In which we discuss some of the critiques of the health care reforms, Comparative Effectiveness research, and how ACEP members need to get involved to effect meaningful and positive changes in the system:
Dr. Yore: Some have criticized these reform efforts as a government take-over of healthcare. Rhetoric aside, are you concerned about excessive governmental interference in healthcare?
Dr. Jouriles: We already have excessive government inference in healthcare. The whole system is based on Medicare. As Medicare sets rates, private insurance follows. Medicare sets the regulations. Medicare allows the Joint Commission to set regulations and we all function under that system; it all traces back to Congress and CMS. We’re under a system of federal control with healthcare currently. I don’t see what people are concerned about.
Dr. Yore: Are you concerned that it might get worse? For example, they have the Comparative Effective Research that they’re looking at putting into place. Does that strike you as something that is potentially concerning or is it sort of well we’re already — and it’s not going to get any worse so we might as well just live with it?
Dr. Jouriles: No, actually I think the comparative effectiveness research — I don’t understand what people are concerned about because that’s something we, in medicine, have done for years. You find a new study or a new device or a new product or a new medicine and you see whether it works or not and you compare it with other current processes. You are probably not old enough to know about MAST Trousers, but for a long period of time we used MAST Trousers and then someone actually did the research and guess what? We don’t use them anymore. The bottom line is that back in the day of George Washington they used leeches. When leeches went out of style, then they came back. Comparative Effectiveness Research is really what we should be doing to find out what really works and what doesn’t. Should they apply payments based on that? Well I think they should pay for stuff that works and not pay for stuff that doesn’t work. That makes sense to me. What I think is going to be problematic is the idea that there is a bell-shaped curve and they are not going to pay the bottom 25 percent but they are going to pay the top 25 percent extra. That is a flawed concept
Dr. Yore: There’s always going to be the bottom 25 percent.
Dr. Jouriles: This isn’t Lake Woebegone where everyone is above average. CMS should be criteria referenced: here’s the Comparative Effectiveness Research and it says 1, 2, 3, 4. If you do 1, 2, 3, 4 then you should get paid and you should be free of medical liability concerns as opposed to you can do 1, 2, 3, 4, but we’re still going to lop off the bottom 25 percent and you’re still going to get sued. So I think there is an opportunity with defining what is quality care and getting everyone to that standard and yet rewarding people for doing that in several ways. We need to both pay and protect physicians who provide quality care. If we do that, then I think that will improve care overall; it will be more efficient, it will be cheaper, and there will be less liability. I think that’s all good. But it’s all in the details of how it’s implemented.
Dr. Yore: On the notion of getting sued, President Obama had indicated that he was open to tort reform as part of Compromise Health Reform package, but we haven’t seen very much in legislative language along these lines. Are you disappointed by this?
Dr. Jouriles: No, I think given the political climate he was very brave. We know that trial lawyers, on average, donate in the $1,000 to $2,000 each to political campaigns, physicians donate in the average of $7 each. Trial lawyers tend to favor Democrats over Republicans in their donations. I think the fact that Obama even said what he did is a minor miracle. So the fact that he is willing to risk some of his political capital on this I think actually is a very, very good sign for the possibility that something may happen along liability lines. He also realize — I mean, he’s not stupid; he’s an Ivy-leaguer, he realizes that’s pretty low hanging fruit when you talk about saving money on healthcare spending. Medical liability and administrative cost, if you can’t recoup that you’ll never, never change a thing. I think the public knows you can’t sue your way to a better healthcare system. The public’s not a big fan of malpractice to attorneys either. So I think there is a possibility; it’s now on the table. It’s a good thing. It’s going to happen slowly but something will happen, I think. It has to.
Dr. Yore: That would be a useful role for the Comparative Effectiveness Research — to create a rebuttable presumption that if the physician followed evidence-based guidelines he wasn’t negligent.
Dr. Jouriles: Correct. Yes, and I think that would be good and I think that would save tons of money for the system. I think that is something that some of the moderate Democrats and the Republic minority could emphasize in terms of, “Hey. We can save a whole bunch of money if we did this…” I think that might be an easy compromise, sausage wise, for the Democrats to do because for them to get the bigger picture through, they’ll have to compromise on this and they don’t look like they’re selling out their big contributors.
Dr. Yore: On another note, this year as we have seen the emergence of social media as a key avenue for communication and ACEP has its blog, The Central Line. Are you going to be contributing as an author?
Dr. Jouriles: Eventually. Right now, between doing Presidential duties, running the 20 million dollar organization, visiting chapters, and actually seeing patients and my family every once in awhile, my schedule is pretty tight. I know that [President-elect] Angela [Gardner] has it on her agenda she Tweets and she blogs and she does all these things. I look forward to turning the reins over to her; that will give me more time to contribute.
Dr. Yore: So will we see you on Twitter then?
Dr. Jouriles: You never know. That’s one of the many things that’s on my list. I’m not sure when I’m going to get to it.
Dr. Yore: Has it been a fun year?
Dr. Jouriles: It’s been great. Some of the things we’ve had the opportunity to do, you would never think that as an emergency physician you would be able to do: TV programs and National Press Clubs, and Capitol Hill, and private meetings with the head of the Joint Commission. As you pointed out earlier, it’s been a very controversial year and a lot is going on and because of that I think I have seen and done more than any ACEP President ever has. I have a very nice collection of photos and scrapbooks and memorabilia. I am very grateful for the opportunity.
Dr. Yore: If you had to pick one moment as the best thing, the coolest thing?
Dr. Jouriles: Probably the coolest thing was releasing the report card. We were at the National Press Club, which is a very cool place, the Prime Minister of Afghanistan, was two rooms over. That was the day that Governor Blagojevich was all over the news. There is all this stuff that was going on and that included us. We got a fair amount of media play and just to be able to stand up in front of a national audience, speak to national TV, being misquoted in the New York Times and quoted in the Washington Post all in the same day was pretty heady stuff for someone who is an emergency physician. I’m not an actor or someone who aspired to that; I’m just a guy who sees patients.
Dr. Yore: Is there anything you wanted to add?
Dr. Jouriles: Healthcare reform is here and something is going to happen over the next couple months. There are a lot of people in this specialty who are very talented. The members, the emergency physicians of this Country need to wake up and realize that the time is now to get involved. We need to make sure we contact our Congress people, invite them out during their break in August. Give some money to NEMPAC. We need to make our voice heard over the next couple months. I don’t think there has ever been a time more crucial in this specialty, short of the 1970s when we were forming the specialty. We are at a crossroads. If things go badly for us in DC, we could lose the specialty completely. Bundling, the whole bit. If we band together and do what we’re capable of doing, then we’re going to have a much better future than we have today. I’d encourage our members, the emergency physicians of the world, to step up to the plate. Now is not the time to say that’s somebody else’s job or it’s not my interest. Everyone needs to step up to the plate and do something over the next couple weeks to months and we’ll get what we need for our patients and for our specialty.