Conference this week was the ICEP Spring Symposium. The symposium included a Research Forum followed by presentations on the impact of the Affordable Care Act (ACA/Obamacare). I would suggest you read the ACA section of these notes with an eye for the following themes:
1. The nation’s current healthcare costs are generally agreed to be not sustainable
2. Emergency physicians have a key role in managing the healthcare costs of both the their individual institutions and the nation overall.
3. Emergency Medicine as a whole provides great value/low cost for the nation’s healthcare system.
4. With the ACA, ED visits are expected go up
5. Patients covered under the ACA may not fully understand the co-pays and coverage limitations that they have.
6. Healthcare systems like Advocate are tasked with moving from a model of generating revenue based on the volume of patients seen and procedures performed to a model of effectively managing the health of their patient population.
7. Illinois and many states have increased coverage under the ACA by increasing enrollment in Medicaid. By Jan 2015 at least 50% of the patients covered under the ACA Medicaid in Illinois will be in a managed care format.
8. Illinois is among the worst states in the country for EM in general and medical malpractice in particular.
2014 Research Showcase
Christ Presentation by Natalie Htet: FEIBA for ICH and life-threatening bleeding due to warfarin coagulopathy. FEIBA was more reliable and worked faster to reverse INR than FFP. FEIBA had more thrombotic events than FFP. Mortality was higher in the FEIBA group likely to more patients having care withdrawn in the ED. Also in the FEIBA group there were more ICH’s than in the FFP group. The FFP group was predominantly GI bleeders who have lower mortality than patients with ICH.
Dr. Htet presenting at ICEP
Stroger Presentation: U/ S evaluation of Dyspnea. They looked for B lines in the lungs, cardiac function and IVC. They looked at diastolic dysfunction as part of the cardiac evaluation. This standardized evaluation was less sensitive but more specific for diagnosing CHF than clinician gestault informed by exam, CXR and labs. Discussion following the presentation involved the validity of the gold standard for diagnosing CHF in this study.
Northwestern Presentation: Firearm injuries in Chicago in relation to day of the week and weather. More shootings occur on Friday & Saturday and with warmer weather (risk is 30% higher when temp is between 80-90). It was estimated that 26% of the risk of gun violence is due to ecological (weather) factors.
Rush Presentation: At presentation to the ED, demographic factors and clinical information of the patient can predict disposition. Earlier disposition decisions have been shown to shorten ED throughput time. Presenters developed a computerized decision algorithm that would provide an admit prediction to the triage nurse or ED physician and bed control. Elise comment: Not sure this is any improvement over physician gestault.
There were also poster presentations at ICEP
Dr. Beckemeyer with her study on how a new Triage Protocol for Abdominal Pain Reduced the Rate of Patients Leaving the ED Prior to Being Seen by a Physician
9 of the 35 Best Residents on the Planet. Thank you to Dr. Iannitelli for this photo!
Illinois gets a D- on the National EM Report Card for access to Emergency Care and a D for our Medical Liability environment. Poison Control Center funding is at risk.. Illinois is one of the bottom 10 states overall for emergency medicine. Elise comment: The only thing that makes me feel alittle better about being in Illinois as an emergency physician is that overall most states are at a C or D level.
There are many problems with FOID (Firearm Owners ID Card) notification requirements for emergency care providers. Technically every patient with a psychiatric complaint in the ED needs to be reported to the FOID agency.
Choosing Wisely Campaign for EM: EM as a specialty is advocating for the following 5 potential cost saving conversations with patients:
1. Avoid CT head for minor head injury.
2. Avoid urinary catheters.
3. Don’t delay the palliative care discussion with patients.
4. Avoid antibiotics and wound cultures for uncomplicated abscesses.
5. Avoid IV rehydration for kids with vomiting and diarrhea without attempting oral rehydration first.
Gerardi (ACEP President) Affordable Care Act: ACEP Perspective
Most of the money spent on healthcare in the US, stays in the US and benefits the US economy. Elise comment: True, but the high costs are a barrier to care for many people. We still need to work to lower costs for patients.
Cost of health insurance is increasing much faster than income growth in the US.
A common comment made in the media is that emergency care is very expensive. This was discussed many times throughout the day. We as emergency physicians have an obligation to inform others that Emergency Medicine is not expensive for the nation, rather it is a great value. Value=Quality/Cost. Emergency care accounts for only 2% of the US healthcare costs. Emergency physicians provide the bulk of acute care to the under and uninsured. Emergency physicians cover 67% of the nation’s unscheduled visits and 50% of hospital admissions.
Average spending on healthcare per person is much higher in the 65 and older group compared to younger ages. Also, in the US, expenditures in this 65 and older age group exceed other nations by far. The majority of healthcare spending occurs in a person’s last year of life. 70% of the population uses 10% of the healthcare. 1% of patients use 30% of the healthcare in the nation. These are called triple threats, they suffer from 3 or more comorbid illnesses.
ED visits continue to increase. The number of hospitals and ED’s are decreasing. Consequently, across the country, average ED size and # of visits have increased. ED’s generally are now large, complex systems.
Triple aim of healthcare reform: Better patient experience, better outcomes, lower cost. This will take a collaborative, team-based, patient-centered effort.
Affordable Care Act (ACA) provisions: Expand Medicaid eligibility, create insurance exchanges, cover dependents up to age 26, and there is a mandate for people to enroll. Patients cannot be denied coverage for pre-existing illnesses, essential health benefits will also be covered. These changes will likely result in increased ED visits.
Threats to emergency physicians: You will be less likely to be an independent physician and more likely to be a hospital employed physician. There is a risk of cuts to emergency physician reimbursement. Minute clinics such as those at Walmart and Walgreens will take away business from primary care docs. Free standing ED’s and urgent care facilities are drawing emergency physicians away from hospital based ED’s that care for the underserved. Nurse practitioners can practice without physician supervision.
ED ‘s can provide immunizations and wellness services to help the hospital meet it’s quality reporting goals. Patient wait times are an important measure to a hospital’s quality success.
ACEP has concerns about the Choosing Wisely Campaign (Campaign described above). They want to be sure that emergency docs won’t get sued if they do these action items. They also want to be sure insurance companies won’t refuse payment if an emergency physician acts counter to one of these recommendations.
ACEP expects that ED patient volumes will increase due to the changes brought on by the ACA (Obamacare)
In Illinois overall, inpatient admit days have decreased.
Illinois has the second highest level of payout for lawsuits in the Country.
Bronze plan of the ACA has a $5000 deductible for emergency care. This will be a unpleasant realization for many people.
Panel Discussion on ACA in Illinois
114,000 Illinois residents in addition to current Medicare enrollees signed up for the ACA.
Sticker shock is expected for ACA covered patients. They will learn as they access the healthcare system that there are significant co-pays and limitations of coverage.
If a patient has not kept up on their monthly payments for ACA insurance, providers may not get paid.
There may be some limitations to preventative care coverage and coverage for certain non-generic medications.
The emergency physician will need to be sensitive to costs when managing the patient covered by the ACA.
Attempts at developing a state-based insurance exchange in Illinois have been stymied by the insurance and small business lobby.
Triple aim again: Improve population health, improve the healthcare delivery system, and lower cost.
The ACA has unleashed the potential for disruptive healthcare delivery initiatives such as pharmacies providing healthcare or cable companies providing telemedicine.
Patients are going to be on the hook for more of their healthcare costs. Emergency Docs have to be very sensitive to the costs that our patients face.
Hospitals are all looking to cut costs based on the perception that re-imbursement for providing care will be decreasing over the next few years.
Hospital systems are changing their focus from acute care to prevention and wellness and long-term management of illness to improve their patient populations’ health.
There is a lot of anxiety in the hospital community and healthcare provider community over how all the change in healthcare is going to shake out.
Jan 2015 50% of Medicaid patients will be in a managed care environment.
On the positive side, there will be millions more patients in Illinois with some type of healthcare coverage.
There may be some pressure on emergency physicians to provide care in a way to keep patients out of the hospital. Emergency physicians will be key players in controlling hospital costs.
llinois is in the bottom 2 states regarding the medical liability climate. This affects how willing emergency physicians are to limit testing and discharge patients.
The ACA provides no increased funding for residency slots and training.
There is still strong job security for emergency physicians. Income security may have pressure in the next few years.
Mila comment: Are there means in the ACA to affect patient behavior to stay within their managed care environment? The ACA provides for community healthcare workers who can help patients make good decisions as to where they seek care.
There seems little political will to make any significant change in the medical malpractice environment in Illinois.
Audience comment: The ED provides rapid diagnosis and acute treatment. It is a US center of excellence for diagnosis. It provides patients the ability of getting a quick answer to their symptoms and get back to work more rapidly. This is an under-appreciated way that emergency medicine provides true value to our country.