008

Source: ACEP.org

Where Do You Start to Fix the System?

Healthcare Reform: Future Track?

• Universal HC Coverage (Access)• Medical Home• Improve Quality (Value)• Change Physician Compensation• Insurance Carrier Reform• Liability Protection• More…

How Will This Effect EM?

Source: www.wremsco.org

What Has Already Been Done

• SCHIP Reauthorization through 2013• Stimulus Plan - American Recovery & Reinvestment Act*

– CMS $338 B– Medicaid state matching $87 B– Extended COBRA Benefits $24.7 B– HIT $19.2 B– NIH new grants $8.2 B

• IOM Summit “Future of Emergency Care Reports”- March 2007 Recommendations

• ED Crowding: High Impact Solutions, April 2008 Source: NEJM Feb 21, 2009

Access to Emergency Medical Services Act 2009 (H.R. 1188 and S.468)

Introduced Feb 2009 – Reps. Bart Gordon (D-TN) & Pete Sessions (R-TX) in House – Sens. Debbie Stabenow (D-MI) & Arlen Specter (R-PA) in Senate

(1) Create Bipartisan Commission – Evaluate Access to EMS– Issues: Crowding, availability of on-call specialists, & medical liability issues on EMS

(IOM recommendation)

(2) Increase in EMTALA-Provider Care Related Payments– Authorizes additional Medicare payment to physicians (including on-call specialists)

(3) Emergency Department Boarding/Diversion Quality Standards – CMS develop hospital boarding & diversion quality standards via National Quality Forum

(NQF) & Hospital Quality Alliance (HQA)

Co-Sponsors: 66 House & 6 Senate (4/1/09)

Obama’s Proposed Source of Cost Savings

Source: White House Office of Management and Budget, AMA News March 16, 2009

Physician Reimbursement Issues

• RAC’s

• Balanced Billing Prohibition in CA

• United HC $350M Settlement

• Participate in AMA RUC Process

• More…

Take Home

• Some Form of Healthcare Reform Will Happen

• Emergency Services are an Essential Part of Healthcare System– Not Just For “Nonurgent” Patients

– Not Just for Uninsured

• EMTALA Mandated Care with No Reimbursement or Liability Provisions

• Patient Centered – “High Value”

Thank You