1997 will be seminal year for emergency medicine
Now that the election is over, a number of health issues that will affect the practice of emergency medicine are moving to the forefront. "This year will be one of the seminal years in the history of American medicine," predicts Larry Bedard, MD, FACEP, president of the American College of Emergency Physicians (ACEP) based in Dallas.
"Emergency physicians, with their direct link to the patient population and communities will continue to play an increasingly important role in the design of health care delivery systems," says Charlotte Yeh, MD, FACEP, chief of emergency medicine at New England Medical Center in Boston and current chair of ACEP’s government affairs committee.
By far, the most significant piece of legislation for emergency medicine is the "Access to Emergency Medical Services Act," which is expected to be reintroduced and passed this year. When the bill was first introduced last year, many felt its chances of passing were slim. Due to grassroots involvement from emergency physicians and increased sponsorship in Congress, things now look much more optimistic. "We’re working very hard to have it introduced quickly, and we’re confident it will be passed," says Bedard.
"We are working now with support from both parties to reintroduce the ER bill in the 105th Congress with maximum support," said Rep. Ben Cardin (D-MD). "We’re very hopeful that this Congress will address this issue and other important managed care issues.
"We’re very encouraged since Congress passed the two-day hospital stay for moms. It shows their willingness to enact minimum standards," he explains. "This is an issue with broader, bipartisan support which has to be instituted at the federal level."
Other reform measures
The Family Health Care Fairness Act, a broader bill establishing minimum standards for all health plans that also includes a provision for the prudent layperson definition of an emergency, will be introduced by Rep. Charlie Norwood (R-GA).
"In the 1997 version, we hope to entirely eliminate pre-certification of emergency care by managed care plans," says Norwood.
Cost savings may be considerable but result in unnecessary complications, he adds. "The human costs have been all too high, as evidenced by the horror stories we are all familiar with of patients directed to nonemergency care with catastrophic results," Norwood says. "This has to stop, and the one certain way to accomplish it is to end managed care emergency pre-certification entirely."
The landmark agreement between ACEP and Kaiser regarding the prudent layperson definition of an emergency paved the way for federal legislation. "It was a breakthrough agreement, and [it] increased support and sponsorship for the legislation," says Bedard. "It’s the right idea at the right time. As we transfer people from fee-for-service to managed care, the patient with restricted choice always has a choice to come to the ED. We think this issue needs to be resolved on the federal level."
ACEP expects the legislation to be introduced within the next few weeks. "We are working on compromise language with Kaiser that will represent both the interests of emergency physicians and the patients we serve, as well as the interests of managed care organizations," says Yeh.
The bill then will be revised further and introduced in the House; a similar bill will be introduced in the Senate. "We anticipate a fair amount of interest and support for this legislation," says Yeh. "It has certainly captured consumer interest, and this is the year that we’ll make sure managed care successfully meets the needs of patients."
Emerging ED issues
Here are some other issues on the horizon that could affect emergency medicine’s patients and practices:
• Welfare reform. The recently enacted welfare law will deny Medicaid benefits to all legal immigrants for at least five years, except for emergency services. This will immediately increase the number of uninsured by at least 1 million, says Bedard.
The law does allow for legal immigrants to be eligible for emergency services, which will be problematic. "That will put emergency physicians in a strange situation," says Bedard. "We’re going to see a lot of people we can diagnose but won’t be able to treat. A patient will come in with a seizure, and I can give Valium or some drug to stop it, but [the patient may] not be eligible for follow-up care, such as being put on anticonvulsants."
The legislation will prevent the emergency physician from getting these uninsured patients into primary care settings. "If you have a patient with an upper respiratory infection who has real high blood pressure, you can either treat the blood pressure in a primary care clinic or wait until [the patient] has a stroke and almost dies, and that’s where it’s going to go," says Bedard. "On the back end we’ll see them in the ED a lot sicker."
"The president indicated he wanted to change it, and we agree it’s flawed," he adds. "This will have a significant adverse effect on public health issues in states like California, Texas, New York, and Florida, which have a lot of immigrants."
Clearly on the radar screen is welfare and Medicare reform, particularly as it returns to the state level for delineation of benefits, says Yeh. "We do have serious concerns that, without careful attention to how benefits are adjusted and reimbursed, it could have a significant impact on emergency departments, which legally, morally, and ethically will continue to provide care for these patient populations."
Emergency physicians should keep a close eye on changes in legislation affecting legal aliens and Medicaid and welfare recipients, she says. "We urge emergency physicians at the state level to keep a very close watch that these populations aren’t inadvertently hurt as a result of these changes."
• Gun control laws. Violence is the No. 1 public health issue facing ACEP and the nation, says Bedard. "There may be an assault on the assault weapon ban, with the Supreme Court hearing on the Brady Bill. As a society, we need to be ever vigilant about attempts to weaken gun control legislation." ACEP will vigorously oppose any backsliding on the issue, he adds.
• Drug abuse. "The AMA has set up a consortium on this issue, and Clinton and Dole talked a lot about it in the election, so hopefully there will be some movement on that issue," says Bedard. ACEP plans to pursue legislation to increase taxes on alcohol to fund health care.
• Insurance coverage for victims of domestic violence. Last year, the Health Security Act addressed the problem of insurance companies denying coverage for domestic violence on the basis of it being a pre-existing condition. "Still, there’s concern that insurance companies will try to get around that," says Bedard. "Legislation is still needed for continued funding for domestic violence programs."
• Funding of graduate medical education. Cutbacks in funding seem inevitable. "Last year, they said they’re only going to fund for three years, so if you’re doing a four-year residency or fellowship, it was no longer funded," says Bedard. "ACEP is very concerned this could have an adverse effect on several fledgling emergency programs."
The proposed funding cuts also would affect combined programs in training, such as internal medicine and emergency medicine. "It will also have a dramatic impact on critical fellowship training in emergency medicine, such as for EMS, toxicology, or pediatric emergency medicine, so we have major concerns if it goes through as recommended," says Yeh.
"There are not enough sufficiently qualified programs for emergency physicians, and we don’t want to see those programs hurt," says Yeh. "ACEP will be lending our support to ensure that funding continues."
Another concern is for-profit companies’ reluctance to fund research and graduate medical education. "I think that HMOs have an obligation to fund graduate medical education and/or research," says Bedard.
• Medicinal marijuana. State legislation was passed in California and Arizona legalizing use of marijuana for medicinal purposes and is expected to be reintroduced in Congress this year.
• Medicare and managed care. This year we are likely to see the transformation of Medicare to managed care. "Something has to be done to preserve the financial integrity of Medicare, and ACEP will be actively involved in the discussions and debate," says Bedard.
Managed care has positive side
"On the positive side, there will be an enhancement in coordination of care and improved access to primary care providers," says Yeh. "Those are the positive aspects of managed care. What we want to do with the Cardin bill is make sure a barrier isn’t inadvertently created, when patients can’t get care when they really need it."
Currently, the Medicare population has the lowest penetration of managed care of any large demographic group about 12% but that may soon change. "I think the government is going to give incentives for these patients to go to managed care, so we’ll see a tremendous influx of managed care patients in the ED," he says.
"The two age groups, which are the most difficult to treat and which emergency physicians tend to see, are the very young and old, so as more patients of Medicare age get on managed care programs, it will potentially compound the problems we have," Yeh says. "That’s one of the arguments we’ll make with the Cardin bill, that this is prophylactic medicine to address the issue."
With the shift from fee-for-service to managed care, there are concerns that huge conglomerates will place profits over patients. "As patient advocates, we must prevent this from happening," says Bedard.
"Right now, to put a program on managed care, you need to get a waiver from the federal government, and Clinton has already promised to make that process a lot easier," says Bedard. Medicaid managed care is growing rapidly throughout the country and is expected to be widespread by the end of the year.
• The President’s Commission on Health Care Quality. There’s no word yet on what the scope of the commission’s issues will be, but emergency medicine is likely to be among them.
• Public safety issues. The federal highway bill will have to be reauthorized, which will affect various injury control and safety programs involving the use of seatbelts, airbags, and drunk driving.
• Banning of "gag" rules. Last year’s bill to prevent insurers from putting gag rules in their contracts will likely be reintroduced this year. A number of states have passed similar legislation. "It’s something that’s equally abhorrent to patients and physicians that you as a patient advocate can’t tell them certain things they need to know to make the best decisions about health care," says Bedard.
"We all stand for open communication with consumers. Nobody should be prevented from saying or doing the right thing," says Yeh. "This issue is part of the overall trend towards a closer look at managed care, to take the good things it’s brought but consider regulating appropriate consumer protection."
• The uninsured. During the campaign, President Clinton talked about health insurance for children and the temporarily unemployed. The larger issue of 41 million uninsured Americans is what really needs to be addressed, says Bedard. "This is the single biggest unconfronted issue in health care," he adds. "This may get us 10% of the way there, but it’s a small step in the right direction."
• COBRA/EMTALA. These regulations will be clarified, redefined, and possibly amended. "The main issues are clarification of definitions, streamlining, and consistency of the enforcement process and improving the interface between delivery of emergency services and managed care expectations," says Yeh. "Our intent is to continue the benefits of patient protection that COBRA has brought, while at the same time making it workable with managed care procedures and policies."
ACEP was represented at a task force set up by the Health Care Financing Administration (HCFA) last summer. "We’re working with HCFA to review legislation for improvements in its regulations as well as enforcements," says Yeh. "Any regulatory change is typically a two- or three-year process, but we’re hopeful that the task force recommendations will eventually be implemented by HCFA."
An opportunity exists to amend COBRA so that managed care plans and their gatekeeper physicians are held accountable under the law. "I think they should be held legally responsible, and the only way to put health plans under COBRA is to change the legislation," says Bedard.
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