ACEP: Health Reform for EDs, Too

John Commins, for HealthLeaders Media , April 15, 2009

Feeling neglected and marginalized in the debate over healthcare reform, nearly 400 emergency physicians from across the nation will head to Washington, DC, next week to make a case for improving patient access to emergency medical care and pushing Congress and the White House for a greater role in how healthcare is restructured.

"In all the discussions about healthcare reform, there has not been any discussion about emergency care. Not having a seat at the table is absolutely wrong," says Nick Jouriles, MD, an emergency physician at Akron (OH) General Medical Center and president of the American College of Emergency Physicians, which is hosting the April 19-22 meetings. "There has been absolutely no funding for emergency medicine. There has been no discussion about improving emergency care, or providing the resources that we need to provide the care that we've been providing."

Jouriles says the nation's emergency physicians treat 120 million people each year, yet account for only 3% of the cost of the $1.5 trillion spent on healthcare annually in the United States.

Emergency physicians are still stinging from a presidential snub last month when they weren't invited to a White House summit on healthcare. Jouriles says it is shortsighted and counterproductive for the people setting the debate over healthcare reform to exclude the physicians who are doing more than anyone else to hold together a crumbling healthcare infrastructure. Beyond providing healthcare to the estimated 47 million or so people in the United States who don't have health insurance, Jouriles says emergency physicians have become the de facto personal physicians of people with insurance but who can't access a primary care physician, including millions of Medicare and Medicaid patients.

"Most Americans have no access to care," Jouriles says. "No matter how we slice and dice the national need for healthcare, there is a certain amount of illness that we are going to have in this country and right now it's not being taken care of. Emergency care by default becomes the safety net for the entire infrastructure."

David H. Newman, MD, director of clinical research and an emergency physician at St. Luke's-Roosevelt Hospital Center in New York City, says the problems facing emergency departments are among the worst-kept secrets in healthcare.

"Everybody thinks these issues haven't been examined. But it's much worse. These issues have been examined and nobody cares," says Newman, author of Hippocrates' Shadow: Secrets from the House of Medicine—What Doctors Don't Know, Don't Tell You, and How Truth Can Repair the Patient-Doctor Breach.

"It's always a money thing. It's not about the greatest good for the greatest number. It's about whatever is going to get your biggest piece of the pie because that is what a hospital needs to survive," he says. "It doesn't make sense to fund your emergency department if you can do an outpatient plastic surgery procedure instead."

Lynn Massingale, MD, a board-certified emergency physician and the executive chairman of Knoxville, TN-base TeamHealth physician staffing service, says the nation doesn't have the primary care infrastructure in place to support universal healthcare. "Nobody talks about that," he says. "There is not primary care capacity for 47 million uninsured people in the United States. Even if you fund healthcare, who's going to take care of them? And it's going to take a long time for that capacity to materialize."

In addition to the 47 million or so uninsured, Massingale says there are another 25 million people who are underinsured with lousy coverage or too-high deductibles and another 10 million or 11 million illegal immigrants. "Nobody has said anything about coverage for those folks and nobody will," Massingale says.

Newman says emergency department volumes have increased dramatically over the last 20 years as the rest of the healthcare infrastructure has crumbled. "It's not a coincidence," he says. "It's like the financial crisis. There is money to be made here and people are willing to play the Russian roulette game of not funding their emergency department, because they are willing to lay their bets, 30-to-1, that they aren't the ones who are going to wind up there."

A key item on the agenda of next week's 2009 Leadership and Advocacy Conference of the ACEP will be the effort to push Congress to enact the Access to Emergency Medical Services Act (S468), which would strengthen access to emergency care.

Massingale says emergency physicians need to rally around the bill. "That bill primarily would provide for some additional payments for both emergency physicians and more importantly, for the specialists who take call in the emergency departments," he says. "One of the biggest problems we have in the emergency department now is getting physicians on the medical staff to take call at the hospital. We have to have a mechanism to try to entice them to want to take call for the emergency room. This specifically calls for increased funding for all those people who take call in the emergency department. It's not just about getting emergency doctors paid to offset their losses on the uninsured."

John Commins is a senior editor with HealthLeaders Media.

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