Everybody has access

1. Everybody has access Walter Limehouse MD MUSC EmergMed

2. George W Bush - 2007 • “The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America,” … “After all, you • just go to an emergency room.” - as he vetoed expansion of S-CHIP from 6m to 10m children - Families could leave private insurance for fed-funded, state-run programs • http://www.cnn.com/2007/POLITICS/12/12/bush.schip/index.html

3. EMTALA - 1986 Emergency Medical Treatment & Labor Act • Federal law requires hospital EDs to screenevery patient who seeks emergency care & to stabilizeor transfer emergencies • regardless of health insurance status or ability to pay • unfunded mandatesince enacted • http://newsroom.acep.org/2009-01-04-emtala-fact-sheet

4. EMTALA • Part of Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 U.S.C. §1395dd) • "anti-dumping" law • prevent hospitals from refusing to see or transferring financially “undesirable” patients to public hospitals • at minimum, provide medical screening examination & treatment to ensure stability for transfer. • Hospitals & physicians violating EMTALA subject to • civil monetary penalties ($50,000 per violation) • threat of Medicare decertification.

5. EMTALA • de facto national health care policy for the uninsured • Medicare-participating hospitals with EDs must screen and stabilize patients with emergency medical conditions  in non-discriminatory manner • regardless of ability to pay, insurance status, national origin, race, creed or color. • 92% of all hospitalizations for uninsured • directly linked with ED visit

6. EMTALA • Emergency medical condition • “condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.” • Prudent layperson standard

7. EMTALA • applies when individual "comes to ED." • dedicated ED • "licensed by State . . . as an . . . ED” or “held out to public . . . as place providing care for emergency medical conditions." • hospital-based outpatient clinics not obligated under EMTALA unless providing more than 1/3 unscheduled care AND those 1/3 visits are emergency medical conditions as defined by the statute. • all aspects of emergency care • Specialists • all available tests & procedures • anything necessary to screen or stabilize emergency medical condition

8. EMTALA • Any individual who comes & requests examination or treatment of medical condition • must receive medical screening examination to determine whether an emergency medical condition exists • No delay to inquire about methods of payment or insurance coverage. • If emergency medical condition exists • treatment must be provided until resolved or stabilized. • If hospital without capability to stabilize the emergency medical condition • "appropriate" transfer to another hospital

9. EMTALA • Hospitals with specialized capabilities • obligated to accept transfers from hospitals without capability to treat unstable emergency medial conditions.

10. EMTALA • Stability for transfer • stable if treating physician determines no material deterioration likely to occur during transfer between facilities. • EMTALA does not apply • unstable, transfer requires • physician certifies medical benefits expected from transfer outweigh risks OR patient requesting transfer aware of hospital's obligations under EMTALA & risks of transfer.

11. EMTALA • "appropriate" transfer of unstable patients • transferring hospital - ongoing care within capability until transfer to minimize transfer risks • medical records • confirm that receiving facility has space, qualified personnel , agreed to accept the transfer • Transfer with qualified personnel & appropriate medical equipment.

12. EMTALA • Enforcement • CMS (hospitals) & OIG (hospitals and physicians • 2-year statute of limitations • Penalties • Termination of hospital or physician's Medicare provider agreement. • Fines • Hospital up to $50,000 per VIOLATION • Physicians $50,000 per violation, including on-call physicians. • Suits • hospital for personal injury in civil court under "private cause of action“ • receiving facility with financial loss as result of another hospital's violation of EMTALA can sue to recover damages.

13. EMTALA • Adverse outcome not necessarily indicate there is an EMTALA violation • violation can be cited without adverse outcome • no violation if a patient refuses examination &/or treatment unless there is evidence of coercion.

14. EMTALA • Who pays • We all do • greatest responsibility on hospitals & EPs providing this health care safety net • Some health insurance plans deny claims retrospectively for ED visits • based on patient's final diagnosis, rather than the presenting symptoms (e.g., when chest pain turns out not to be a heart attack • endangers health of patients & undermines emergency care system by failing to financially support America's health care safety net.

15. EM Facts / Myths • Most emergency patients insured • most with serious medical problems best treated in EDs • Emergency care < 2 % of US $2.1 trillion in health care expenditures • EDs treat 136 million people a year. (AHRQ 2008) • ED crowding complicated • EPs try to improve everyone’s access to emergency care.

16. EM Facts / Myths • Patients having medical emergencies require expertise of EPs to diagnose & treat them • Not to be second-guessed by health insurance plans. • EDs valuable to communities & are central part of medical neighborhood.

17. EM Facts / Myths • ED Crowding & non-urgent problems • < 8 percent of emergency patients classified as “non-urgent” by CDC (need to be seen 2 – 24h) • Non-urgent does not mean “unnecessary.” • CDC’s definition includes bone fractures and bronchitis. • Wait longest for medical care.

18. EM Facts / Myths • ED Crowding & non-urgent problems • Reducing number of non-urgent patients does little to reduce ER delays for sicker patients (triage), and hence does little to reduce crowding. • Many of these patients seek care when no other resources are available — in the overnight hours.

19. EM Facts / Myths • ED Crowding & minor problems • only 6.3 % of ED visits determined to have “primary care treatable” discharge diagnoses • Same chief complaints reported for 88.7 percent of all other emergency visits • substantial portion required immediate emergency care or hospital admission.

20. EM Facts / Myths • ED crowding & urgent care centers/health clinics • majority of people seeking emergency care need to be there • aging population increases need for emergency care • urgent care centers do not shrink number of people appropriately seeking emergency care every year.

21. EM Facts / Myths • EM &“Obamacare”? • The Affordable Care Act • expanded insurance coverage for many uninsured people • affirmed the “Prudent Layperson Standard,” which ensures that if a person thinks they need emergency care their health insurance company is not allowed to deny payment. • emergency departments continue to close because of low or no reimbursement for care by uninsured and Medicaid patients.

22. EM Facts / Myths • EM &“Obamacare”? • 15 million new people to Medicaid rolls does not guarantee them access to medical care. • Many physicians will not take Medicaid patientsbecause it reimburses so poorly so they go to EDs. • ACA does not address liability system & practice of defensive medicine.

23. EM Facts / Myths • ED efficiency • all of a hospital’s resources in one place EDs do in hours what could take patient days going from office to office for testing, specialty expertise and medication. • Ninety-seven percent of emergency physicians responding to a poll in 2011 reported treating patients at least once a day who had been referred to the ER by their primary care physician, often because the ER can accomplish quickly what a primary care office cannot.viii

24. EM Facts / Myths • ED efficiency • Emergency physicians treat 136 million people a year for just two cents out of every health care dollar, and their expertise ranges from pediatrics to geriatrics and from trauma to infection. • Emergency departments offer one-stop-shopping complete patient-centered care 24 hours a day, every day of the year for anyone who needs it.

25. EM Facts / Myths • ED Patients & insurance • Eighty-five percent of emergency patients have some type of insurance, either government (Medicare, Medicaid or SCHIP) or private. • ER is a health care safety net for everyone, not just the uninsured.

26. EM Facts / Myths • Cost-sharing for treating uninsured in Eds • uncompensated care has closed hundreds of emergency departments in the United States • significant burden for treating the uninsured bourne by EPs, providing thousands of dollars in uncompensated care every year

27. EM Facts / Myths • ED care expense • just 2 percent of all US health care spending • treats 136 million people a year. • difficult to put a price on the lives saved every day in EDs

28. EM Facts / Myths • Cost-sharing for treating uninsured in EDs • uninsured themselves charged highest rate for care. In fact, uninsured patients pay a higher proportion of emergency department charges than Medicaid patients. • Less than 50 percent of all emergency department charges are reimbursed. • http://newsroom.acep.org/2009-01-04-myths-and-facts-about-emergency-care

29. ED Frequent Users • Main Points • Most frequent users of the emergency department have serious medical problems only treatable in an emergency department • Most frequent users of the emergency department have regular source of medical care and health insurance • Emergency departments are safety net for everyone, especially these most vulnerable patients.

30. ED Frequent Users • Main Points • Emergency physicians committed to helping frequent users obtain access to ongoing care in their communities when appropriate and available. • Diverting frequent users of EDs to other sources of care not likely to reduce costs significantly.

31. ED Frequent Users • typical frequent users • Many with serious chronic illnesses like cancer or heart problems or sickle cell anemia. • Diseases not necessarily predictable & may require medical care on days they can’t get in to see their regular doctors • regular doctors may not have equipment or medicine to help them in office

32. ED Frequent Users • typical frequent users • “overwhelming majority of frequent users have only episodic periods of high ED use, instead of consistent use over multiple years.” Health Affairs, 2013 • subset with severe social issues (homelessness, drug addiction or psychiatric illness) in minority with no place else to go. • usually not admitted to hospital where majority of health care expenses are incurred.

33. ED Frequent Users • Cost for frequent users • 4.5 - 8 % of all emergency patients • responsible for 21 to 28 percent of all emergency department visits.  • emergency care constitutes approximately 4 percent of all health care spending • amount allocated to frequent users is not significant.

34. ED Frequent Users • focus on these patients? • Policymakers & states – particularly state Medicaid offices – looking to reduce health care costs. • EPs committed to this as well but many sources of rising health care costs are NOT in ED.

35. ED Frequent Users • focus on these patients? • largest sources of health care waste • unnecessary services, inefficient delivery • administrative costs, missed prevention opportunities • fraud. •   Policymakers & health insurers know fixes to these problems not quick, so easier to “demonize” patients unable to get care when needed

36. ED Frequent Users • ongoing primary care keep them out of ED • Many have regular, ongoing primary care. • but illness requires complicated interventions found in ED • Massachusetts General Hospital study: frequent users were NOT more likely to make emergency visits that could have been handled by a primary care physician.

37. ED & mental illness • role of untreated mental illness • High odds of coming to ED for mental health or substance abuse-related reasons suggests dearth of community resources contributes to frequent emergency visits for some patients. • Lack of resources for mental health emergencies well-documented, & every EP can talk about difficulties of treating psychiatric emergencies in system not equipped to handle them.

38. ED & mental illness • role of untreated mental illness • San Diego study: occasional & frequent psychiatric patients tend to visit more hospitals compared to non-psychiatric patients. • shows how great unmet needs of these patients are.

39. ED & mental illness • doctor shopping to get drugs • drug abusers may visit multiple health care facilities to obtain drugs • including different physician offices, clinics & EDs. • Without knowing patient’s history, EPs cannot always determine if patient has legitimate medical needs or just drug-seeking. • Many drug seekers have real pain. Eps’ first responsibility is to the patient & to relieve suffering.

40. ED & mental illness • doctor shopping to get drugs • Emergency physicians not in law enforcement. • But prescription monitoring programs very helpful to determine if patient is habitual drug-seeker • http://newsroom.acep.org/2009-01-04-frequent-users-of-the-er-fact-sheet

41. Everybody has access • EPs there to meet & treat 24/7/365