In these post-election days of uncertainty, when the words "repeal and/or replace" are echoed in many circles, there are a few issues meriting clarification and particular emphasis.
First, emergency physicians have championed the issue of patient access for decades. The American College of Emergency Physicians (ACEP), emergency medicine's largest professional association began in 1968, with patient access as a primary mission to American society. This issue is of central importance, as our population continues to age, coincidental with the increasing age of emergency department patients, however there are substantial risks in this environment for adults as well for children. A just released Children's Health Fund report1 noted that "approximately 28% of children in the U.S. still do not have full access to essential health services."
Second, emergency physicians' commitment to their patients is no more clearly evident than in the prudent layperson definition of an emergency, established in Sally Richardson's letter2 in 1998 and in the Affordable Care Act. Today it is especially important and significant to review this definition here:
"The Balance Budget Act defines emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body functions or serious dysfunction of any bodily organ or part. While this standard encompasses clinical emergencies, it also clearly requires managed care organizations to base coverage decisions for emergency services on the severity of the symptoms at the time of presentation and to cover examinations where the presenting symptoms are of sufficient severity to constitute an emergency medical condition in the judgment of a prudent layperson."
This definition is a central issue in every emergency medicine physician contract with insurance companies. Prior to the standard being formally promulgated in the Federal Balance Budget Act of 1997, insurance companies were denying patient claims for a variety of reasons, but it was clear the Federal government had confirmed the central importance of recognizing and respecting the patient's perception of their illnesses upon coming to the emergency department regardless of the final diagnostic outcome. It is the patient's presenting symptoms that carry the day, not the final diagnosis. This nuance heightens the significance of the experience, skill-set and knowledge of emergency physicians who must engage their patients frequently without any prior history, faced solely with the presenting picture of illness and/or accident as presented by the patient. This allows the emergency physician to make the diagnosis of an emergency, not the patient or an insurance representative over the phone. Experience showed that to do otherwise unacceptably put patient lives at risk, a fact emergency physicians testified to during the creation of the law.
The issue being challenged again by the insurance industry is their desire to refuse payment, and shift costs on to the back of their patients through high deductibles and co-pays, with only the health of their bottom line as a beneficial outcome. This exponential increase in patient responsibility harkens back to the HMO insurance era when the prudent layperson definition of an emergency was created. An October 2015 survey by ACEP3 showed the following results:
1. Seven in 10 emergency physicians responding to a new poll are seeing patients with health insurance who have delayed seeking medical care because of high out-of-pocket expenses, high deductibles or high co-insurance.
2. Nearly three-quarters (73 percent) reported seeing increased numbers of Medicaid patients who have delayed medical care, because health plans are failing to provide adequate numbers of primary care physicians ("narrow networks").
3. A recent survey of registered voters conducted by Morning Call Consult for the American College of Emergency Physicians found4 that 30 % of respondents said they delayed or avoided emergency medical care out of fear of costs.
Emergency physicians have coupled the prudent layperson concept with championing patient access to secure fair insurance company payment for emergency services. It has by no means an easy path to secure these hallmark principles.
Third, The Emergency Medical Treatment and Labor Act (EMTALA) formally established by Congress in 1986 is a hallmark of emergency medicine, establishing the unfunded mandate requiring everyone presenting to an emergency department receive a medical screening examination, regardless of their ability to pay for the services provided to them. This federal law set the standard for emergency medicine care being available to all patients 24/7/365. Emergency medicine today provides the highest incidence of EMTALA mandated care among all medical specialties.5
Now let's establish a few related and very significant facts about emergency medicine.
1. As specified in Federal law, emergency physicians do not bill insurance companies and patients at different rates, nor at different charge levels. This is an erroneous perception commonly promulgated in lay articles.
2. Emergency physician, professional-fee bills only on unusual and very rare occasions reach into the thousands of dollars. If any emergency physician, professional-fee bill reaches into 4 figures at all it would necessarily mean the service provided by the emergency physician was at the ceiling of his/her skill-set and with the patient's life at stake.
3. Expanding the scope of emergency care to include EMS to the patient's final disposition, including laboratory and radiology, emergency medicine accounts for just 2% of our nation's health care expenditures.6
4. The Federal government and insurance companies pay far less than the billed charges. In point of fact the average emergency physician reimbursement across the nation is in the hundreds of dollars. EM experts believe the average professional fee payment per emergency department visit is approximately $160 per visit with geography, payer mix, Medicaid expansion or not and extent of out-of-network billing restrictions potentially influencing the number. This is certainly far below the thousands of dollars commonly portrayed today in many industry articles. This is coupled with the reality that many patients cared for in emergency departments actually pay the physician nothing for their care. This is referred to as charity care. We make the distinction between charity care, that for which no payment is expected and uncompensated care, which you expected to be paid, but received nothing.
Putting this issue of cost in a broader, societal perspective Jones7 notes Americans were projected to spend $82.83 this year on Halloween. Lake8 notes Americans today spend $100/month solely on fast food, or $1,200 annually. Pressman9 reports the average monthly American cable television bill is $103. Lazar10 notes the average monthly American auto payment for a new car is $493.
5. The current and increasingly pervasive issue of out-of-network balance billing issue as it applies to emergency medicine is simply one of emergency physicians rightfully insisting on fair reimbursement for their services. Unlike other physician specialists, emergency physicians may not turn patients away if they have no insurance, cannot pay for their care, or cannot afford their co-pay or deductible. In other words no patient, regardless of their ability to pay, may be turned away from the emergency department for any reason. This is US federal regulatory law, the aforementioned EMTALA Act.
6. No one has ever considered Medicare, and definitely not Medicaid, as a system of fair reimbursement. Medicare reimbursement amounts have been based on federal budgetary considerations rather than on what physicians have been customarily paid. To consider either or both of these rate structures, or even a system based on a modicum reimbursement factor above Medicare reimbursement rates, would bankrupt many emergency practices and departments across the country. It would also harken our healthcare system back to the days when emergency departments were routinely staffed by non-certified physicians.
7. The exploding system of retail healthcare and urgent care center development has had virtually no impact on emergency department visits in the country. Pines11 reports that retail clinics have done nothing to reduce the lower acuity patient visits to emergency departments. These visits occur due to the lack of patient access to primary care and/or the lack of an ability to secure an appointment. Clearly Americans trust emergency physicians to deliver high quality, expert and efficient care when they are concerned they have an emergency condition.
8. Emergency department visits continue to rise in both volume and also acuity. This year emergency departments are tracking at 150,000,000 patients. To put this in perspective this translates to 5 patients per second; 18,000 patients per hour; or 411,000 patients per day treated in our emergency departments. This daily number of patients treated in our emergency departments equates to approximately the population of Oakland, CA.
As the baby boomer population ages, Americans are surviving longer with more chronic conditions, making the patient population and management of them by emergency physicians more complex. This coupled with the fact people are delaying care due to concern about insurance coverage and/or cost (i.e. high deductibles) heightens the significance of the importance of emergency physicians and the central place and function they hold and serve in our healthcare system.
9. The current insurance company mega-mergers being considered involving Aetna-Cigna and Anthem-Humana reportedly involve a price tag of $90 billion.12 In today's healthcare marketplace it is a frequent call-to-action that physicians and insurance payers move toward a more amicable and conciliatory working relationship. Insurers commonly refer to "surprise bills" while emergency physicians refer to "surprise coverage."13 In this context it is critically important to distinguish the emergency physician, professional-fee payment as contrasted with hospital, facility-fee payments, with the former being dramatically less than the latter, as explained above. A reimbursement increase of as little as 1% of the $90 billion insurance industry mega-mergers to emergency physicians could potentially move this needle, in the sense of both advancing better relationships between insurers and emergency physicians, as well as easing strained relationships between patients and emergency physicians.
10. The bottom line is emergency medicine is a central and stable rock, in a healthcare system that continues to change and evolve. Emergency physicians continue as the safety net of the system; in many ways and for many patients they are the only net. Regarding healthcare costs, the above note of emergency physician, professional-fee payments, on average, being $160 per patient visit certainly puts the issue in perspective, demonstrating emergency physicians are not a central problem today in American healthcare. Their proposed solution is to utilize an independent, transparent charge database, such as Fair Health, coupled with fair coverage for our patients. Model legislation will potentially also include a minimum benefit standard as well. In the meantime, amid all of the evolving changes in our healthcare system, emergency medicine remains a rock solid, stable constant, always there for Americans, always reliable, 24/7/365.
1 "UNFINISHED BUSINESS: More than 20 Million Children in U.S. Still Lack Sufficient Access to Essential Health Care" Children's Health Fund. November 2016.
2 Richardson, Sally. Letter to State Medicaid Directors, February 20,1998.
3 "Insurance Industry Drives Patients to Sacrifice Necessary Medical Care." October 26, 2015. ACEP
4 "Morning Consult Intelligence. September 8-10-2016. http://newsroom.acep.org/statistics_and_reports?item=30145
5 " Physician Marketplace Report: The Impact of EMTALA on Physician Practices." American Medical Association. February 7, 2003.
6 "U.S. Health Care Expenditures and Emergency Care: Can Emergency Visits Be Prevented? Will Significant Costs Be saved?" American College of Emergency Physicians. https://www.acep.org/uploadedFiles/ACEP/newsroom/NewsMediaResources/StatisticsData/Just%202%20booklet.pdf
7 Jones, Charisse. "Americans to Spend $82.93 per Shopper on Halloween." USA Today, September 22, 2016.
8 Lake, Rebecca. "Fast Food Statistics: 23 Shocking Facts and Habits." Credit Donkey. May 30, 2015.
9 Pressman, Aaron. "The Average Cable TY Bill Has Hit a New All-Time Record." Fortune, September 23, 2016
10 Lazar, Michael. "The Average American Auto Payment Is..." Huffington Post. March 7, 2016.
11 Pines, Jesse, MD. Why Retail Clinics Do Not Substitute for Emergency Department Visits and What This Means for Value-Based Care. Annals of Emergency Medicine. October 2016.
12 Teichert, Erica. "Anthem-Cigna merger trial to start next week." Modern Healthcare. November 14, 2016.
13 Murphy, Brooke. "5 More Thoughts on Balance Billing from the President of ACEP." Becker's Hospital Review. February 24, 2016.
Authors:
John G. Holstein, Director of Development
Zotec Partners
James Augustine, MD, FACEP, Board Member
American College of Emergency Physicians
Jay Kaplan, MD, FACEP, Immediate Past President
American College of Emergency Physicians
Rebecca Parker, MD, FACEP. President
American College of Emergency Physicians
Alex M. Rosenau, DO, CPE, FACEP, Past President
American College of Emergency Physicians
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