Emergency Medicine 2009: Current Issues & Crises

1. Emergency Medicine 2009:Current Issues & Crises Jennifer L. Wiler M.D., M.B.A. Councilor, ACEP Young Physicians Section Vice Chair, AMA Women Physicians Congress Speaker, AMA Young Physicians Section EM Advisor, AMA RVS Updates Committee (RUC) Immediate Past-Vice Chair, Missouri State Medical Society YPS

2. Obama’s Domestic Agenda • Healthcare Reform • Education • Energy

3. Reasons for Healthcare Reform • Problem: • Cost • Quality • Un/Under Insured • Access / Coordination of Care

4. Healthcare Spending “Out of Control” Est. by 2018: HC spending 1/5th total US economy Government (taxpayer) pay >50% costs (Source: CMS)

5. Cost ≠ Quality; Variations by State Relationship Between Quality of Care and Medicare Spending, by State, 2004  Composite measure of quality of care (100 = maximum) Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality

6. How Does U.S.A. Compare? Source: UC Atlas of Global Inequality.com

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

8. A Question of Value

9. Jobless & Uninsured Rates are Climbing

10. Aging Adult Population www.princetoncme.com

12. Increasing System Demand Decreasing Capacity

13. Projected Workforce Shortage – Physicians Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html;

14. Physicians NOT Accepting Medicaid -- On the Rise Modern Physician 11/06

15. Shortage of On Call Specialists Affecting nearly 75% of all hospitals Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html

17. “I mean, people have access to healthcare in America. After all, you just go to an emergency room.” President Bush Cleveland Ohio June 10, 2007

18. Increasing ED Patient Volumes 1996-2006: Annual # of U.S. ED visits rose by 32% (90M to 119M)  EDs decreased 5% “Hospital Ambulatory Medical Care Survey” 9/06 www.CDC.gov

19. EMTALA … • 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA) • a.k.a. Federally mandated uncompensated care

20. The Result …Your ED Waiting Room Looks Like This

21. And It is Not Just Your ED... Source: www.boston.com

22. % of Hospitals with ED At or Over Capacity Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html

23. Many ED’s Report Being On Diversion… 500,000 Ambulance Diversions Qyr  On average one every minute Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; American Hospital Association, 2007 Survey of Hospital Leaders

25. Institute Of Medicine 2006“Hospital Based Emergency Care – At The Breaking Point” • Many EDs and trauma centers are overcrowded. • Emergency care is highly fragmented. • Emergency care system is ill-prepared to handle a major disaster. • EMS and EDs are not well equipped to handle pediatric care. • Underfunded system. www.iom.edu

26. EDs Have No Surge Capacity Chairman Rep. Henry A. Waxman (D-CA)

27. ED Crowding/Boarding is Bad • Worse Patient Outcomes • Sig increase serious complications (~6 vs. 3 %) in ACS pts 1 • Crowding Causes Deaths 2 • ~1/3rd ED sentinel events (serious injury/death) related to crowding 3 • Crowding / Boarding is Expensive • Increases total hospital LOS 4 • Increases LWTC & adverse outcomes 5 • Increases ambulance diversion 6 • Increases medical negligence claims 7 1. Pines JM, et al. ACEP SA 2007 Abstract; 2. Chalfin DB, et al. Crit Care Med. 2007; 35(6):1477-1483; 3. Joint Commission. Sentinel Event Alert, June 17, 2002; 4 Krochmal P, et al. Am J Emerg Med 1994;12(3):265-266.; Richardson B. Med J Aust. 2002; 177(9):492-495.; Liew D, et al. Med J Aust. 2003; 179(10):524-526.; 5. Richardson DB, et al. Confirmation of Association between overcrowding and adverse events in patients who do not wait to be seen. Acad Emerg Med. 2004; 11(5):462.3; 6. Burt CW, et al. National Center for Health Statistics, 20067. 4 ED Crowding: High Impact Solutions www.acep.com

28. ACEP’s National Report Card The State of EM 2008 Source: ACEP.org

30. Where Do You Start to Fix the System?

31. Healthcare Reform: Future Track? • Universal HC Coverage (Access) • Medical Home • Improve Quality (Value) • Change Physician Compensation • Insurance Carrier Reform • Liability Protection • More…

32. How Will This Effect EM? Source: www.wremsco.org

33. What Has Already Been Done • SCHIP Reauthorization through 2013 • Stimulus Plan - American Recovery & Reinvestment Act* • CMS $338 B • Medicaid state matching $87 B • Extended COBRA Benefits $24.7 B • HIT $19.2 B • NIH new grants $8.2 B • IOM Summit “Future of Emergency Care Reports”- March 2007 Recommendations • ED Crowding: High Impact Solutions, April 2008 Source: NEJM Feb 21, 2009

34. Access to Emergency Medical Services Act 2009 (H.R. 1188 and S.468) Introduced Feb 2009 Reps. Bart Gordon (D-TN) & Pete Sessions (R-TX) in House Sens. Debbie Stabenow (D-MI) & Arlen Specter (R-PA) in Senate (1) Create Bipartisan Commission – Evaluate Access to EMS Issues: Crowding, availability of on-call specialists, & medical liability issues on EMS (IOM recommendation) (2) Increase in EMTALA-Provider Care Related Payments Authorizes additional Medicare payment to physicians (including on-call specialists) (3) Emergency Department Boarding/Diversion Quality Standards CMS develop hospital boarding & diversion quality standards via National Quality Forum (NQF) & Hospital Quality Alliance (HQA) • Co-Sponsors: 66 House & 6 Senate (4/1/09)

35. Obama’s Proposed Source of Cost Savings Source: White House Office of Management and Budget, AMA News March 16, 2009

36. Physician Reimbursement Issues • RAC’s • Balanced Billing Prohibition in CA • United HC $350M Settlement • Participate in AMA RUC Process • More…

38. Take Home • Some Form of Healthcare Reform Will Happen • Emergency Services are an Essential Part of Healthcare System • Not Just For “Nonurgent” Patients • Not Just for Uninsured • EMTALA Mandated Care with No Reimbursement or Liability Provisions • Patient Centered – “High Value”

39. Thank You