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News and Announcements
AEP Positions on Healthcare Reform
Publish Date : 9-30-2009   Author : AEP BOD

To the Congressional Delegation:

     As emergency room physicians on the front lines every day, we are aware of the inherent inadequacies of our present healthcare system.  While we agree that the status quo is unsustainable for the medical community and the patients we wish to serve, the proposals that have been drafted ignore some fundamental issues that will likely lead to a worsening of access to care and financial viability in the future.  By adding more participants to an already ailing system without actual health insurance reforms or addressing major areas of waste and expenditures, any proposal is deemed to fail and accelerate the decline to bankruptcy of the present system. 

     We actively join you in support of these concepts below if implemented correctly:
1) Removing preexisting clauses and denial of care once you get ill and actually need to use the services.
2) Establishing real portability of insurance plans.
3) Allowing universal access to medical records for the medical community.
4) Achieving the goal of universal coverage for all US citizens.
5) Instituting primary care and preventive medicine initiatives.

     All the healthcare reform proposals to date are ignoring some of the major elephants in the room.  If any plan for reform is to succeed, the largest expenditures need to be modified and fixed.
     We need to act now to institute meaningful tort reform to stop frivolous lawsuits and start decreasing the costs of defensive medicine which account for excessive expenditures of about $200 billion per year. There is real cost to our system as 80% of the lawsuits are found in favor of the physician but can costs hundreds of thousands of dollars to defend each occurrence.  Several states already have programs in place.  Texas has instituted a cap on liability awards.  The positive aspect was that premiums decreased and more doctors returned to the state with improved access for patients. However, the practice of defensive medicine did not change appreciatively. Wisconsin has a doctor funded Patient Compensation Fund to help for awards above the insurance cap which stabilized the system. Please review some of these programs and modify to incorporate the positive aspects now. Other ideas have included medical courts or tribunals to weed out the frivolous suits. However, any of the options discussed must have input from the medical community and patients.
     Another issue that has huge quality of care and financial implications is the desire of a small percentage of the population to misuse the emergency medicine system. These patients are different from the ones that use the emergency department strictly because of lack of access or insurance. This misuse leads to excessive wait times, negative outcomes for time critical emergencies and huge financial burdens on the institutions that render care.  At one hospital emergency room in South Carolina, the 50 most frequent patients averaged more than 20 visits in a calendar year with one individual averaging over 225 times per calender year since 2005. These 44 patients (exclusion of 6 patients who had appropriate visits for emergent conditions such as cancer, heart disease, diabetic complications, etc.) had  accounted for a $4.5 million write-off.  This issue is controversial  but important if you look at the math. Using approximately 5,000 emergency departments in the US with a conservative $2.5 million in write-offs from abuse of the system, this adds up to billions of dollars of wasted healthcare dollars nationally and millions of dollars that the local institution is forced to incur. The present solution by private insurers, Medicaid and Medicare is to  pass the costs of any inappropriate visits on to the patient.  Most of  these patients don't have the ability to pay and/or don't care to pay.  However, they still maintain the right to sue if it is perceived that something was missed.  This has led to emergency departments across the country performing extensive work-ups for non-existent ailments.
     Some local plans involve contracts and involvement of primary care, social work and emergency  department personnel.  A set of hospitals in Texas with such a system in place noted approximately $2 million less in write-offs after implementation. There was also positive patient feedback and improved care.  These patients are entitled to a medical screening exam (MSE) but may not meet criteria for their treatment of choice.  The  treatment should be based on a discussion with all parties involved to avoid further abuses.  The system should be set up to review the charts of the most frequent visitors each quarter by a panel consisting of physicians, attorney and laymen. If this panel feels that abuse is occurring,  the patient should then be offered a training session with a social worker.  It should be determined as to what the stumbling blocks are for each patient and  help them obtain appropriate access in the community as well as  training on what constitutes appropriate visits.  A treatment plan should also be implemented by the primary physicians for emergent visits so that the emergency physicians and patients are on the same page.  This had led to better patient satisfaction in Texas as the patients did not have unrealistic expectations since it was spelled out. This approach would not exclude treatment for appropriate visits for the same patients.  If the patients continue to abuse the system, however, they should then lose the right to sue for a period of time (say 2-3 years) if something is missed on a MSE.  Unfortunately,  they have cried wolf too many times and have unfairly burdened the system.  The Emergency Medical Treatment and Labor Act (EMTALA), an unfunded federal mandate, already approves the use of the screening exam only but most hospitals and emergency physicians are uncomfortable with the potential increased liability or turning people away. This is one possible solution to this issue. Maintaining the Emergency Medical Treatment and Labor Act (EMTALA) is important as a safety net but should include immunity for acceptable medical screening exams or if patients don't followup as advised. This should again lessen the prevalence of defensive medicine and make patients more accountable for their own actions.
     Geographical variations and disparities in care also need to be addressed with worsened outcomes in the Southeast, urban and rural regions due to limited access to providers and resources. Ways must be found to encourage physicians, particularly primary care physicians, to work in these under served regions and improve social services to address social barriers that interfere with obtaining adequate care for these patients.  This would lessen the burden on the emergency departments which are the safety net and would allow more efficient treatment for all emergency department patients. However, the emergency departments will continue to be where a large number of citizens get their primary care needs met until the primary care shortage is reversed.  This was evidenced in Massachusetts which had a 7% increase in emergency department visits even after people were insured, as there were no primary care practitioners available for routine care.  If  the emergency departments are to survive and remain the safety net for a community, the above concerns need to be considered. 
     Thanks for taking the time to review these important items that will be crucial to any healthcare reform proposal.

     Sincerely,
    
     Board of Directors of the Association of Emergency Physicians
     
     Officers:
     Jim Hayes MD FAAFP, President
     Ellyn Meshel MD FAEP, Chairman
     Jeffrey Bates MD FAEP, MS, Vice President

     Board Members:
     Luis Saldana MD MBA, FAEP, FACEP
     John Newcomb MD FAAFP, FACEP
     Darryl Barksdale DO, FAEP, MS
     Gregory Neyman MD
     Steven Henson MD
     Ramachandran Madhavan MD FAEP, EMDM
     James Meade MD FACS, FAAEP
     H. Kyle Sheets MD
    
www.aep.org        9/27/09

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