Archive for category From the President
After an extensive look at ways to provide cost effective care to emergency department patients, the American College of Emergency Physicians believes there is room to improve the use of specific tests or procedures in emergency medicine to participate in the national “Choosing Wisely” campaign.
“Choosing Wisely” is part of a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation to help physicians be better stewards of finite health care resources. The campaign encourages medical specialty organizations to identify five tests or procedures commonly used in their field, the necessity of which should be questioned and discussed by patients and physicians.
ACEP had previously declined participation in the “Choosing Wisely” campaign because of the challenges of this approach with the unique nature of emergency medicine, liability concerns, and a potential harm to physician reimbursement.
The College meanwhile remained steadfast in its commitment to cost-effective care and a high-value health care system, and last year, Immediate Past President Dr. David Seaberg appointed a Cost Effective Care Task Force, chaired by Dr. David Ross. The Task Force was charged with considering tests, processes and procedures with little or no value to emergency care that might represent meaningful cost savings if eliminated.
In a report to the ACEP Board of Directors this month, Task Force member Dr. Jay Schuur said that their Delphi panel and ongoing member surveys have suggested that a number of tests will meet the criteria of the “Choosing Wisely” campaign. They also determined that these tests would not increase the physician’s liability, and would not negatively impact payments for emergency physicians.
After being reviewed by experts, emergency medicine leaders, and the ACEP Board, the report’s data indicates that it would be appropriate for emergency medicine to participate in the campaign. A letter of ACEP’s intention to participate was sent to the ABIM Foundation today.
The list of recommendations should be established by June. ACEP’s Task Force is finalizing the evidence base for these recommendations, in part though the Emergency Medicine Practice Research Network (EMPRN). Attaching estimates of potential real-dollar savings to the recommendations is also being completed. Members of the Task Force and the ACEP Board believe this responsible approach will validate the substance of our recommendations, and provide assurance that there will be a real savings to the health care system while not impacting patient care.
But joining this national campaign is not the only approach ACEP is using its in journey to identify cost savings measures without compromising patient care.
In order for there to be a serious reduction in unnecessary tests and costs of defensive medicine over time, meaningful liability reform and safe harbors are vital. ACEP is encouraging ABIM and its campaign partners to lend their voices to the need for medical liability reform. This remains a top priority in ACEP’s advocacy agenda.
Additionally, the College is working on other significant and impactful efforts, including proposing an elimination of the 3-day-stay rule and better management of transitions of care.
A variety of recommendations that strive to improve patient care and provide meaningful cost savings continue to be initiated, developed, and adopted by ACEP. We are dedicated to ensuring that our specialty can be leaders in health care system efficiency while maintaining a high quality of emergency care and patient safety.
ACEP Calls for Increased Investment in Mental Health Resources and a Ban on the Sale of Assault Weapons
The American College of Emergency Physicians (ACEP) today expressed deepest sympathy to all those affected by the senseless tragedy in Connecticut and called on government at every level to increase investments in mental health resources and to ban the sale of assault weapons and high-capacity magazines.
Emergency physicians see the tragic consequences of gun violence every day. Our hearts go out to the families of the victims and to everyone affected by this terrible event in Newtown. We deplore the improper use of firearms and support legislative action to decrease the threat to public safety resulting from the widespread availability of assault weapons. We also are urging policymakers to restore dedicated funding for firearms injury prevention research.
ACEP’s policy on firearm injury prevention endorses limiting the availability of firearms to those “whose ability to responsibly handle a weapon is assured.” It also calls for aggressive action to enforce current laws against illegal possession, purchase, sale or use of firearms.
The nation’s emergency physicians call for increased funding for the development, evaluation and implementation of evidence-based programs and policies to reduce firearm related injury and death. We will fully support legislation that supports the principles of ACEP’s policy on firearms injury prevention.
The lack of mental health resources in the United States has contributed to a significant increase in visits to the emergency department. Psychiatric emergencies grew by 131 percent between 2000 and 2007, according to a recent study in Annals of Emergency Medicine. This is symptomatic of the lack of resources for these patients.
As you may know, today the United States Supreme Court decided to uphold The Patient Protection and Affordable Care Act. (Read the 193-page decision here.)
This decision will impact emergency medicine because it is clear that the amount of visits to the nation’s emergency department will continue to increase even with the implementation of health care reform.
As I stated in a press release today, the nation’s emergency physicians fully support the emergency care provisions in the law, such as inclusion of emergency services as an essential part of any health benefits package and the prudent layperson standard, which guarantees that health plans base coverage on the patient’s symptoms, not the final diagnosis.
And regardless of the Supreme Court’s decision, it does not change the mission of emergency physicians — we pledge to be there for our patients.
However, while there are provisions in the law to benefit emergency patients, it is clear that emergency visits will increase, as we have already seen nationwide. There are physician shortages and there are also drug shortages and serious mismatches between patient needs and available resources.
The College will continue to urge lawmakers and regulatory agencies to ensure that the implementation of the health care reform law does not endanger patient care or threaten the practice of emergency medicine.
ACEP has worked with — and will continue to work with — members of Congress to find solutions to improve the safety and efficiency of emergency care for all Americans. Emergency departments are a critical, life-or-death part of our health care system and we need help now. This crisis in emergency care is everyone’s problem, because every person is only one step away from a medical emergency.
According to the most recent GAO report, emergency patients who need care in 1 to 14 minutes are being seen in more than twice that timeframe — 37 minutes.
Significant growth of Medicaid is intended as one of the means of expanding coverage. Increasing the number of patients on Medicaid without an equivalent increase in the number of physicians willing to take that insurance will surely increase the flood of patients into our nation’s emergency departments.
Coverage does not equal access and critical problems facing emergency patients are not going away.
A recent study in Annals of Emergency Medicine shows that crowding in emergency departments is growing twice as fast as the rate of ED visits, principally because emergency patients are showing up sicker and with more complicated health problems.
As the nation moves forward with implementing the health care reform law, we urge the Senate to follow the lead of the House in repealing the Independent Payment Advisory Board (IPAB), which was included in the law. The IPAB panel does not have any accountability to Congress, health care providers or the public and will harm Medicare patients’ access to medical care.
This law also includes medical liability dispute resolution alternatives, but that the scope is extremely limited, which limits its potential effectiveness. America’s medical liability system is broken and without true medical liability reform, patients’ access to lifesaving care will continue to suffer.
ACEP will continue to fight for meaningful medical liability reform and other emergency medicine issues. You can aid in this battle. Contributions to NEMPAC will support candidates who can positively impact emergency physicians and your patient care. Consider donating at the Give-A-shift level for maximum leverage of your PAC contribution.
Participation in the Emergency Medicine Action Fund is now more important than ever. With the Supreme Court decision upholding the law, an avalanche of regulations are being written and emergency physicians desperately need the EM Action Fund to keep them out of the regulatory and legal crossfire between payers, patients, policymakers and hospitals.
The EM Action Fund has unified the house of emergency medicine and become a powerful and influential voice in federal regulatory and legal issues that matter to you and your colleagues. Join the EM Action Fund today.
Although ACEP has previously reviewed the Choosing Wisely Campaign and agreed not to participate, due to continued questions and comments from our members, I convened a workgroup to re-review the campaign and ACEP’s participation. The workgroup consisted of a wide and diverse representation of ACEP members and Committees.
The group was overwhelming in support of not joining the Choosing Wisely Campaign. Although the issue of cost control is crucial for emergency medicine’s future, the Choosing Wisely Campaign is not the vehicle for ACEP’s participation.
Several important points were made during the workgroup meeting:
- The College needs to be viewed by CMS, payers, and the public as proactively addressing cost containment and overuse.
- ACEP needs to be seen as proactively providing solutions rather than appearing to be against any cost cutting or savings suggestions.
- The College developing and communicating a plan with proactive proposals/solutions will mitigate some cost cutting measures from those that do not understand the unique position of emergency care. It was noted part of the success of the Washington State initiative was the ability to come to the table with a plan, rather than push back against the plan of action presented by the State.
- Whatever is developed should showcase the specialty in a favorable light and not contradict or conflict with current advocacy efforts.
- There was support for identifying over-use and developing a positive message on cost savings and efficiencies in the emergency department.
- To come to consensus on a certain number of tests or services that have limited use would require so many caveats that it would be almost impossible to develop lists as found in the Choosing Wisely Campaign.
- Ideally any recommendations should include some liability reform/recommendations in using guidelines that may suggest certain tests or procedures are not effective or necessary.
It was recommended that ACEP develop a task force from committees, sections, and members with expertise in these areas to develop a proactive campaign that recognizes the role the emergency department and emergency physicians can play in controlling costs while improving efficiencies and quality patient care.
The process has already begun with the task force being constituted with the goal of developing messages and strategies for cost control in the emergency department. The task force will make their recommendations at the October ACEP Board of Directors meeting.
We also will be educating our members about cost savings programs from other specialties, such as the Image Wisely and Image Gently programs from the American College of Radiology.
DAVID SEABERG, MD, FACEP
President, American College of Emergency Physicians
A campaign called Choosing Wisely has gotten some attention of late because of its stated goal of reducing health care costs by eliminating tests and procedures that are not “necessary.” Since Choosing Wisely launched, nine medical specialty organizations have offered up their top five items for the chopping block. These range from CT scans for fainting from the American College of Physicians to antibiotics for chronic sinusitis from the American Academy of Allergy, Asthma and Immunology.
ACEP was asked to join the campaign in 2011, and after extensive review and discussion at the Committee level, ACEP declined. There are several reasons for our initial response:
- Emergency physicians have no right of refusal with our patients and often pick up the slack for other members of our esteemed profession. A recent member poll showed that 97% of us report seeing patients on a daily basis who are sent to the emergency department by their primary care physician. Many of these patients have been sent in with expressed instructions from the family physician to have this or that test ordered either because their office practice is swamped, the office is closed, or they lack the facilities to perform these tests.
- ABIM, the organization sponsoring the campaign, refused to allow any discussion of liability reform as a component of the Choosing Wisely campaign. To quote from the letter ACEP Past President Dr. Sandy Schneider sent to Daniel Wolfson, ABIM’s Executive VP and COO: “This is a significant issue in emergency medicine and a critical factor as to why emergency physicians order the number of tests and procedures they do. Unlike primary care physicians, emergency physicians are not chosen by their patients, who have a greater tendency to sue for any perceived untoward event. In addition, we often lack prior care information. It is simply not possible for emergency physicians to talk about reducing ‘unnecessary’ testing without including messages about the need for medical liability reform.”
- Emergency physicians approach our patients with the goal of eliminating anything life threatening. We cannot afford to miss anything, even something that seems like a long-shot. The consequences may be life or death for our patients. A test that is unnecessary for 99 patients may save the life of patient number 100.
- Emergency medical care constitutes just 2 percent of all health care spending in the United States, no doubt in part because so much of the care we deliver is uncompensated. We are masters of efficiency and improvisation but there is only so far a dollar can be stretched. Emergency departments have been closing at an alarming rate across the country because so much care isn’t paid for. This is not the place to cut costs any further.
- Lastly, should ACEP participate in this campaign, it very well may assure that emergency physicians will not receive reimbursement for the five identified procedures or tests.
ACEP is dedicated to advancing emergency care and promoting evidence-based quality improvement measures for its patients. To that end, we are reevaluating our response to the Choosing Wisely campaign by developing a workgroup, comprised of members from the Reimbursement, Medical-Legal, EM Practice, Clinical Policies, Quality and Performance, and Public Relations Committees to examine the issue and prepare a proposal for ACEP Board consideration.
DAVID SEABERG, MD, FACEP
President, American College of Emergency Physicians
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.
Thank you for your leadership and partnership in this endeavor,
Angela F. Gardner, MD, FACEP
American College of Emergency Physicians
In a letter to the ACEP Council this week, ACEP President Dr. Angela Gardner outlined the current state of national health care reform and conveyed the essential components of reform outlined in ACEP policies. Her letter includes ACEP’s positions and a breakdown of the EM provisions in the pending bills.
“In recent years, there has been an increasing focus on the need for comprehensive reform of America’s health care system. With almost 50 million uninsured Americans and sharply rising costs in health care, the current system is unsustainable. There is, however, considerable disagreement and controversy over how to fix the severely challenged health care system.”
ACEP President Angela Gardner, MD, FACEP, had a front row seat Wednesday for President Obama’s release of his final version of a health care reform bill and shook the President’s hand after his speech.
The White House invited ACEP to bring several emergency physicians to attend the high-profile press conference. Joining Dr. Gardner at the event were ACEP President-Elect Sandra Schneider MD, FACEP; Federal Government Affairs Committee member Bruce Auerbach, MD, FACEP; and EMRA Board of Directors member and Legislative Advisor Nathaniel Schlicher, MD, JD.
President Obama released a revised bill, calling it a compromise plan that combines the best ideas of Democrats and Republicans, including insurance reforms, measures to curb waste, fraud and abuse in the system and increased funding for state grants on medical malpractice reform projects.
In his speech, the president urged Congress to “finish its work” and that “now is the time to make a decision” about health care reform.