Gardner's Gate

Physicians File Suit to Prevent Washington State Plan that Classifies more than 700 diagnoses as “non-emergent” for Medicaid Patients

2011-10-03T10:36:00.000-05:00

Emergency physicians in Washington State today filed suit in the Superior Court of Washington for Thurston County against a state plan that would limit payment for Medicaid visits to three "non-emergency" visits to emergency departments each year and classify more than 700 diagnoses as "non-emergent," including chest pain, abdominal pain, miscarriage and breathing problems.

The Washington Chapter of the American College of Emergency Physicians said the basis for the suit is multi-factorial and includes:

*The state has not implemented a rule making process that included stakeholder comments; yet the plan is being forced on hospitals and providers with no warning.

*The state has violated requirements that this be a collaborative process as outlined by the legislature.

*The state has violated the requirements that this be a collaborative process as outlined by the legislature.

*The state has misconstrued the ability to bill patients for services. Federal law prevents physicians from meeting Medicaid requirements for billing patients through EMTALA, and state law blocks hospitals from billing under charity requirements.

*The state is violating the federal Prudent Layperson standard by applying it to managed care patients.

ACEP Sues Washington State over Proposed Medicaid Rules

2011-10-02T02:15:00.000-05:00

Proposed List of "Non-Emergency" Diagnoses Includes Those with Symptoms of Serious Medical Conditions

The American College of Emergency Physicians (ACEP) this week urged the Centers for Medicare & Medicaid (CMS) to reject a list of more than 700 diagnoses that Washington State will treat as “non-emergent” for Medicaid patients, effective October 1. The list includes the symptoms of serious medical conditions, including chest pain, shortness of breath, miscarriage and abdominal pain.

The state’s plan will limit Medicaid patients to three non-emergency visits to the emergency department each year, putting the most vulnerable members of society — including children — at risk of serious harm. Physicians in the state have offered to work with state officials to come up with a list of truly non-emergent conditions.

“The list of conditions was generated solely by state Medicaid office over the objections of physician and hospital task force representatives,” said Dr. Sandra Schneider, president of ACEP. “The use of discharge diagnoses instead of presenting symptoms/conditions is a clear violation of the prudent lay person standard required for Medicaid managed care organizations. With Washington State having close to 60 percent of its Medicaid population enrolled in managed care, how will the state comply with the law? Also, what implications does this have for the millions of people who will be added as Medicaid beneficiaries as part of health care reform?”

Specifically, ACEP asked CMS to ensure that the Washington’s State Plan Amendment:

Requires the state to create a notification system or website so providers will know that an individual has reached his/her third annual “non-emergent” visit,
Requires the state to ensure that patients who reach this status have access to viable primary care services before imposing this policy, and
Ensures the state does not apply this policy to managed care patients in violation of federal law.

“The symptoms of many of these medical conditions indicate life-threatening emergencies, and people with these symptoms should seek emergency care,” said Stephen Anderson, MD, president of Washington ACEP. “Not doing so could lead to severe illness, disability, and even death. Including conditions such as congestive heart failure, kidney stones, miscarriage, chest pain, and asthma is outrageous and dangerous.”

The prudent layperson standard requires health plans to cover visits to emergency departments based on an average person‘s belief that he or she may be suffering a medical emergency due to the symptoms he or she is experiencing, not a final diagnosis. It is designed to protect patients who experience the symptoms of a medical emergency but who, after a medical examination and testing by a trained professional, are diagnosed with an acute care or non-emergent medical condition.

“We understand the financial stress that states are under and we support efforts at the state and national level to link Medicaid beneficiaries to primary care practitioners, but those resources have to be available and accessible,” said Dr. Schneider.

Dr. Schneider also said that hospital emergency departments are required by law to see patients, but then this state plan is requiring the services not to be paid.

2011-07-15T22:59:00.017-05:00

The American College ofEmergency Physicians sent a comment letter to Dr. Donald Berwick, Administratorof the Centers for Medicare and Medicaid Services in response to the draftAccountable Care Organization regulations published Spring 2011. The ACEP commentletter lists a seriesof concerns regarding structure, governance, start-up costs and risk sharingthat would make physician-based ACOs inaccessible except to large, well-capitalizedmulti-specialty practices. Further, EM practices that cover large geographic areas could possiblytrigger an expensive and resource consumptive Federal Trade Commission reviewas a result of the anti-trust requirements created by the new regulations. If the final regulation is not changedsignificantly, the pool of applicants may be quite small.

The letter in its entirety is posted below:

December 2, 2010

Donald M. Berwick, MD, MPP, FRCP

Administrator, Centers for Medicare & Medicaid Services Department of Health and Human Services 445-G, Hubert H. Humphrey Building 200 Independence Avenue,

SW Washington, DC 20201

Attention: CMS-1345-NC Re: Policies and Standards for ACOs Participating with the Medicare Program

Dear Dr. Berwick:

On behalf of the American College of Emergency Physicians’ (ACEP) more than 29,000 members and the Emergency Department Practice Management Association (EDPMA) and its 83 affiliated member organizations, we appreciate the opportunity to submit preliminary comments regarding aspects of policies and standards for Accountable Care Organization (ACO) design and development.

CMS has provided various background documents and public forums over the past few months in preparation for implementing Sec. 3021 and 3022 of PPACA. The vision for primary care physicians and/or hospital-based systems developing ACOs has been well-outlined. However, any description of expectations of the roles for emergency care physicians (and other hospital- based specialists) has not been addressed. We are concerned that once ACOs, medical homes, and expanded coverage are implemented, many policy makers expect emergency visits to all but disappear. While the health reform law will greatly expand insurance coverage starting in 2014, the volume of emergency visits is showing no signs of diminishing. In states like Massachusetts where 97 percent of the population has coverage, emergency department visits continue to grow.

According to the HHS’ Centers for Disease Control and Prevention, emergency visits in 2008 grew to 124 million, the highest level ever reported, and the number of uninsured recently reported by CDC has now reached 50 million, which will undoubtedly add to the volume of already crowded emergency departments. In addition, we predict that when the estimated 16 million individuals are added to Medicaid, the volume of emergency department visits will rise again as the supply and willingness of physicians in the community to add more low paying Medicaid patients to their practices falls short of demand.ACEP/EDPMA Response to ACO Questions December 2, 2010 Page 2

We believe there is a significant, and often overlooked, role for emergency physicians in new delivery system models that will greatly contribute to improvements in quality and coordination of patient care.

We have selected three of the seven questions posed in the November 17th Federal Register notice for response today. We will have more extensive reactions and recommendations when the draft regulation is released for comment.

• What policies or standards should we consider adopting to ensure that groups of solo and small practice providers have the opportunity to actively participate in the Medicare Shared Savings Program and the ACO models tested by CMMI?

We urge CMS, FTC, and OIG to strongly consider concerns on the structure and the need to remove certain legal barriers that have been articulated to CMS by the American Medical Association, American Hospital Association, the Federation, and other provider groups.

With regard to the question above, we believe that practice size is not the only factor that CMS needs to consider in planning shared savings models. Approximately one-third of emergency physicians are hospital employees while the majority are members of practice groups of varying sizes that contract with hospitals to provide 24/7 coverage of their emergency departments.

Fifty percent of Medicare admissions come through the emergency department and the majority of those have time-sensitive conditions. Our members play a critically important role coordinating care at the front end of an episode, i.e. they conduct a medical screening examination and assess the patient’s need to be either admitted, treated and discharged, or kept in observation for several hours before a final disposition decision is made. Approximately 25 percent of US hospitals have dedicated observation units and they are generally directed by emergency physicians. If the patient requires inpatient care, the emergency physician contacts the patient’s treating physician – primary care and/or specialty – who actually admits the patient. If the patient has no physician, the decision goes to the hospitalist or other hospital medical staff member. At the end of the inpatient stay, many patients are discharged into the community or to post acute care settings with little or no coordinated follow up. And, some of these individuals return to the emergency department when their conditions worsen and they don’t know where else to go.

This is an area where emergency physicians can improve transitions between sites of care, particularly when a patient comes back to the emergency department and is re-admitted within 30 days of discharge. As electronic health records continue to expand to link community-based physicians with the emergency department and other health care providers, emergency physicians will be able to play a more integral and expanded role in care coordination. Payment policies for specialty groups like emergency physicians who have little control over who comes to the emergency department should evolve over time as the ACO infrastructure improves and participating physicians can undertake joint risk sharing.

• The Affordable Care Act requires us to develop patient-centeredness criteria for assessment of ACOs participating in the Medicare Shared Savings Program. What aspects of patient-centeredness are particularly important for us to consider and how should we evaluate them?

ACEP/EDPMA Response to ACO Questions December 2, 2010 Page 3

We believe that collaborative patient education is the most effective tool to improving quality and patient satisfaction. ACEP has long provided public education regarding when an individual should come to the emergency department, based on the now universal ‘prudent lay person standard’ that is based on the individual’s belief that he/she may have a medical emergency. Appropriate use of the emergency department requires much more than communication between the emergency physician and the patient.

It starts with the patient’s primary care provider, who is often the one who tells the patient to go

directly from home to the emergency department for tests, especially on nights and weekends.

The ACO should provide a framework to engage all the physicians in coordinating the patient’s care and keeping the patient informed about what types of services are actually needed at the most appropriate site for that care. We envision that inclusion of collaborative clinical decisions can reduce the number of diagnostic images and foster greater consideration of alternatives to inpatient care. Patient understanding and satisfaction should improve along with the quality, safety and efficiency. A team approach is especially important for Medicare patients with chronic conditions.

Again, real time exchange between providers will require extensive investments in health information technology (IT) infrastructure to facilitate coordination using EHRs and other technology. We urge CMS to reassess the EHR incentive program as policies and standards continue to be established and the current state of health IT adoption and functionality evolves. At the same time, HCAHPS and/or other instruments can be refined to measure patient understanding and satisfaction with their overall care.

We also note that emphasis on physicians providing more extensive education, coordination, and collaboration through participation in ACOs may result in higher costs for physician services, while reducing costs of inpatient and post acute care. The current payment silos must be adjusted to recognize overall system savings so physicians are not penalized.

• In order for an ACO to share in savings under the Medicare Shared Savings Program, it must meet a quality performance standard determined by the Secretary. What quality measures should the Secretary use to determine performance in the Shared Savings Program?

The most important aspect of performance measurement for nascent ACOs is to begin with existing measures endorsed by a consensus based entity (e.g., National Quality Forum) and work with consensus groups and private payers to further standardize measures and metrics. Most physicians and other providers are responding to myriad “quality” measures, and new, ACO-specific measures make no sense at this point.

The majority of physician groups are now participating in PQRI/PQRS including emergency physicians who were early adopters, so PQRI/PQRS measures are the best source of measures for the foreseeable future. As CMS and ACOs glean experience with these new delivery models, more outcome measures should be added, while some of the more process- oriented measures should be retired.

We also recommend that as the experience is gained, measures that reduce emergency department overcrowding be considered, as well as measures encouraging communication

ACEP/EDPMA Response to ACO Questions December 2, 2010 Page 4

between hospital physicians and primary care physicians and coordination of emergency department transitions so that a loop of continuous care is created to diminish morbidity and mortality at critical transition points.

We look forward to working with CMS and other physician and hospital groups to share research and clinical guidelines that can be integrated into larger bundles of care. If you have any questions about our comments, please contact Barbara Tomar, ACEP’s Federal Affairs Director at (202) 728-0610, ext. 3017.

Sincerely,

Sandra H. Schneider, MD, FACEP Randy Pilgrim, MD, FACEP President, ACEP Chairman, Board of Directors, EDPMA

American College of Emergency Physicians Announces Leadership Nominations

2011-04-07T11:24:00.000-05:00

Today the Board of Directors of the American College of Emergency Physicians released the slate of candidates seeking elected leadership positions in 2012.

President-elect

Dr. Alexander Rosenau

Dr. Andrew Sama

Dr. Robert Solomon

Council Speaker

Dr. Marco Coppola

Council Vice Speaker

Dr. James Cusick

Dr. Kevin Klauer

Dr. William Meeks

Board of Directors

Dr. Michael Gerardi (Incumbent)

Dr. Hans House

Dr. William Jaquis

Dr. David John

Dr. Mark Mackey

Dr. David Mendelson

Dr. John Rogers

Elections will be held during the annual Council Meeting in San Francisco in October.

Off The Grid

2011-03-20T21:57:00.000-05:00

I'll be off the grid for the next ten days. See on April Fool's Day!

Americans Living Longer

2011-03-17T23:07:00.002-05:00

Life expectancy in the United States has reached an all-time high. An individual born in 2009 has a life expectancy of 78 years, according to a preliminary CDC report. The death rate has declined for the 10th year in a row and infant mortality is expected to reach a new low, as well. Deaths from all causes declined proportionately, making it difficulty to distinguish a single explanation for decrease. The gender difference in lifespan persists, with the overall male life expectancy at around 75.5 and the overall female life expectancy at about 80.5.

President Obama Launches Medical Malpractice Reform Proposal

2011-02-16T09:50:00.000-06:00

President Obama’s budget, discussed at a press conference yesterday, launches a new presidential focus on professional liability laws as they apply to medicine. He intends to revamp state medical malpractice laws and curb the practice of so-called “defensive medicine.” The budget specifically calls for $250 million in Justice Department grants to help states rewrite malpractice laws that are consistent with the recommendations made by the bipartisan debt reduction commission last year. Health and Human Services Secretary Kathleen Sebelius told the Senate Finance Committee yesterday that her agency would advise the Justice Department on grant awards.

The president’s proposals for professional liability reform include:

Establishing health courts to deal with medical liability cases. Health courts would use specially trained judges instead of juries to decide medical malpractice cases. Awards would be made according to a set schedule.
Creating a “safe harbor” for physicians who adhere to guidelines for best clinical practices.
Creating some protections for physicians who demonstrate acceptable use of an electronic medical record.
Providing protections for hospitals and physicians that employ early apology and compensation for medical errors.
Changing proportionate share laws such that instead of each defendant being held liable for the entire amount of an award in a malpractice suit, each defendant is liable for a percentage proportionate to the responsibility for the harm.

NOT covered in the president’s proposal is a cap on jury awards. President Obama has long said that he would not entertain caps as a solution to the professional liability insurance crisis, but has said that he would entertain other options as outlined in his proposal.

President Obama’s debt reduction commission estimates that implementation of the recommendations could save government programs $17 billion by 2020. Although the cost of defensive medicine is widely debated, conservative estimates start at around $50 billion per year. The president’s budget does not include any actual savings from the new proposal.

The Future of Emergency Medicine Summit

2011-01-27T11:31:00.000-06:00

Leaders from the major organizations in emergency medicine are meeting to discuss the needs of emergency patients both now and in the future. Major areas of discussion include workforce, access to care, the daily practice of emergency medicine, and the value of emergency medicine in the emerging era of healthcare reform, with discussion of emergency medicine's role in the formation of accountable care organizations.

Future of EM Summit 2011

Participants in the conference include:

James G. Adams, MD, FACEP (AACEM)

Dennis M. Beck, MD, FACEP (ACEP)

Howard Blumstein, MD (AAEM)

Marilyn Bromley, RN (ACEP)

Michele Byers, CAE (EMRA)

Steven H. Bowman, MD, FACEP (CORD)

Thomas Brabson, DO, FACOEP (ACOEP)

Gregory Christiansen, DO (ACOEP)

Theodore A. Christopher, MD, FACEP (AACEM)

Tammy Crowley (ACEP)

Nathan Deal, MD (EMRA)

Angela F. Gardner, MD, FACEP (ACEP)

Marjorie Geist, RN, PhD, CAE (ACEP)

John Graykoski, PA-C, MPAS (SEMPA)

Robert Heard, MBA, CAE (ACEP)

Cherri D. Hobgood, MD, FACEP (SAEM)

Michelle Hoppes, RN, MS, AHRMQR, DFASHRM (ASHRM)

Hans R. House, MD, FACEP (ACEP)

Nicholas J. Jouriles, MD, FACEP (ACEP)

Douglas F. Kupas, MD, FACEP (SAEM)

Douglas L. McGee, DO, FACEP (CORD)

Robert McCurren, MD, FACEP (EDPMA)

Mark Mitchell, DO, FACOEP (ACOEP)

Dighton Packard, MD, FACEP (EDPMA)

AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN (ENA)

Michelle Parker (SEMPA)

Randy Pilgrim, MD, FACEP (EDPMA)

John J. Rogers, MD, FACEP (ACEP)

Sandra Schneider, MD, FACEP (Chair of Summit, ACEP)

Donald Stader, MD (EMRA)

Cary J. Stratford, PA-C, DFAAPA (SEMPA)

Jim Tarrant, CAE (SAEM)

Harold A. Thomas, MD, FACEP (Observer only)

Jill Walsh, DNP, RN, CEN (ENA)

Dean Wilkerson, JD, MBA, CAE (ACEP)

Joseph Wood, MD, FACEP (AAEM)

Led by Dr. Sandra Schneider, ACEP President, the group will produce a document detailing both the discussions and recommendations in the near future.

Top 10 Doctor Movies

2010-12-24T15:18:00.000-06:00

One of my social media buddies recently challenged me to share my "Top 10 Emergency Doctor Movies." Although I could not rattle off ten movies that have an emergency doc as the main character, I did come up with 10 of my favorite doctor movies. My favorite "doctor movie" is based on the true story of an emergency doc in a busy urban ED who could not get a specialist to take care of a critical patient. (Sound familiar? It's a way of life for many of my colleagues.) The movie stars Joe Mantagne, and depicts the choices that face emergency physicians every day - choices made without enough information and without a crystal ball.

Here is my list:

1. State of Emergency

1994 (Joe Mantegna)

2. M*A*S*H*

1970

3. The Elephant Man

1980

4. Beyond Borders

2003

5. Guess Who’s Coming to Dinner

1967

6. And The Band Played On

1993

7. Spellbound

1945

8. Miss Evers’ Boys

1997

9. Flatliners

1990

10. The Hospital

1971

Honorable mention: What About Bob? (1991)

A parting thought: As one of a generation of emergency doctors who grew up with Hawkeye Pierce for a hero, let me say that he COULD have been an ER doc, but was created one war too early.

Happy Holidays to all!

Independent Contractor Status At Risk For Emergency Physicians

2010-12-09T06:50:00.000-06:00

As Congress tries to complete work for the year, several bills are being considered and funding must be found to offset their costs. The Senate is considering a menu of funding mechanisms that could be used to pay for the legislation under consideration. One source of offset funding under consideration is The Fair Playing Field Act of 2010. Currently, the law allows businesses a safe harbor to treat workers as independent contractors for employment tax purposes if the company has had a reasonable basis for such treatment and has consistently treated such employees as independent contractors by reporting their compensation on Form 1099s.

As proposed, The Fair Playing Field Act would require the Treasury Secretary to issue regulations or other prospective guidance clarifying the employment status of individuals for federal employment tax purposes. It specifically allow the Internal Revenue Service the ability to individually question independent contractor status.

How would this impact the delivery of Emergency Care?

If enacted, this provision could have a negative impact on the delivery of emergency care by harming the ability of independent contractor emergency physicians to provide much-needed staffing of emergency departments throughout the country. Restricting the ability of hospitals to staff their emergency departments using emergency physician independent contractors could have dire results for patients' access to lifesaving emergency care.

ACEP's Message:
Please contact your U.S. Senators and urge them not to attach The Fair Playing Field Act to any other bill during the lame duck period and/or use its provisions as an offset to legislation under consideration.

Thank you for your prompt action.

Questions: Contact Brad Gruehn in the ACEP Washington DC office.

The Joint Commission Reveals New Areas of Field Review and More...

2010-12-07T05:32:00.000-06:00

The Joint Commission has several areas that are currently in the process of field review:

Proposed National Patient Safety Goals addressing ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTI).

Start Date: December 2, 2010
End Date: January 27, 2011

Proposed revisions to credentialing and privileging requirements for the Long Term Care accreditation program

Start Date: December 2, 2010
End Date: January 17, 2011

Proposed requirements for advanced heart failure certification

Start Date: November 3, 2010
End Date: December 15, 2011

To participate in any current field reviews, visit the Joint Commission Web site at http://www.jointcommission.org/Standards/FieldReviews.

The Joint Commission also has the following areas currently in development:

STANDARDS AND GOALS

Proposed revision to the National Patient Safety Goal on medication reconciliation for the ambulatory care, behavioral health care, critical access hospital, home care, hospital, long term care, Medicare/Medicaid certification-based long term care, and office-based surgery programs.
Proposed applicability changes to urgent care requirements in the ambulatory care program.
Proposed 2012 National Patient Safety Goals pertaining to health-care associated infections for the hospital and long term care programs.
Proposed standards for the "Primary Care Home" initiative in the ambulatory care program.
Proposed clarifications and applicability changes to the home health standards in the home care program.
Proposed standards to encompass the continuum of care provided to heart failure patients in a variety of health care delivery settings in the disease-specific care program for Heart Failure Advanced Certification.
Development of a model to integrate performance expectations on accountability measures into a standards requirement for the hospital accreditation program. The tentative implementation date for a new requirement is January 2012.

POLICIES AND PROCEDURES

Proposed revisions to the Sentinel Event Policy for all programs.

For more information on any or all of the forthcoming changes, please visit the The Joint Commission site at http://www.jointcommission.org.

Policies and Standards for ACOs Participating with the Medicare Program

2010-12-03T16:11:00.001-06:00

In response to pre-ACO regulations, CMS posed questions to physicians concerning their possible participation in soon to be developed accountable care organizations. ACOs are a product of the new Patient Protection and Affordable Care Act (PPPAC) and will serve a minimum of 5000 Medicare beneficiaries. It is assumed that most ACOs will enroll private patients as well as Medicare once they are up and running. ACEP's comments to CMS Administrator Donald Berwick regarding aspects of policies and standards for ACOs' design and development include the need to recognize the potential role that emergency physicians can play in coordinating care across sites of service.

Below is the text of the letter sent to Dr. Berwick by ACEP President Dr. Sandra Schneider and EDPMA Board Chairman Dr. Randy Pilgrim.

December 2, 2010

Donald M. Berwick, MD, MPP, FRCP

Administrator, Centers for Medicare & Medicaid Services

Department of Health and Human Services

445-G, Hubert H. Humphrey Building

200 Independence Avenue, SW

Washington, DC 20201

Attention: CMS-1345-NC

Re: Policies and Standards for ACOs Participating with the Medicare Program

Dear Dr. Berwick:

CMS has provided various background documents and public forums over the past few months in preparation for implementing Sec. 3021 and 3022 of PPACA. The vision for primary care physicians and/or hospital-based systems developing ACOs has been well-outlined. However, any description of expectations of the roles for emergency care physicians (and other hospital-based specialists) has not been addressed. We are concerned that once ACOs, medical homes, and expanded coverage are implemented, many policy makers expect emergency visits to all but disappear. While the health reform law will greatly expand insurance coverage starting in 2014, the volume of emergency visits is showing no signs of diminishing. In states like Massachusetts where 97 percent of the population has coverage, emergency department visits continue to grow.

We have selected three of the seven questions posed in the November 17^th Federal Register notice for response today. We will have more extensive reactions and recommendations when the draft regulation is released for comment.

We also recommend that as the experience is gained, measures that reduce emergency department overcrowding be considered, as well as measures encouraging communication between hospital physicians and primary care physicians and coordination of emergency department transitions so that a loop of continuous care is created to diminish morbidity and mortality at critical transition points.

Sincerely,

Sandra H. Schneider, MD, FACEP Randy Pilgrim, MD

President, ACEP Chairman, Board of Directors, EDPMA

Voters Favor Health Care Reform Bill, Polls Show

2010-11-23T22:32:00.002-06:00

Steven Thomma reports this morning in the Miami Herald that voters actually favor the new healthcare reform law, as determined by a new McClatchy Newspapers-Marist poll. The post-election survey reportedly states that 51 percent of registered voters want to keep the law or change it to do more, while 44 percent want to repeal it or change it to do less. Despite the Republican rhetoric that the recent mid-term elections represent a mandate to repeal the controversial law, many Americans actually favor many aspects of the bill.

Not surprisingly, voters favor aspects of the bill that benefit patients. The requirement that insurance companies provide coverage to people with pre-existing conditions is favored by 59% of respondents, with 36% opposed. Allowing children to remain on a parent’s insurance policy until the age of 26 is also popular, with 68% of respondents favoring and 29% against. Additionally, closing the “doughnut hole” in Medicare prescription drug coverage was favored by 57% of the respondents, compared to 32% against.

The results of the poll portend a more complex and challenging political landscape ahead for the Republicans in Congress than perhaps anticipated. It will be difficult to repeal bill in its entirety when significant portions are so popular. Instead, this may represent the opportunity to create a truly bipartisan solution to America’s healthcare system problems.

Senate Passes Doc Fix Bill

2010-11-18T22:23:00.000-06:00

The U.S. Senate tonight passed a bill entitled the “Physician Payment and Therapy Relief Act” that will postpone a 23% cut in Medicare reimbursement to physicians from December 1^stto January 1^st. The bill was constructed by Senator Max Baucus (D-MT), chair of the Senate Finance Committee, and Senator Chuck Grassley (R-IA). Senators Baucus and Grassley also announced that they would seek a second “doc fix” that would further delay the scheduled December 1^st pay cut as well as the 2% pay cut scheduled for January 1, 2011. The second bill would postpone all pending physician reimbursement cuts until January 1, 2012.

Unfortunately for physicians facing the 23% pay cut in 12 days, the House has already adjourned for the Thanksgiving holiday, meaning that they cannot take up consideration of the Senate bill before November 29^th. There is currently a bill proposed by Representative John Dingell (D-MI) that would extend the effective date of Medicare cuts until January 1, 2012. Whether the House pursues Dingell’s bill or takes up the Senate bill on the 29^th is unclear, but spokespersons for House Speaker Nancy Pelosi (D-CA) have indicated that the House would consider “doc fix” legislation prior to the December 1^st deadline.

It's official. EMS is now a subspecialty of Emergency Medicine

2010-09-24T13:37:00.000-05:00

The American Board of Medical Specialties (ABMS) approved the American Board of Emergency Medicine (ABEM) application for subspecialty certification in Emergency Medical Services (EMS) yesterday at their meeting in Chicago. This effort was led by Dr. Debra Perina, Immediate Past President of ABEM.

Unofficial reports are that the first exam will be scheduled for 2013.

The American College of Emergency Physicians kicks off it's Scientific Assembly tomorrow in Las Vegas, Nevada. As part of the week-long conference members of the ABEM Board will attend the EMS committee meeting on Tuesday, September 28th in the Las Vegas Convention Center.

It is especially fitting that EMS gain recognition as a subspecialty on the 50-year anniversary of the publication of the first scientific research in cardiopulmonary resuscitation (CPR), a basic skill for all involved in pre-hospital care.

Emergency visits up 23% according to the CDC

2010-08-10T22:45:00.001-05:00

A new report from the Centers for Disease Control and Prevention once again debunks the myth that emergency departments are crowded with non-urgent patients, a finding noted by the American College of Emergency Physicians (ACEP).

The percentage of non-urgent patients dropped to only 7.9 percent in 2007 [from 12.1 percent in 2006]. The report also makes the excellent point that non-urgent does not imply unnecessary. As ACEP has said repeatedly, our patients are in the ER because that’s where they need to be.

There were approximately 222 visits to U.S. emergency departments every minute in 2007 (http://bit.ly/9B5kHJ) and the number of visits increased by 23 percent between 1997 and 2007, according to the report.

Preliminary data for 2008 indicate that emergency visits will increase to a record high of more than 123 million (http://bit.ly/ak6oRx).

Babies under 12 months old had the highest visit rate at 88.5 visits per 100 infants. The second highest visit rate was by adults age 75 and older, with 62 visits per 100 people.

Approximately one-quarter of all visits were by patients insured by either Medicaid or the State Children’s Health Insurance Program. The uninsured represented about 15 percent of all visits.

The report, “National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary” offers far more detail than the data brief released by the Centers for Disease Control and Prevention (CDC) in May. The U.S. Department of Health and Human Services, of which the CDC is a part, has indicated that this is the last fully detailed report of its kind to be issued about emergency department visits.

I am urging the CDC to reconsider:

“It is essential to know what is happening in our emergency departments as we implement health care reform. This report is rich in data about who our patients are, how old they are and why they are seeking care in the ER. From a planning perspective, this information is invaluable. It would be a mistake for the CDC to discontinue tracking what is happening on the front lines of healthcare, the nation’s emergency departments.”

The report also notes that only 0.1 percent of patients die in the emergency department.

The report says the main issue contributing to overcrowding has been delays in moving the sickest patients to inpatient beds. Admitted patients have often been boarded in the emergency departments or hospital hallways for hours to days, resulting in overcrowding and diversion of incoming ambulances to other hospitals.

Congressional Update

2010-08-09T23:53:00.001-05:00

Senate Approves Additional Medicaid Funding for States

The House will return next week to vote on the measure.

The Senate on Thursday passed a $26.1 billion state-aid package that the House is poised to consider next week, when it will return briefly from its August recess. The bill would provide $10 billion to save education jobs and six more months of increased federal Medicaid payments to states at a cost of $16.1 billion. The vote was 61-39 with Maine Republican Senators Olympia Snowe and Susan Collins joining all 59 members of the Senate Democratic Caucus. The Congressional Budget Office (CBO) says the bill is budget-neutral over 10 years and will reduce future deficits by $1.37 billion. Offsets include the end to a tax loophole for multinational corporations and reductions starting in 2014 in extra food stamp benefits provided under the 2009 economic stimulus law.

On Thursday House Speaker Nancy Pelosi (D-CA) announced on Twitter that she would call House members back to Washington, D.C. next week to take up the measure. The House adjourned for the August recess last Friday and the chamber was not scheduled to return until September 14.

Senate Schedule in the Fall

The Senate now heads home for their August recess with Senate Democrats working on scheduling post-Labor Day votes that will make up the first portion of what appears a daunting fall agenda.

Even before the recess, the Senate's focus was shifting to Democratic plans to push what could be a massive tax policy package extending trillions of dollars in tax cuts passed in 2001 and 2003. Senate Finance Chairman Max Baucus (D-MT) wants to mark up the package after Labor Day and Democratic leadership aides said Senate Majority Leader Reid (D-NV) hopes to bring it to the floor before October.

In the face of the November midterm elections, that effort could be politically explosive. The bill could pit traditional Republican backing for tax reduction against pressure for deficit reduction that many GOP members are pushing on the campaign trail. A small-business jobs bill is expected to be the first measure on the Senate floor after Labor Day.

With time running short for legislating this year, Sen. Reid on Thursday announced the Senate will convene for a lame-duck session after the election. The Senate will be in session the week of Nov. 15, then off the following week for Thanksgiving. The chamber will return Nov. 29 and remain for an undetermined period. The Senate is scheduled to be in session from Sept. 13 to Oct. 8, then out until Nov. 12 in preparation for the elections.

NAIC will set medical-loss ratios by mid-August

2010-07-27T23:35:00.000-05:00

Officials with the National Association of Insurance Commissioners (NAIC) last week said that they may be able to complete guidelines to define administrative and medical spending under medical-loss ratio (MLR) rules by mid-August. Under the overhaul bill, large health plans will be required to spend at least 85% of premiums on medical services and quality improvement, rather than administrative costs or profits,beginning on Jan. 1, 2011. MLR for individual and small-group health plans must be at least 80%. Although the new law requires the recommendations to be made by year's end, federal health officials had urged the group to submit the draft guidelines by the end of May to give insurance companies ample time to adjust to the new regulations.
Earlier this week, Sen. John Rockefeller (D-WV) sent a letter to NAIC urging the group to resist lobbying efforts by insurers to ease the MLR standards. Following this letter, Sen. Al Franken (D-MN) and Rep. Bill Pascrell (D-NJ) held an event Thursday with "Health Care for America Now" to highlight the liberal group's report on industry lobbying efforts to influence medical loss ratio provisions in the health care reform overhaul law.

Save the Everest - 2011

2010-07-26T19:28:00.004-05:00

   I had the opportunity to meet one of the world's leading climbers, Wongchu Sherpa, during this week's meeting of the Wilderness Medical Society in Snowmass, Colorado. Wongchu Sherpa has summited Everest and many other peaks in the Himalayas. He was immortalized in the 1996 David Brashears IMAX film EVEREST and has continued his work as the chairman and managing director of Peak Promotion Pvt. Ltd. The company specializes in trekking, mountaineering, filming and expedition logistics.

   Wongchu came to Kathmandu in search of his future at the age of 16, leaving his home village of Chyangba, about 500 km north of Kathmandu in the Solu Khumbu District. Through Sherpa friends he eventually found a job as a kitchen assistant with a trekking company, and went on to eventually found his own enterprise, Peak Promotions, in 1992.

   He is a man who believes in giving back to the community. He built Wongchu Biswa Darshan Junior High School, bringing higher education to his community. With the help of David Brashears and Broughton Coburn, he brought electricity and clean drinking water to the village as well. He repaired the Chyangba Gompa (monastery) and helped to establish a health post at this school.

"There is only one life. We don't have a life after this and whatever we earn we must leave here. We cannot take with us. And this is how I will leave what I have earned," says Wongchu Sherpa.

In Photo: Dr. Angela Gardner, Wongchu Sherpa

   Wongchu Sherpa is in the United States to promote the "Save the Everest - 2011" campaign. Since May 29, 1953 when Sir Edmund Hillary and Tenjing Norgay Sherpa reached the peak of Everest for the first time, more than 4500 climbers from eighty countries have climbed Everest, leaving behind a junk yard of oxygen cylinders, abandoned camping equipment, and food packaging debris. Wongchu Sherpa and the Everest Summiteers Association, in conjunction with the government of Nepal, want to change that.

   The goal of "Save the Everest - 2011" is to remove 8 tons of garbage from base camp and high camp by the end of the 2011 Spring Season. Following the cleanup effort, the campaign hopes to establish Everest as a garbage-free zone from base camp to summit, preserving the beauty of the world's most enigmatic mountain for generations to come. The garbage will be brought down by participating national and international expedition teams.

   To learn more about "Save the Everest - 2011" or to support the effort physically or financially, go to www.everestsummiteersassociation.org or send an email to esa@wlink.com.np

ACEP sends letter to Dr. Berwick, CMS

2010-07-23T18:04:00.000-05:00

ACEP sent a letter to newly appointed CMS administrator Dr. Donald Berwick this week. The letter outlines emergency physician concerns with several health care reform law implementation issues and highlights specific provisions of the new law that affect the delivery of emergency care. The letter is as presented here:

July 19, 2010

Donald M. Berwick, MD, MPP, FRCP

Administrator Centers for Medicare & Medicaid Services

200 Independence Avenue, SW

Washington, DC 20201

Dear Dr. Berwick:

On behalf of the American College of Emergency Physicians (ACEP) and our 28,000 members, I want to congratulate you on your appointment as Administrator of the Centers for Medicare & Medicaid Services (CMS). We look forward to working with you and your staff during this critical time that the new health care reform law regulations are being promulgated and we believe your clinical and health care policy experience give you a unique perspective on how these rules may impact the delivery of health care in America.

As an elected member of the Institute of Medicine (IOM), we're sure you are familiar with the 2006 IOM reports on the "Future of Emergency Care in the United States Health System," which detailed the challenges and concerns this nation faces in maintaining access to emergency medical care. As articulated in the IOM reports, America's emergency medical system as a whole is overburdened, underfunded and highly fragmented. As a result, ambulances are diverted from emergency departments once every minute on average and patients in many areas may wait hours, or even days, for hospital beds causing admitted patients to be boarded in the emergency department and redirecting precious emergency care resources away from incoming patients.

Emergency departments in this country handle more than 120 million patient visits per year and utilization of our services continues to steadily increase. As we have learned from observing the evolution of the Massachusetts medical care system, and its near universal coverage, emergency department utilization has actually increased in that state, rather than decreased, as many projected. We believe this is the result of a number of factors, including the federal mandate applied by the Emergency Medical Treatment and Labor Act (EMTALA), the lack of internal medicine physicians and general practitioners in the state, injuries and illnesses that occur after normal physician office business hours, and the fact that emergency departments continue to be the sole source of access to the health care system for many in that state, despite their insurance status. The one true lesson from Massachusetts is that coverage does not equal access.

Frankly, we are concerned that the combination of health care law reforms and the general delay in producing more primary care physicians could potentially overwhelm America's emergency departments, many of which currently operate at or above capacity on a regular basis. In particular, we would like to focus your attention of the followingprovisions of the "Patient Protection and Affordable Care Act" and the "Health Care and Education Reconciliation Act:"

Patient Protections (§10101) - This measure extends the "prudent layperson standard" to group health plans, or issuers of group or individual health plans, which offer hospital emergency department services, as well as eliminates the need for prior authorization and provides parity in coverage and patient co-payments for in- and out-of-network providers. We urge you to consider expanding these important patient protections to grandfathered health plans as well.

Hospital Value-Based Purchasing Program (§3001) – As this program advances, we want to ensure measures that will improve emergency department efficiencies are considered an essential component of this plan.

Improvements to PQRI System (§3002) – Please assure emergency physician measures continue to be available in the PQRI program and that these measures promote integration of clinical reporting using electronic health records, as well as demonstrate both meaningful use of electronic health records and quality of care furnished to the patient.

Value-Based Payment Modifier (Physician Fee Schedule) (§3007) – As CMS develops its own transparent episode grouper software; it must account for the unique delivery aspects of emergency services. In addition, it is critical that future risk-based measures developed by HHS ensure emergency physician measures are applied only to services that are within the control of the physicians.

Medicare Shared Savings Program (§3022) and Payment Bundling (§3023) – We urge you to recognize the important role emergency physicians play in providing the full continuum of care to Medicare beneficiaries. There must be commensurate recognition of these distinctive services as an integral part of any Accountable Care Organization (ACO) and through the coordination of bundled payments for an episode of care.

Distribution of Additional Residency Positions (§5503) – Due to the statutory obligation to provide at least 75% of the redistributed residency positions to primary care or general surgery, it is even more imperative that CMS provide as many of the remaining slots to emergency medicine residency programs. The expected immediate increase in emergency department visits demands that we accelerate the availability of residency-trained emergency physicians in our communities.

National Health Care Workforce Commission (§5101) – The growing disparity between the increasing number of emergency department visits each year and the decreasing number of emergency departments is alarming and of great concern to us and our constituents. We strongly encourage you to highlight the education and training needs of emergency medicine as the commission proceeds.

Patient-Centered Outcomes Research (§6301) – Due to the integral role of emergency physicians in providing all types of care for elderly patients, we ask that the emergency medicine perspective be represented in the identification of research priorities and the establishment and implementation of the research project agenda.

Extension of Medical Malpractice Coverage (§10608) – The law extends Federal Tort Claims Act liability protections to an officer, governing board member, employee or contactor of a free clinic. This is an important recognition of the unique role of those individuals who provide medical services without requiring compensation from the patient. As you know, the federal mandate of the Emergency Medical Treatment and Labor Act (EMTALA) requires emergency department physicians and many on-call specialists to provide similar, and in fact more comprehensive, services as those provided at free clinics with a substantial burden of uncompensated care. We urge you to review the unique requirements on physicians who provide EMTALA- related services and consider how the Federal Tort Claims Act may be applied to ensure the availability of these emergency and on-call physicians.

In addition, we are writing to request your assistance with another matter of significant importance to the coordination and delivery of high-quality medical care in America's emergency departments. Senator Debbie Stabenow (D-MI) has requested a formal response from HHS on her proposal to create a CMS working group that would be responsible for reviewing issues affecting access to emergency care and for developing standards and measures to reduce emergency department boarding and crowding, as well as ambulance diversion. Both of these issues can have dire consequences for patient care and we urge you to develop your response to her request as soon as possible.

Thank you for your consideration of these important issues. As you know, enactment of health care reform was only the first step. We look forward to working with you to ensure the implementation of these laws help our patients receive the best medical care possible, including maintaining access to lifesaving emergency medical services that are so vital to our communities.

Sincerely,

Angela Gardner, MD, FACEP

President

New Medicare Economic Index Changes

2010-07-21T21:27:00.000-05:00

The Medicare Economic Index (MEI) is used in conjunction with the SGR formula to update the physician fee schedule. For 2011, CMS will "rebase" the MEI, i.e. update the base year to 2006 (the most recent year with complete information) to reflect changes in physician expenses and "revise" some of the components or categories that comprise the MEI.

The impact of the proposed MEI changes varies by specialty. Data from the PCPI survey (that ACEP supported and participated in) showed that practice expense (PE) and medical liability costs grew at a faster rate than physician work. Therefore, CMS increased the PE RVUs used in the MEI to 47.44%, malpractice RVUs from 3 to 4%, and reduced work from 52.46%-48.27% of total RVUs.
Because these changes must be budget neutral in overall impact, CMS proposes to reduce the Conversion Factor by 7.9%, rather than reduce work values. Therefore, the proposed payment levels for high practice expense specialties will increase, while payment to low practice cost specialties, such as emergency medicine may decrease slightly.

Primary Care Incentive Program: The health reform law passed in March 2010 created a 10% bonus payment for primary care services performed by specific specialties of family practice, internal medicine, pediatrics, or geriatrics (but not emergency medicine). General surgeons are also eligible for a 10% bonus if they practice in designated shortage areas. Bonus funds are not budget neutral so money will not be taken from other specialties to pay for the bonuses.

Physician Quality Reporting Initiative: CMS is proposing to add 20 new measures to the physician quality reporting initiative (PQRI) and will make 12 additional measures reportable through electronic health records. A list of measures will be provided in the web update. The new law extends the PQRI program through 2014. Payments to eligible professionals will equal 1% of estimated total allowed fee schedule services for 2011 and .05% for 2012-2014. In 2015 the payment is replaced by a penalty of 1.5% for non-reporting. This increases to 2% for 2016 and thereafter.

Imaging: Last year, CMS increased amount of time that complex diagnostic imaging machines (valued at > $1m) are used in practices from 50% of the time to 90% using a 4-year phase-in. The Affordable Care Act changed the amount to 75%. This will affect the technical component only but will reduce practice expenses for many physicians who perform complex imaging services in their offices. The policy will not be phased in and is not budget neutral, meaning that savings will not be redistributed within the fee schedule.

Congress Passes Delay of Scheduled Medicare Cut

2010-06-26T10:20:00.001-05:00

On Thursday, the U.S. House of Representatives approved the legislation (H.R. 3962) that passed in the Senate last week, which postpones cuts to Medicare physicians' reimbursement until November 2010, effectively postponing this issue until after the mid-term elections. The $6.5 billion bill reverses the 21% payment cut that took effect June 18th and affected all Medicare claims dated June 1, 2010 or later, and passed in a 417-1 vote. The measure increases payments by 2.2% for six months, applying retroactively to June 1st. President Obama signed the bill into law this morning, and CMS promises to quickly process retroactive payment claims.

Happy Memorial Day!

2010-05-31T21:07:00.000-05:00

Courtesy of Dr. Andrew Bern

Buy a Bike Helmet

2010-05-21T14:00:00.000-05:00

I was quoted today in an article by the New York Times on the importance of buying and wearing a bicycle helmet. Here is a little light reading as we head into the weekend....

http://well.blogs.nytimes.com/2010/05/21/buying-a-bike-helmet/

Ohio Senate passes limited tort reform

2010-05-20T12:50:00.001-05:00

On May 19th the Ohio Senate passed S.B. 86, a limited tort reform bill, with a bipartisan floor vote of 22-10. Many chapter leaders were involved in the passage of this bill, including Dr. Gary Katz, Ohio ACEP President, and Dr. Catherine Marco, Ohio ACEP Government Affairs Committee Chair. The Chapter conducted a State Senator contact campaign on May 18th to encourage legislators to pass the bill. Ohio Senator Steve Buehrer sponsored this important legislation.

The bill extends limited liability protections for physicians providing emergency care under EMTALA, changing the standard of negligence to that of "reckless disregard" instead of the simple negligence standard used for medical malpractice cases. This support for emergency physicians and on call specialists will improve access to emergency care for patients in Ohio and enhance the practice environment for emergency physicians. The Ohio chapter of ACEP looks forward to introducing the bill in the Ohio House of Representatives in the fall.

ACEP Defends The Use Of Propofol In The ED

2010-05-05T11:26:00.001-05:00

After sending a joint letter that outlined ACEP’s concerns with CMS’ interpretive guidelines on what constitutes anesthesia and who is “qualified” to administer it, ACEP, the Emergency Nurses Association (ENA), and the American Association of Emergency Medicine (AAEM) met April 19 with CMS Survey and Certification staff requesting an exception for emergency departments.

I participated in this meeting, as did ACEP Board Member Dr. David Seaberg and ACEP Committee Chair Dr. Kevin Klauer, along with ENA and AAEM representatives.

CMS staff acknowledged the emergency medicine concerns, emergency physician training in sedation and airway management, and the unique environment of emergency departments, with all un-scheduled patient needs.

After the meeting, additional clinical literature was sent to CMS.

“We didn't expect a response to our request for an exception for EDs at the time of the meeting, but are hopeful that revisions will be made to language as it relates to emergency medicine,” said Barbara Tomar, ACEP’s Federal Affairs Director.

“We will post something to the ACEP website as soon as we hear from CMS, which may be a few months,” she added.

ACEP's current policy on procedural sedation defends the use of Propofol by emergency physicians and can be reviewed at http://acep.org.

Senate Back to Work Today

2010-04-12T14:14:00.000-05:00

The Senate is back to work today after a two week break. There is a scheduled cloture vote that would limit debate on a bill implementing a 30-day freeze to a 21% Medicare cut for doctors. The 21% reimbursement cut for physicians technically took effect April 1, 2010, but CMS has requested that physicians hold billing for two weeks in anticipation of Senate action today.

Republicans and Democrats reached a stalemate on the bill prior to the spring recess, largely based on disagreement about whether the $9.2 billion cost of the bill should be offset. The success of a cloture vote today would allow lawmakers another 20 days to consider a longer extension or a permanent solution to the scheduled reductions. In addition, the more than 200,000 people who lost their jobless benefits on April 5, including subsidies to pay for health insurance through COBRA, would have an opportunity to apply for a one month extension of those benefits.

Democratic leaders have pledged to work to make an extension retroactive to April 1. The American College of Emergency Physicians is working with lawmakers to develop a permanent fix to the situation that leaves emergency physicians facing large Medicare cuts yearly based on a formula that is flawed.

A Message from Dr. Angela Gardner

2010-04-06T22:01:00.000-05:00

In my last President's Podium address, I said 2010 would be a pivotal year for ACEP, as well as for me personally. The fact is, we are not only witnessing history, but taking part in it. Even though many details about the future of national health care reform are yet to be determined, the focus, mission and vision of the American College of Emergency Physicians remain as clear as ever. The need to shore up our nation's emergency departments is more urgent than ever, and we have a lot of work to do.

Emergency departments continue to close. About a month ago, Deaconess Hospital in Cincinnati announced the closure of its emergency department, because millions of dollars in losses have made sustaining it impossible. St. Vincent's Hospital, an icon of emergency care in New York City, announced it may close its emergency department. And right in the shadow of the U.S. Capitol, United Medical Center in Washington, DC, is on the brink of failure. The U.S. Government Accountability Office last year released a report that found emergency patients who need to be seen in 1 to 14 minutes are being seen in twice that timeframe (37 minutes), These closures and disturbing statistics are unacceptable.

We must continue to advocate on behalf of emergency physicians and our patients to ensure we will be able to provide high-quality emergency care. For you, an ACEP spokesperson, that means continuing to stay in the public eye, as well as stay on message.

Dr. Angela Gardner about to meet President Obama following a health care reform address in the White House.

In February, ACEP's Board of Directors traveled to Washington, DC, and met with members of Congress, the Administration and key players in the health care industry, such as the American Hospital Association. This trip was a huge success, with ACEP converging in high-level meetings throughout the nation's capital and making key people aware of the critical problems facing emergency physicians and emergency patients.

A few weeks later, I was invited back to Washington - this time at the invitation of the White House. I was honored with a front-row seat in the East Room as President Obama made a major address on the state of health care reform. ACEP's president-elect Dr. Sandra Schneider, as well as Drs. Nathan Schlicher and Bruce Auerbach also attended the event.

Our presence at the White House was not an endorsement of the Obama plan, but it shows all how far we have come - that the specialty organization of emergency medicine is at the table with representatives of the highest levels of government and the health care industry. As determined spokespeople, you have helped make that possible. You are the voice of ACEP, and there has never been a more crucial time to speak out on behalf of our specialty and our patients.

Sincerely,
Angela Gardner, MD FACEP
President, ACEP

EMF Announces Medical Director of the Year

2010-04-05T17:15:00.000-05:00

Blue Jay Consulting and the Emergency Medicine Foundation announced today that Dr. Rex G. Mathew of Thomas Jefferson University Hospital, in Philadelphia, PA, has been named Emergency Department Director of the Year and honored three additional finalists for the award.

“We are proud to announce that Dr. Rex Mathew was selected as the Emergency Department Director of the Year,” said Mark J. Feinberg, Managing Partner, Blue Jay Consulting. “We received numerous, very impressive nominations and are pleased to honor Dr. Mathew and the finalists for their contributions to their discipline. They labored tirelessly to improve processes, demonstrated a superior level of expertise, and worked with their team to enhance patient care. We look forward to seeing these doctors fulfill their limitless potentials as they continue to provide patients and the hospitals they serve with the utmost efficiency, clinical standards, education and community service.”

This new annual award created by Blue Jay Consulting recognizes current emergency department physician leaders who made significant impacts on improving the operations of his/her departments, resulting in improvements in the quality of patient care. The award winner and finalists were chosen from nearly 80 nominations from across the country, including some overseas, by a selection panel composed of appointees from Blue Jay Consulting and the Emergency Medicine Foundation.

The winner and finalists demonstrated significant contributions to their emergency department in the following categories: quality patient care, operational effectiveness, education, and community service. They demonstrated collaborative relationships with nursing and ancillary departments to implement and improve operational and clinical standards based on evidence-based practice. They also stood out for their abilities to create and sustain high degrees of patient satisfaction, while implementing creative and innovative strategies to address emergency department throughput.

Linda Lawrence, MD, FACEP, EMF board member, will honor the winner on April 26, 2010, at the American College of Emergency Physicians Emergency Department Director’s Academy, Phase II.

This year’s winner, Rex G. Mathew, MD, FACEP, is vice president of emergency medicine clinical operations at Thomas Jefferson University Hospital, a Level 1 Trauma Center in Philadelphia. Dr. Mathew displayed his leadership abilities, combined with his clinical knowledge, to work with leaders throughout the hospital to improve care in the emergency department. He fulfills a unique roll for the department and the hospital as both an administrator and a practicing physician. Having his “feet in both doors” has enabled him to make a positive impact on his patients and fellow clinicians. In addition, Dr. Mathew was instrumental in developing many quality improvement projects including the newly accredited Thomas Jefferson Chest Pain Center.

“The emergency department director not only sets the tone and direction for the emergency department, but serves as the point person to satisfy patient’s needs and provide safe, quality care,” said EMF Chair, Alexander Rosenau, DO, FACEP. “Because the emergency department serves as the safety net for our community, emergency directors’ roles are invaluable and a service that the community needs 24/7. We are pleased to honor Dr. Mathew as he demonstrates that emergency medicine is a team sport and provides the quality care that patients come to expect.”

The two organizations applauded this year’s finalists who are listed alphabetically:

Patrick J. Crocker, DO, MS, FACEP, is the chief, of emergency medicine at Dell Children’s Medical Center of Central Texas in Austin, TX. Dr. Crocker was instrumental in working across disciplines to create the Comfort Zone Program, which addresses the comfort, anxiety and pain perception of patients. In addition, he worked closely with emergency nursing leadership to adopt high standards of professional performance and conduct.

William Dalsey, MD, MBA, FACEP, is the chairman of the department of emergency medicine at Kimball Medical Center in Lakewood, NJ. Dr. Dalsey’s collaborative approach to patient care earned Kimball Medical Center top honors for the last five years in patient satisfaction scores by Press Ganey. In addition, Dr. Dalsey and the nurse manager transformed emergency operational efficiency to reduce door-to-doctor times, as well as overall throughput while never compromising quality. His “no wait ED’’ was one of the first of its kind.

Paul Ernest Pepe, MD, MPH, FACEP, is the chief of emergency services at Parkland Health & Hospital System in Dallas, Texas. Dr. Pepe’s strong team philosophy stood out in his application. Both he and Jennifer Sharpe, RN, director of nursing, were recognized because they epitomize the work ethic and philosophical temperament that guaranteed the tremendously successful journey to better patient care and enhanced community service at one of the most visible emergency care centers. Dr. Pepe is an award-winning physician who serves as an inspirational mentor.

Call for Unity

2010-03-21T15:01:00.001-05:00

Today’s health care reform vote on Capitol Hill, while high drama, really only signals the beginning of the work that needs to be done by emergency physicians to improve access to emergency care for our patients and future patients. As I write this, I am watching the floor deliberations via the miracle of technology, and I know that the outcome will disappoint 48% of ACEP members, 48% of all physicians, and 48% of the American public, if polls are to be believed......and that will occur regardless of the outcome.

The greatness of our democracy lies in the ability of our people to freely elect their government representatives and to express themselves fully in the debate over crucial issues. Never in my lifetime has this been more apparent than during the health care reform debate. I believe that almost everyone has an opinion on health care, including many non-Americans, and almost everyone has expressed that opinion at some point.

The real challenge to our democracy, to our specialty, and to our organization is to move forward once today’s vote has been taken. We must have great care not to fall victim to Jefferson’s “tyranny of the minority.” We must move forward to create the greatest health care system in the world, befitting the greatest nation in the world, no matter the outcome of today’s vote.

There is no “win” today for emergency medicine. There is only new illumination on the path to achieving better emergency care. The real work comes as we identify areas that need our skills in innovation and problem-solving and get to work shoring up the nation’s emergency care system. My fervent wish is that emergency physicians will find a common bond in the needs of our patients, and put the rancor and division of the path to health care reform behind us in the interest of better emergency care for everyone.

Am I A Traitor To Shake Hands With President Obama?

2010-03-04T18:50:00.002-06:00

Photo courtesy of Dr. Andrew Bern

Yesterday I had the great pleasure of attending an event at the White House at the invitation of President Obama. I was surprised to learn that my attendance at the recent Presidential address in the East Room has caused some members to threaten to leave ACEP. It is of concern to me that some members feel this way, in spite of the existence of a well-publicized advocacy agenda that focuses on improved access to health care for all Americans. Being invited to and attending an event at the White House in no way implies wholesale endorsement of the President’s health care reform proposal or any other proposal.

Let me say that being invited to attend an event at the White House, being able to have a few words and shake the hand of the President of the United States, being able to have a short conversation with Secretary Sebelius, and having the opportunity to meet and discuss strategy with my counterparts in the major specialty organizations in medicine was a unique and productive opportunity. I think it important that representatives of the college be able to take advantage of such opportunities without fear of members quitting the college over the action, not the substance, of the visit.

A dose of reality is needed here. We are a 28,000 member organization. It is a matter of pride that we have developed a respected and requested voice in Washington D.C. health policy. However, declining an invitation to the White House would gain nothing for our patients and for our members. Hopefully, our members will understand and respect that fact.

Lastly, attending the President’s announcement of his new health care reform plan and applauding his request that Congress take action sooner rather than later does not imply that the American College of Emergency Physicians endorses carte blanche every aspect of that proposal. We will continue to work tirelessly to ensure that health reforms include provisions that improve the health and well-being of our patients and our member physicians.

It is a challenge to lead an organization as diverse and as divided as ours is at this moment in time. We are a representative organization, and I ask those of you with concerns about the policies of the college to speak up, get involved, make your perspective known to your Chapter president, the Council, your Board of Directors, and to me. One opinion will not have the opportunity to be heard in the density of Washington politics, but many voices joined together to promote better emergency care for all can change the course of history.

Please join me in that pursuit.

Physicians Face 21% Payment Cut at Midnight

2010-02-28T17:35:00.003-06:00

The fight over the flawed SGR (Sustainable Growth Rate) formula is familiar to physicians. Every year the scheduled cut in fees increases, and every year physicians fight for and eventually obtain a postponement. Friday, the House passed HR 4691, legislation that extends a number of expiring programs for 30 days, including current Medicare physician payment rates, which would once again postpone the 21% cut that was scheduled to take effect this year. The Senate attempted unsuccessfully on several occasions Friday night and Saturday morning to pass the same bill by unanimous consent, but objections were raised by Senator Jim Bunning (R-KY), on the basis that $10 billion cost of the program extensions was not offset . The Senate has adjourned for the weekend, so the 21% Medicare physician payment cut will be effective on Monday, March 1.

The Centers for Medicare and Medicaid Services (CMS) are notifying their contractors to hold Medicare physician claims for 10 business days, effective Monday. The agency will also be sending out a similar message on its various list serves this afternoon to physicians, and contractors will be instructed to disseminate this information as well.

Senate Democratic leaders likely will need to use the cloture process requiring 60 votes to overcome Sen. Bunning's objections. Completing those procedural steps will push final action on the measure into next week.

In The Shadow of the Summit: The Prospect of Health Care Reform in 2010

2010-02-25T17:24:00.001-06:00

In spite of Max Baucus’ repeated assurances that “we’re just not that far apart,” the Democrats seem unable to find common ground with Republicans on the issue of health care reform. President Obama seems to be the only person in the discussion who believes there is agreement on the basic premise – that health care reform is needed. In fact, Rep Hoyer alluded to the notion that only costs need to be contained, and Harry Reid referred to the insurance industry as the “creator of the current health care environment.” Taken altogether, the participants in today’s summit at Blair House did little to dispel the notion that the entire event amounts to little more than political theatre.

There is speculation among the Hill watchers in the nation’s capitol that President Obama’s production today is simply the overture, and that the real performance will begin shortly in the guise of the reconciliation process. There are also pundits who predict that the President will proceed with small health care bills of the “Mom-and-apple-pie” variety. The goal, ostensibly, is to create legislation that improves the health care environment and appeals to enough Republicans to allow for passage. The passage of a jobs bill with the support of five notable Republicans this week portends well for this strategy.

The eventual outcome for health care reform in this presidency remains unpredictable. There is no doubt that both parties regard the coming mid-term elections as a barometer of the political will for reform and increasingly view health reform rhetoric as a key component of the campaign process. Republicans increasingly project the mid-term elections as a mandate to defeat health care reform at all costs.

Recent polls suggest that the American public is “angry” or “negative” on the subject of health care reform, although the most common reasons given for this in a recent Washington Post poll are the failure to address the economic situation, the continued high rate of unemployment, and frustration with the health care reform process rather than satisfaction with the current health care climate. Public reaction to the summit in the coming days will likely give some indication of whether the Republican strategy will pay off, continuing the stalemate in reform or whether they will suffer negative the negative consequences of obstructionism in the name of party politics.

My Last Day.....by David Darrigan

2010-02-05T20:44:00.003-06:00

Today I accompanied Dr. Gardner on her day trip to Austin. The Texas Medical Board was discussing rule 164.4, which deals with advertising the term “board certified” in Texas. Advertising involves how a physician identifies himself or herself to peers and hospitals, on the web, in print, and in the media. A hot debate arose from the issue. Many influential leaders testified, including Dr. Gardner. Towards the end of the debate, the board was gracious enough to let me throw my thoughts into the discussion. Being able to see the board in action and speak to them was a quite an experience.

Afterwards we went to tour the Texas Medical Association (TMA) building. The building, staff, and the work that gets accomplished there were impressive. The TMA has developed a new leadership development program, the Texas Medical Association Leadership College. It is designed to train young physicians for future leadership positions.

Next up was visiting the Texas College of Emergency Physicians headquarters. Nancy Davis and Jim Coles showed us a great time. The building has been a wonderful investment, and everyone is hard at work preparing the upcoming TCEP annual meeting this April in Frisco.

What’s next for me? It’s time to go back to being a grunt doc working in the trenches. The lessons I learned on this policy elective will allow me to better understand the big picture in medicine, and it will help me be a more informed practitioner. There are a lot of hard working physicians that work behind the scenes to allow us to do what we do best...taking care of patients. Their job is not easy, and I thank them.

-David Darrigan, DO

Photo: Dr. David Darrigan and Dr. David Mendelson at TCEP Headquarters by Angela Gardner

What Next for Health Care?

2010-01-27T19:55:00.000-06:00

The popular news of the day on the healthcare front is that Congressional Democrats have a strategy in place that would pass the Senate bill and then use the budget reconciliation process to make necessary changes. The reconciliation process is complicated. Because of its rules, some of the changes that need to be made for a compromise might not be possible. If these key provisions aren’t included, then the House likely will not have the votes needed to finalize the bill into law.

An interesting poll was taken in Massachusetts after the election of Mr. Brown. The poll showed that 68% of the voters said they supported THEIR states health plan. A little more than half of the 68% voted for Mr. Brown. Also, it has been reported that Mr. Brown himself voted for the Massachusetts health program in 2006. He didn’t campaign against his states plan this year, but he vowed to block reform in Washington. Doesn’t make a lot of sense does it?

-David Darrigan, D.O.

What Brown's Election Means for Health Care

2010-01-20T15:23:00.002-06:00

Oh how I miss you Ted! The senate seat that was filled for so long by one of the biggest, if not THE biggest, supporter of healthcare reform is gone. State Sen. Scott Brown's (R-MA) win and takeover of Mr. Kennedy’s seat has huge repercussions. This seat has been Democratic for 50 years. That is a huge momentum swinger for the Republicans.

What does this mean? The Democrats 60-vote filibuster-proof majority in the Senate is gone. Mr. Brown has been campaigning on the message that he would be the 41st vote in the Senate AGAINST passage of the Democrats' plans for health reform. In all likelihood, the Dems need all 60 votes to pass meaningful healthcare reform.

Backup plans??

1.) Democrats are contemplating trying to pass the bill before Mr. Brown’s seat gets confirmed. That takes about 15 days, so it isn’t very likely. Plus, rushing a bill through could look bad to the public and give the Republicans ammunition to eventually overturn whatever is passed.

2.) Another option on the table is to have the House pass the Senate bill, and then use a procedural rule known as "budget reconciliation" to amend it later on. This is not a great option because reconciliation is a long and complicated problem that lawmakers would rather avoid.

3.) Get the vote somewhere else. Who will be the brave Republican to step up to the plate and save the country of a reform blockage.....which when you break it down is saving lives. Many more than I could ever imagine saving in my career...in one simple vote. Come on Olympia Snowe...the country needs you.

What I hope comes out of this is for the Republican’s to step up and start helping fix the problem of healthcare reform. Right now they have done a good job of "Just say NO.” We all know the current system cannot be sustained. I don’t believe the public will allow for a complete blockage of healthcare reform. As one of my mentors always says, “Knowing the answer is the easy part, making it happen is the hard part.” Maybe it all starts with tort reform...I don’t know. Now that they have the seat...It’s time for them to bring something to the table.

David Darrigan, DO

Ed. Note: Dr. Darrigan’s post reflects his personal opinions, and not necessarily those of the American College of Emergency Physicians.

George Stephanopoulus spoke with President Obama today, and reports that the President was not “waving the white flag,” but seemed focused on finding a “peaceful” solution to controversy about health care. AFG

Health Care Reform: On The Brink?

2010-01-15T12:55:00.001-06:00

Congressional leaders hope to reach a deal on the broad outlines of a final health care bill by late today. The bill would go to the Congressional Budget Office for a cost analysis, which must be completed before Congress can act. While the CBO is doing its calculations, lawmakers plan to resolve issues that don’t affect cost, like immigration and abortion.

The White House and Congressional leaders have reached a tentative deal on a proposed excise tax on high-cost, employer-sponsored insurance plans. Immediate details of the tentative agreement were not provided, but it is expected to include an increase in the thresholds at which policies are hit by the tax.

House Democratic leaders are pushing for more generous subsidies to help make health insurance affordable to a greater number of middle-class households, as well as other concessions. Future blog posts will address those plans as they develop.

Nineteen Senate Democrats on Wednesday released a letter calling for a provision in final health reform legislation to repeal the insurance industry's longstanding exemption from antitrust laws. The letter comes shortly after a report that several large insurers quietly contributed millions of dollars to help fund an advertising campaign against health reform legislation. The House's health reform bill (HR 3962) includes a provision to eliminate the antitrust exemption, but the Senate bill (HR 3590) does not.

The fight over whether states or the federal government should run proposed health insurance marketplaces is heating up. The House would establish a national exchange run by the federal government. They would set a uniform program that would help protect consumers. The Senate wants each state to create and run its own exchange. They feel states have more experience overseeing insurance plans and know their residents’ needs better. Besides the details of the fed vs state approaches, there are major political overtones at the backbone of the debate. Liberal Democrats are angry that the public option is all but certain to be omitted from the final package, and they want the federal government to have as much power over insurers as possible.

David Darrigan, DO

Health Care Reform: Get It Over With?

2010-01-14T09:44:00.002-06:00

This month Gardner's Gate is proud to present a guest blogger, Dr. David Darrigan, D.O. Dr. Darrigan is a resident at the University of Texas Southwestern emergency medicine program, in his final year. He is currently participating in the "Emergency Medicine Policy, Politics, and Advocacy" elective. Please welcome him in his first guest blog............

Chances are if you are reading this blog, you probably can’t get enough of the exciting developments in healthcare reform. That sentiment doesn’t hold true with everyone, though. "Healthcare: Get it over with," is the message Rep. Marcy Kaptur (D-Ohio) said she got from voters in her economically ravaged district over the holiday recess. With so many big issues affecting the country right now, Democrats are feeling pressure from various lobbyists and voters to get a compromise and move on.

It looks like the “Cadillac Tax” on high-end health care plans won’t be in the final bill after all. House Democrats have pushed back over the Senate’s proposal to tax generous health-insurance plans, and it appears they have won. The two sides are trying to form a compromise that would lessen the burden on the middle class. One big issue is that some union members have high-value health plans, and opposition from unions could be politically problematic.

Senate Majority Leader Harry Reid is on the brink of delivering a national health program that some rank alongside the formation of Medicare and Social Security. Sounds like something that would land you a nice page in the history books...but not so fast. In Nevada, that very achievement is imperiling his re-election prospects. The health care debate is very polarizing, and the man at the top of the matter will undoubtedly take most of the heat. Combine this with the conservative nature of Nevada, its tough economy, the 3rd highest unemployment rate in the country, and the 2nd highest foreclosure rate in the country....well let’s just say Mr. Reid has more on his plate than you would think.

It was recently reported that from September to December 2009, six of the nation's largest health insurers companies contributed between $10 million and $20 million to the Chamber of Commerce for television advertisements aimed at killing or changing health reform legislation. So you mean to tell me that insurance companies were financing anti-reform messages while publicly endorsing reform effort??? I believe that is called “two faced.” And I thought they were so honest.....

The White House wants to include a national health-insurance exchange in the health bill. At issue is who would run the new insurance exchanges that would allow consumers to comparison-shop for health coverage. The House version of the health reform calls for the federal government to run a single, national exchange, while the Senate version allows states run their own exchanges.

A few of my own thoughts: So if there is no public option, “Cadillac plans” don’t get taxed, and we are all required to purchase private insurance....then it looks like the big winners will be..... the health insurance companies???? Unfortunate and ironic. I miss the public option before it was even born.

David R. Darrigan, DO

2010 Council Steering Committee Convenes

2010-01-12T09:50:00.001-06:00

Dr. Arlo Weltge, MD, MPH, FACEP convenes the ACEP 2010 Steering Committee today at headquarters in Dallas, Texas. Dr. Weltge, who serves as the Council Speaker, is from Houston, Texas. He is assisted by Council Vice-Speaker Dr. Marco Coppola, DO, FACEP, who practices in Fort Worth, Texas.

The Steering Committee reviews the results of the Council Meeting held in Boston, Massachusetts in October 2009 and makes recommendations to improve future Council deliberations. In addition, the Speaker, Vice-Speaker and Steering Committee supervise the election process for the American College of Emergency Physicians.

The members of the 2010 Council Steering Committee are:

Dr. Ashley Booth Norse, MD, FACEP

Jacksonville, Florida

Dr. Stephen A.D. Grant, MD, FACEP

Aiken, South Carolina

Dr. Theresa Gunnarson, MD, FACEP

Orr, Minnesota

Dr. Kenneth L. Holbert, MD, FACEP

Smyrna, Tennessee

Dr. Kaedrea Jackson, MD, MPH

Brooklyn, New York

Dr. David P. John, MD, FACEP

Dorchester, Massachusetts

Dr. Terry Kowalenko, MD, FACEP

Brighton, Michigan

Dr. Eric E. Maur, MD

Danville, Pennsylvania

Dr. John G. McManus, MD, FACEP

San Antonio, Texas

Dr. William J. Meggs, MD, FACEP

Greenville, North Carolina

Dr. Abhishek Mehrotra, MD, FACEP

Chapel Hill, North Carolina

Dr. John J. Rogers, MD, FACEP

Macon, Georgia

Dr. Peter E. Sokolove, MD, FACEP

Sacramento, California

Dr. Christopher S. Weaver, MD, FACEP

Indianapolis, Indiana

Dr. Jennifer L. Wiler, MD, MBA

St. Louis, Missouri

Dr. James Williams, DO, FACEP

San Antonio, Texas

The American College of Emergency Physicians 2010 Council will have 1429 Councilors from across the nation, who will meet to discuss the issues facing emergency medicine and recommend policy to the Board of Directors. That meeting will take place September 26– 27, 2010 in Las Vegas, Nevada.

Emergency Medicine in the Health Reform Bills

2009-12-30T22:32:00.003-06:00

Work continues in D.C. to produce a health reform package to send the president. Here is a short summary of the provisions that directly concern emergency medicine:

Both the House bill (HR 3962) and the Senate bill (HR3590) contain the following elements:

*Include emergency services as part of an essential health care benefits package.

*Contain emergency care/trauma regionalization pilot project grants.

*Contain trauma stabilization grants.

*Include the HHS demo project to reimburse private psychiatric hospitals that provide EMTALA services to Medicaid beneficiaries.

The House bill contains these elements:

*Quality improvement measures for ED patient through put.

*Statutory authorization for ECCC & ECCC Council of Emergency Medicine.

*HHS annual report to Congress on ECCC activities with focus on ED crowding/boarding and delays in ED care.

*Establishes HHS incentive payments to states that establish medical liability reforms such as Certificate of Merit or early offer.

The Senate bill contains these elements:

*Directs Secretary of HHS to expand emergency medicine research and pediatric emergency medicine research at NIH, AHRQ, HRSA, CDC, et. al.

*Reauthorizes EMSC for five years

*Requires Exchange health plans to provide emergency services without regard to prior authorization or the contractual relationship to the Emergency Physician or the Emergency Physician Group

*Applies the Patient's Bill of Rights and the prudent layperson standard to all health care plans

In addition there was a provision for an HHS working group to develop ED boarding and ambulance diversion standards and to develop quality measures for hospitals to improve ED efficiency and patient flow. This will be addressed administratively, so it is no longer necessary to provide this in the legislative language.

ACEP fought hard for a time extension for Section 1011 (Federal reimbursement of emergency health services provided to individuals not lawfully present in the U.S.) It was not included in the Senate Manager's amendment. It may still be considered as the House-Senate Conference negotiations continue.

As the negotiations continue through the holidays and into the New Year, I'll keep you posted on the latest changes.

Breaking News from Capitol Hill

2009-12-16T14:33:00.001-06:00

......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

2009-12-09T23:18:00.002-06:00

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

2009-12-08T17:05:00.004-06:00

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

2009-12-07T13:44:00.001-06:00

http://www.youtube.com/emergencycareforyou

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

Senate Stall

2009-12-03T11:36:00.002-06:00

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

2009-12-01T19:22:00.000-06:00

Texas Recognizes ABPS Certification

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

Senate Begins Debate On Health Reform

2009-11-30T17:37:00.003-06:00

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?

2009-11-26T21:47:00.004-06:00

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?

2009-11-08T08:14:00.002-06:00

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

2009-10-19T22:57:00.002-05:00

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.

2009-09-25T22:16:00.000-05:00

file:///Users/angelagardner/Desktop/Screen%20shot%202009-09-25%20at%2010.15.53%20PM.png

An Open Letter from America’s Emergency Physicians

2009-09-22T21:22:00.009-05:00

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?

2009-09-17T14:51:00.001-05:00

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

2009-09-08T09:57:00.003-05:00

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

2009-08-10T13:55:00.003-05:00

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

2009-06-17T08:47:00.001-05:00

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?

2009-05-22T14:59:00.003-05:00

"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

2009-05-19T08:59:00.003-05:00

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

2009-04-30T21:50:00.001-05:00

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

2009-04-25T08:53:00.001-05:00

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!

2009-04-17T18:51:00.000-05:00

Gardner's Gate: HAPPY 100TH EPISODE!

HAPPY 100TH EPISODE!

2009-04-17T18:47:00.002-05:00

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

2009-04-15T05:08:00.002-05:00

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)

Obama Creates Office of Health Reform

2009-04-09T20:25:00.002-05:00

Yesterday President Obama established the White House Office of Health Reform. Obama signed an executive order formally creating the new office and assigning the task of expanding and improving health coverage in America.

In March, Obama named former Clinton administration official Nancy-Ann DeParle to oversee the office. DeParle will have wide latitude in establishing a team to accomplish Obama's goals, and unlike cabinet secretaries, she will not answer to Congress. Ms. DeParle's duties include working with Congressional leaders to enact health reform legislation, coordinating relevant activities with all executive branch agencies, establishing working relationships with state and local officials, and eventually, supervising the implementation of health policy changes.

EXECUTIVE ORDER:

ESTABLISHMENT OF THE WHITE HOUSE OFFICE OF HEALTH REFORM

By the authority vested in me as President by the Constitution and the laws of the United States of America, and in the interest of providing all Americans access to affordable and high-quality health care, it is hereby ordered as follows:

Section 1. Policy.

Reforming the health care system is a key goal of my Administration. The health care system suffers from serious and pervasive problems; access to health care is constrained by high and rising costs; and the quality of care is not consistent and must be improved, in order to improve the health of our citizens and our economic security.

Sec. 2. Establishment.

(a) There is established a White House Office of Health Reform (Health Reform Office) within the Executive Office of the President that will provide leadership to the executive branch in establishing policies, priorities, and objectives for the Federal Government's comprehensive effort to improve access to health care, the quality of such care, and the sustainability of the health care system.

(b) The Secretary of Health and Human Services, to the extent permitted by law, shall establish within the Department of Health and Human Services (HHS) an Office of Health Reform, which shall coordinate closely with the White House Office of Health Reform.

Sec. 3. Functions. The principal functions of the Health Reform Office, to the extent permitted by law, are to:

(a) provide leadership for and to coordinate the development of the Administration's policy agenda across executive departments and agencies concerning the provision of high-quality, affordable, and accessible health care and to slow the growth of health costs; this shall include coordinating policy development with the Domestic Policy Council, National Economic Council, Council of Economic Advisers, Office of Management and Budget, HHS, Office of Personnel Management, and such other executive departments and agencies as the Director of the Health Reform Office may deem appropriate;

(b) work with executive departments and agencies to ensure that Federal Government policy decisions and programs are consistent with the President's stated goals with respect to health reform;

(d) coordinate public outreach activities conducted by executive departments and agencies designed to gather input from the public, from demonstration and pilot projects, and from public-private partnerships on the problems and priorities for policy measures designed to meet the President's goals for improvement of the health care system;

(e) bring to the President's attention concerns, ideas, and policy options for strengthening, increasing the efficiency, and improving the quality of the health care system;

(f) work with State, local, and community policymakers and public officials to expand coverage, improve quality and efficiency, and slow the growth of health costs;

(g) develop and implement strategic initiatives under the President's agenda to strengthen the public agencies and private organizations that can improve the performance of the health care system;

(h) work with the Congress and executive departments and agencies to eliminate unnecessary legislative, regulatory, and other bureaucratic barriers that impede effective delivery of efficient and high-quality health care;

(i) monitor implementation of the President's agenda on health reform; and

(j) help ensure that policymakers across the executive branch work toward the President's health care agenda.(h) work with the Congress and executive departments and agencies to eliminate unnecessary legislative, regulatory, and other bureaucratic barriers that impede effective delivery of efficient and high-quality health care;

(i) monitor implementation of the President's agenda on health reform; and

(j) help ensure that policymakers across the executive branch work toward the President's health care agenda.

Sec. 4. Administration.

(a) The Health Reform Office may work with established or ad hoc committees, task forces, or interagency groups.

(b) The Health Reform Office shall have a staff headed by the Director of the Health Reform Office (Director). The Health Reform Office shall have such staff and other assistance as may be necessary to carry out the provisions of this order.

(c) As requested by the Director, each executive department and agency shall designate a liaison to work with the Health Reform Office on improving access to health care, the quality of health care, and the sustainability of the health care system.

(d) All executive departments and agencies shall cooperate with the Health Reform Office and provide such information, support, and assistance to the Health Reform Office as it may request, to the extent permitted by law.

Sec. 5. General Provisions.

(a) Nothing in this order shall be construed to impair or otherwise affect:

(i) authority granted by law to a department, agency, or the head thereof; or

(ii) functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.

(b) This order shall be implemented consistent with applicable law and subject to the availability of appropriations.

(c) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity, by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.

BARACK OBAMA
THE WHITE HOUSE,
April 8, 2009.

Thank You Tennessee!

2009-04-01T20:29:00.002-05:00

Thank you to the Tennessee College of Emergency Physicians for inviting me to speak and hosting me at their annual meeting in Chattanooga, Tennessee. My special thanks to my dear friend Sandy Herman, who organized the excellent program, and was generous enough to include me. I gave an update on health care reform, and in a separate lecture provided a review of the latest literature affecting wilderness medicine. My favorite part of the meeting, though, was participating in a luncheon panel discussion with Greg Henry, Todd Taylor, and David Seaberg, moderated (refereed?) by Sandy Herman. None of are shy, and the ensuing debate was lively. (....and just for the record, Greg, you ARE wrong.)

I also would like to express my appreciation to David and Carol Seaberg, who invited me into their home, treated me to wonderful food and great company, and took me to Rock City. The Seaberg’s sons, Ryan and Tyler, showed me the secrets of the boulders atop Lookout Mountain with all the energy and enthusiasm that teenage boys have. Who could resist the dare to follow a narrow path, appropriately named “Fat Man’s Squeeze,” between two giant boulders on the way up the mountain? I stood near the top of that mountain, in front of a green waterfall, and saw seven states. It doesn’t get any better than that.

I spoke with representatives of the Tennessee Emergency Management Agency, who expressed dismay that Tennessee ranked 51^st in disaster preparedness in the recently released National Report Card on the State of Emergency Medicine. They presented the Tennessee disaster preparedness program to the group, vigorously defending their preparedness and their integration with physicians and hospitals. My defense of the Report Card is based on the methodology. Tennessee received the ranking based on the metrics chosen by a group of emergency medicine experts, and based on the data available at the time from public sources. Their presentation revealed a disaster plan that appears cohesive and well-considered, and does have some physician involvement. If nothing else, the controversy caused by the Report Card led to a better dialogue and a better working relationship between TEMA and the emergency physicians of Tennessee. If the result is better disaster planning, then the Report Card has served its purpose.

Again, I thank the Board of the Tennessee College of Emergency Physicians, their president, Dr. Kenneth Holbert, and my many old friends from Tennessee – John Proctor, Bob Roth, Sandy Herman, Harry Severans, Jim Creel, David Seaberg, and too many others to name – for a wonderful experience. Tennessee Rocks!

White House Report on Health Reform

2009-03-30T17:09:00.000-05:00

Today the White House issued the Forum on Health Reform Report. It is a summary of the events of March 5, 2009, and includes the remarks of President Obama, the findings of the “breakout sessions,” and a transcript of the Town Hall session. I won’t repeat the report here. All 54 pages are available at www.whitehouse.gov/assets/documents/White_House_Forum_on_Health_Reform_Report. His attendees included representatives from Congress, physician groups, the insurance industry, the hospital industry, and the private/business sector. I do applaud the president on a carefully orchestrated public display of unity on a topic that is inherently divisive.

Several common themes appear in the text of the breakout sessions. The participants stressed the need for:

Access

Quality

Fair Payment/Reimbursement

Incidentally, those are three of the Priority Objectives for 2008-2009 for the American College of Emergency Physicians.

Not among ACEP Priority Objectives, but also stressed by participants in President Obama’s were:

Cost control

Expanded (insurance) coverage

Prevention of illness/Promotion of health

Each group expressed urgency in the need for reform to the delivery system for health care in this country.

I witnessed the press event on March 5, 2009, and I read the report eagerly. Both times I found something missing: EMERGENCY MEDICINE. One hundred and nineteen MILLION patients seek emergency care every year in this country, and the only words spoken about emergency medicine were these, “Now, keep in mind, we’re already paying for those folks. Every single person at home, the average family

is paying $900 per family in additional premiums because of the care that people are receiving in emergency rooms. So we’re paying for it, but it’s oftentimes hidden.”

Mr. President, if you’re paying for it, I’d like to know where the money is going. One of the problems in emergency medicine is the fact that emergency physicians are required by EMTALA to provide care for all who present with an emergency condition, without regard for payment. Emergency physicians are not paid for that care forty percent of the time. I dare you to name another specialty that donates forty percent of their income to charity care.

I do not care to come across as another doctor whining about not making enough money. I love my specialty, I love the practice of medicine, and I would rather spend seven night shifts in an row in an emergency department than spend one day as ......[fill in any specialty here.] However, if we are to have health reform in America, some unpleasant truths must be told. One of those unpleasant truths is that the system for delivery of emergency care is strained to the breaking point. If meaningful discussion of reform is to be had, emergency physicians must be included. The U.S. population was 263 million at the last census, and 119 million people seek emergency care each year. You do the math.....

A Day at NASA

2009-03-21T08:28:00.004-05:00

I had the pleasure of spending a day at NASA this week. I met Dr. Joseph P. Kerwin, M.D. (Captain, MC, USN, Ret.), the first physician astronaut to serve with the National Aeronautics and Space Administration. Dr. Kerwin has had a long and varied career. He logged 4500 hours flight time as flight surgeon before being selected by NASA in 1965. He served as science-pilot for the Skylab 2 (SL-2) mission, and subsequently managed the on-orbit branch of the Astronaut Office, where he coordinated astronaut activity involving rendezvous, satellite deployment and retrieval, and other Shuttle payload operations. He later served as Director of Space and Life Sciences at the Johnson Space Center, Houston. In that capacity he was responsible for direction and coordination of medical support to operational manned spacecraft programs, including health care and maintenance of the astronauts and their families; for direction of life services, and for managing Johnson Space Center earth sciences research, light experimentation projects, and scientific efforts in lunar and planetary research.

We compared notes on our respective fields, and on the progress that has been made in medicine in the past 50 years. Dr. Kerwin told me, “The only difference between your specialty and mine is that I made house calls.” I guess that’s true, but I think most people would consider a house call thousands of miles away in space an adventure. Dr. Kerwin is the co-author of “Homesteading Space: The Skylab Story,” a compelling tale of the Skylab from the near-disastrous launch to the descent into the Indian Ocean.

I had the opportunity to tour the historic Mission Control, and I admit to developing a lump in my throat at the thought of the teams who labored tirelessly and risked their personal safety to send human beings into space. Every mission was an exercise in learning......learning the tasks necessary to live in a weightless environment, learning the mechanical skills to manage spacecraft, learning the nuances of flight. In the early days of the space program every person had a singular focus – get a man on the moon. Today NASA has a new program known as Constellation. The Constellation Program is focused on carrying a new generation of explorers to the moon, and then to Mars.

In these troubled days of challenges in healthcare, economic depression and worldwide warfare, there is a bright spot in the form of Orion, NASA’s first Constellation Program vehicle. Orion is a reminder that whatever the challenges, the human spirit will continue to seek knowledge and understanding beyond what is currently known.

Thank you, Joe.

Too big to fail: the malpractice industry?

2009-03-13T16:45:00.001-05:00

“I will pursue tort reform in America until every state enjoys the same success as Texas,” announced Texas Governor Rick Perry to a group of physicians gathered in Washington D.C. In a speech eerily reminiscent of another Texas governor, Perry detailed the successes of the tort reform movement in Texas, stating, “We need tort reform, and we need it now!” Unsurprisingly, the group of physicians gathered for the American Medical Association’s National Advocacy Conference greeted the remarks with a standing ovation.

Since the passage of Proposition 12 in September 2003, Texas has transformed from one of America’s “judicial hell-holes” into the land-of-milk-and-honey for physicians. Neurosurgeons, obstetricians, and emergency physicians flocked to the state, seeking shelter from the litigation wars in Florida, Ohio, and Mississippi. Malpractice insurance rates have declined by 23% overall. There is a 2,300 case backlog for the Texas State Board of Medical Examiners, struggling to provide licensure for the litigation refugees of other states. Seventy-two counties in sparsely populated west Texas boast physicians where there were none 5 years ago.

As the debate for health care reform heats up in Washington D.C., the focus is appropriately on accessible, affordable, high-quality medical care. Policy-makers struggle to find an economic model that will pay for the kind of care that Americans want and deserve. Physicians make up a very small percentage of those serving as elected officials in Washington. Perhaps that explains why lawmakers, who overwhelmingly come from another line of work, fail to see the blunt truth that is right in front of them.

Americans could provide the highest quality medical care to everyone in the country, conveniently and affordably, by eliminating defensive medicine.

Of course, the economic cost would be borne by those involved in the litigation industry, which includes far more people than the the much maligned plaintiff attorneys. Also securing monetary gain from the pursuit of malpractice litigation are defense attorneys, malpractice insurance companies, professional (I mean, expert) witnesses, arbitrators of all types, professional and paraprofessional case reviewers, settlement structure analysts, actuarials , courthouse personnel, and purveyors of advertising. In fact, perhaps tort reform is not a part of health care reform discussions because the entire malpractice industry is too big to fail?

Congratulations, Dr. Jeff Runge

2009-03-11T21:46:00.002-05:00

I am in Washington D.C. this week participating in the discussions about health care reform. Last night I had the honor of being invited to participate in honoring one of emergency medicine’s own, Dr. Jeff Runge.

Dr. Jeffrey W. Runge, MD, FACEP, received the Dr. Nathan Davis Award for Outstanding Government Service in a ceremony last evening. Dr. Runge practiced emergency medicine for 25 years, and was assistant chairman of the Department of Emergency Medicine at the Carolinas Medical Center in Charlotte, North Carolina when President Bush appointed him administrator of the National Highway Safety Administration. While there he implemented a combination of legislative and law enforcement initiatives, including the “Click It or Ticket” program. Dr. Runge went on to serve as chief medical officer within the Department of Homeland Security (DHS), working as an advisor on medical and bioterrorism issues. While there Dr. Runge founded the Office of Health Affairs, providing oversight of the Department’s biodefense and medical readiness programs. Dr. Runge now acts as a consultant in the areas of disaster medicine, bioterrorism defense and homeland security technology.

A Message from Dr. Nicholas Jouriles, ACEP's President

2009-03-08T21:30:00.001-05:00

It is imperative that Congress and the Obama Administration address the escalating crisis in our nation’s emergency departments. Every American expects emergency departments to provide expert medical care when they need it. Emergency departments are a vital part of every community - caring for critically ill or injured patients, as well as victims of epidemics, natural disasters and acts of terrorism. Emergency physicians also care for people who have nowhere else to turn and often are the only source of medical care available at night, on weekends and on holidays.

The consequences of our nation’s economic turmoil and mounting job losses can be seen every day in emergency departments across the country, where the newly uninsured increasingly are turning for care. Emergency departments are the health care safety net for everyone, insured and uninsured alike, and their role in America’s health care system has never been more critical.

As Congress tackles health care reform this year, it must not ignore the issues raised in the American College of Emergency Physicians’ National Report Card on the State of Emergency Medicine, which gave the nation a near-failing D- in the category of access to emergency care.

Recognizing the important role of emergency medicine and trauma care in this country and acknowledging the critical problems patients face when these services are not readily available, the "Access to Emergency Medical Services Act" was introduced in February 2009 by Reps. Bart Gordon (D-TN) and Pete Sessions (R-TX) in the U.S. House of Representatives (H.R. 1188), and Sens. Debbie Stabenow (D-MI) and Sen. Arlen Specter (R-PA) in the U.S. Senate (S. 468).

10 Things to do Today

2008-12-31T04:13:00.003-06:00

Tomorrow is the first day of a new year. Resolutions will be made, new leaves will be turned over, and fresh starts will be taken. As a big believer in lists, I'd like to offer a list of things to do TODAY........things that will clear the way for a healthier new year.

_____1. Clean out the medicine cabinet.

If possible, relocate the contents to another area of the house. The heat and humidity of the typical bathroom are not good for medications.

_____2. Throw away any prescription medications more than a year old.

Medicines lose their potency and may even be harmful if they are expired.

_____3. Make a list of all medications, including over-the-counter and herbal medicines.

Include the name of the medicine, the strength (mg, units, etc), the prescribing doctor's name, and the way that it is taken (twice daily, at night, with meals, etc.)

_____4. Make a copy of the medication list. Place the list in a clear jar with a lid, and place the jar in the back left corner of the top shelf of the refrigerator.

In the event of an emergency, loved ones and EMS will not have to dig through a pile of paperwork to find the medication list.

_____5. Program an "I.C.E." number in your cell phone.

I.C.E. stands for In Case of Emergency. Program the number of the person that you would like to be notified if you are unconscious or unable to speak. Many EMS, fire, and police departments now look for this number in an emergency.

_____6. Check your thermometer. Does the digital display work?

If you do not have a digital thermometer, get one. They are easy to use, will not shatter, and do not contain mercury.

_____7. Throw away any sunscreen left over from last summer.

Sunscreen ingredients do not have a long shelf life. Using a sunscreen that has been open for a year could result in an unexpected sunburn, and increases the risk of developing a cancer related to sun exposure.

_____8. Replace the batteries in the emergency flashlight in the medicine cabinet.

An emergency flashlight in a known location is important to prevent falls and/or injuries in case of a power outage.

_____9. Replace the batteries in ALL of the smoke detectors in the house.

This should be done twice yearly. Replacing the smoke detector batteries on New Year's Eve and the Fourth of July makes it easy to remember.

____10. Have a happy, healthy, and safe new year!

Snow in Galveston and Cold Weather Tips

2008-12-17T05:21:00.004-06:00

I realize that snow in December is not shocking for many of my northern neighbors, but in Galveston, Texas, snow at anytime is a shocker. I also know that most people know the common sense tips for staying healthy in cold weather:

*Avoid going outdoors in extreme cold unless absolutely necessary. This is especially important for children and the elderly.

*Dress warmly, and in layers, to avoid overheating during exertion.

* Most body heat is lost through your head, so wear a warm hat that covers the ears.

*Mittens provide more warmth to your hands than gloves.

*Wear insulated, waterproof boots to prevent frostbite and to keep firm footing on snow and ice.

*Stay hydrated and well fed during outdoor activities.

*Be aware that some cold weather activities, such as snow shoveling, may place a strain on the heart from overexertion.

*Pay attention to the weather forecast and be prepared for a sudden change in the weather.

A few days ago it was 79 degrees here on the balmy Gulf. Most of the island residents are unprepared, and many don't have heat in their homes. (Of course, many don't have homes after Hurricane Ike, but that's another story.) For this reason, I have developed a very special set of

COLD WEATHER TIPS FOR GULF COAST RESIDENTS

*Don't surf if there is snow on the beach.

*Dress warmly, in layers. A bikini AND shorts do not constitute layers. A winter coat is required.

*Most body heat is lost through the head, so wear a warm hat. A ballcap, regardless of decoration, does not qualify as a warm hat.

*Wear gloves or mittens or socks or anything warm that you can put on your hands. Do not bother to go to the local WalMart to find snow gloves. They do not have any. They do have small plastic packets called "hand warmers" that will warm hands nicely.

*Flip flops are not proper snow footwear. Wading boots are not proper snow footwear. Cowboy boots are not proper snow footwear. Tennis shoes are not proper snow footwear. Your hunting boots will do.

*Drink plenty of water. Avoid alcohol during snow-related outdoor recreation. The alcohol may temporarily make you feel warmer, but it actually causes you to lose heat faster. Passing out in the snow on the beach will also make you lose heat faster.

*Don't let your kids stay outside until the snow melts. They don't control body temperature as well as adults.

*Call and check on your mama. Older folks don't control body temperature very well, either.

*Don't try to shovel the snow, especially with the garden hoe. It will all be melted in a few hours anyway.

*Enjoy this moment. Never before has a hurricane destroyed the island and been followed ninety days later by a snowstorm.

Photo courtesy of Catrena Hughes