Archive for May, 2012
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
I don’t get it. I do not understand why the US government has decided to paint a target on the backs of physicians who, according to the AMA, provide more charity care than any other specialty, in a program that uses so-called hired gun auditors to recoup over-payments in Medicare’s fraud and abuse prevention strategy. These are physicians who give away, on average, more than $140,000 a year in unreimbursed services to the poor and uninsured (4-10 times more than any other specialty), and serve a larger proportion of Medicaid and under-insured patients than the vast majority of other physicians. These charitable physicians are willing to treat everyone, regardless of their insurance status or ability to pay, day or night, Sundays and holidays, whether the patients are upstanding citizens or the disheveled homeless. These docs provide care to everyone who asks to be treated or comes to their door, even if they are intoxicated to near stupor, or ranting obscenities, or smell like a garbage dump, or shed deadly viruses in an epidemic, or are soaked in toxic chemicals released in an accidental spill or a terrorist attack.
None of these physicians are engaged in a criminal enterprise to cheat Medicare and the tax payers out of millions of dollars for care they never provided, or using stolen or purchased patient IDs to submit fake claims, or billing for tests not performed, or charging for equipment they never ordered. In fact, these specialists work almost exclusively in hospitals that carefully screen their credentials, and in medical groups that have some of the most extensive claims coding and billing compliance programs in the health care industry. Nonetheless, the government has selected these physicians for auditing under the Medicare Recovery Audit Contract (RAC) program by focusing on the evaluation and management (E&M) CPT codes that are used almost exclusively in claims submitted to Medicare by these specialists. Other E&M and procedure codes are also being targeted for audits by these RACs, but these other codes are widely used by many other physician specialties.
There is no question that fraud and false claims are a serious problem for Medicare, and cost taxpayers hundreds of millions of dollars every year. For every $1 the government spends on these RACs, it gets back $40. I am all in favor of dealing a heavy blow to those who try to cheat the system, provided the adjudication process is fair and the focus is on activities that are clearly in violation of the rules. There are those who believe that hiring these private audit contractors on a contingency basis (based on the amount of overpayments they find) is like paying a bounty hunter to bring in a possible suspect dead or alive, especially since many claims that the RACs deem overpaid are frequently found to be ‘not guilty’ on appeal. The rules that are applied to these claims are, unfortunately, not always clear and concise: E&M coding in particular is about how sick the patient is, and how complicated or difficult the medical decisions are to make. In other words, medical coding is an art, not a science, and using an auditor that is financially incentivized to interpret these rules in the most aggressive way, with the threat of big penalties and forfeitures, is like writing a law that stiffs you with a big fine for ‘parking too close to a fire hydrant’ without specifying how close is too close, or paining the curb red.
I don’t doubt that a few of these ‘charitable physicians’ stretch the coding rules a bit, or even overcharge for their services. It happens, but it’s not the rule, by any means. I have talked to quite a few of these particular specialists who have experienced RAC audits. They usually consider themselves to be good at documenting their care, who employ careful and conscientious claims coders for their billing service. They come away from the RAC audit experience angry, frustrated, baffled, fearful, indignant, and depressed. These physicians don’t go out of their way to intentionally up-code their claims, or un-bundle them (charge separately for items that should be covered under a single charge), and they take pride in their willingness to treat patients few other physicians are willing to see, regardless of the patient’s ability to pay. They are all overworked, sometimes underpaid, subject to stress burnout, and challenged by a seemingly impossible mission; and they do this for over 130 million patients in the US every year. These docs just don’t understand why their government would go out of its way to paint a target on the backs of emergency physicians.
This post also appears in The Fickle Finger www.ficklefinger.net/blog/
May Annals Audio Summary/Podcast is up: Click here for the audio!
Highlights this month:
-The UK 4-hour length of stay rule – what can we learn?
-Episodes of care: how will EM payment structures work in a new world?
-ED closures: who does it hurt most?
-Banana bags – bringing change to a department
-Does viral testing in the ED reduce antibiotic prescribing?
-Pharmacists in the ED: saving the day, invisibly
-Nontechnical EP skills: how to find them
Email us any time at firstname.lastname@example.org, talk to you soon,
David and Ashley
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
Please send your stories to Tracy Napper (email@example.com) today!
By Gerald A. Coleman, III, DO, FACEP
Driving in to my shift in mid-December 2009, it was snowing out. As a child, I loved the snow, but as grew older, I learned to dislike its presence when I had to drive to work in it. It reminded me of my daily commute when I went to medical school in New England. I could only think of all of the stuff I had to get done before the holidays which were quickly approaching. We are all guilty at times of getting caught up in the daily grind of our lives. My mind was on the various holiday distractions but soon it would be filled with an experience that would change my life. My shift that day started out being a typical case load of chest pain, sore throats, elderly abdominal pain and dementia patients with change in mental status. Halfway through my shift, the command radio went off alerting me to a possible stroke alert coming inbound to my emergency department which was at 110% with typical inpatient holds. Their ETA was less than 5 minutes. I discharged two of my patients in preparation for this critically ill patient who was inbound. Moments later, the medic busted through the door, yelling for a doc because his “stroke alert” patient was now vomiting and becoming more confused. I rushed to bed #8, our trauma resuscitation room, to evaluate a burly 62-year-old male with a long, partially gray beard. When I asked what was going on he simply stated: “Doc, I feel like crap and my head is going to explode.” His exam was non focal but I cleared the CT scanner with the tech via phone and we rushed him over immediately because I was concerned about a non-traumatic subarachnoid hemorrhage. The patient’s GCS at this time was 14.
The next of kin showed up with another 12 family members in tow. She was visibly upset and told me that her husband John was cutting down a Christmas tree with his grandkids when he screamed out and collapsed under the tree with the ax by his side. He was found by his youngest granddaughter who ran over to her and stated, “Pop Pop is hurt, Gammy.” John came to, stating he felt like an M-80 firecracker went off in his head. The CT tech phoned over to ED asking me to come over to the CT suite immediately. He stated: “Looks like John is not going to ride his motorcycle anytime soon.”
When I arrived, I stared at the monitor and dropped my head, my worst fear was confirmed; there was a large subdural and subarachnoid space extending into the R large ventricle with substantial mass effect at the level of the foramen magnum. We rushed John back over to the ED; en route he started to violently vomit all over my scrubs. I felt this was a bad omen and prepared to RSI the patient. His airway was predicted to be difficult so I made various adjustments in positioning John prior to securing his airway. When the respiratory tech came in to the room she immediately called the operator to page anesthesia. I looked up and stated, “Please give me a chance before you call in the cavalry, what gives?” I later learned that this respiratory tech was the niece of the patient and he had had airway trouble in the past with elective surgery. After I intubated John on the second attempt and made appropriate arrangements to transfer him to the receiving hospital, I sat down and talked to his family.
I walked into that room with a very uneasy feeling about the outcome of this case. One of the things that I learned early on in my career when dealing with families during a difficult case is to be truthful, direct, and professional. His wife asked me a direct question to which the entire room hung on my every word: “Dr. Coleman, is my husband going to die; you know his dad died the same way.” I had been through the gut-wrenching experience of losing a child at birth during my residency, so her fear was palpable and personal to me. This experience brought back unpleasant images of my deceased daughter. I simply stated while trying to ignore a salty tear streaming down my face, “We are going to do everything in our power to help John, I am in full court mode right now, take one step at time, he is a fighter, we can only hope for the best and prepare for the worse, time will only tell.”
Medevac had aborted the round trip 35-minute flight to the receiving hospital due to snow and low visibility, so my ground ALS crew was standing by to take John. I had to send an RN with John and the ALS crew because I started the following intravenous drips: cardene, mannitol and proprofol. John made it down to the receiving hospital’s interventional radiology suite in record time: door to IR suite within 86 minutes. This was amazing considering it was a 52-mile ground transport in suboptimal driving conditions.
After the dust settled, John had a protracted course in the ICU, staying there and in rehab for the next 4 months. He was finally discharged. Life went on in the ED as usual and a year passed. That year was a rough one for me because I survived my first year as a medical director after only being board certified for 6 months. A year later, to the exact day that John had his near fatal subarachnoid hemorrhage, I was working clinically when a middle-aged male without a beard come up to the physician charting area of the ED. I politely asked, “How can I help you today?” This gentleman’s eyes had strange familiarity to them. I said to myself, “Where have I seen this guy before?” He replied: “Hi Dr. Coleman, my name is John, and I wanted to say thank you in person for saving my life and giving me a second birthday.” I stood up for the desk in utter shock, “My god, John, you look amazing.” He had lost a ton of weight and lost the beard. He walked me to the conference room and there were more than twenty of his family members waiting to see me. Anyone who knows me well knows that I have an iron-clad exterior but at times can be emotionally sensitive when the time is right. I became overwhelmed with emotion as I listened to his family tell me John’s success over the last year in his recovery. We exchanged hugs, tears of joy, laughs, and simple stories of the heart. There are defining moments in your career; this was one of mine.
I firmly believe that everyone has a role and a purpose on this earth; mine was right here being an emergency physician. After a brief celebration with John’s family, he came over to me and said, “Dr. Coleman”; I immediately corrected him and said, “Please call me Jerry. “ He said, “Sure, Jerry, come outside, I have a surprise for you.” John was a lifelong motorcyclist and had an obsession for Harley motorcycles. During his ICU stay, I learned from numerous conversations with his wife that John’s goal was get back on his bike and ride again. When I stepped outside of the ED ambulance entrance, I saw a huge Harley Davidson bike sitting there. John asked ”Hey Jerry, you gave my life back, can I take you for a spin.” I stated, “I would love that, but John, my patients are waiting, I hope you understand. Can I take a raincheck on this one?” He understood. We embraced with a handshake that turned into a “man hug.” He again said thank you. I simply stated, “John, I did what I was trained to do, trying to save lives and alleviate suffering.” I walked back through the doors of the ambulance entrance, and picked the next chart with a renewed sense that I am doing what I was meant to do.
What I learned from this case is that life is far too short. Sometimes through personal life experiences or extraordinary cases such as this one, we are reminded that we need to take a step back and realize what is truly important in this world. Take time to enjoy life’s simple pleasures; tell people you love them unconditionally because you never know when your time is up.