Looking Ahead to 2012

While the 2012 elections may still be a year away, campaign season has already begun. The action is heating up in Iowa, with frequent visits by the Republican frontrunners, and even President Obama finding time to check in on the Midwest. While they speak of big changes for the future, the past year has been devoted to crisis-driven legislation, with our divided government seemingly only able to make a decision with a deadline hours away on critical financial issues. This focus on the immediate crisis (first the federal budget, then the debt ceiling) has taken legislators’ time and attention away from the ongoing crises facing medicine: medical liability reform and threats to Medicare reimbursement.

As advocates of emergency physicians and emergency patients, we have promoted HR 157. This legislation would improve liability protection for emergency physicians and on-call physicians providing emergency care and would thus improve emergency patients’ access to specialists. In addition, we have continued to advocate for a long-term fix to the Sustainable Growth Rate (SGR), the formula used to calculate Medicare physician reimbursement. Without a legislative patch, the SGR mandates a 29.4% cut in Medicare’s payments to physicians on January 1st, 2012.

These critical legislative issues were addressed at the first meeting of the Emergency Medicine Action Fund in Washington, D.C. on July 14th. Representatives from each of the 18 groups that hold seats on the Board of Governors attended the inaugural meeting. President Nathan Deal and I attended as your EMRA representatives. Each of the other five stakeholder organizations (American Academy of Emergency Medicine, Association of Academic Chairs of Emergency Medicine, American College of Osteopathic Emergency Physicians, Emergency Department Practice Management Association and Society for Academic Emergency Medicine) was also represented, along with ten groups and coalitions who made large donations to the Action Fund.

ACEP’s Washington, D.C. staff partnered with our health policy consultants to provide an overview of the legislative and regulatory scene from our nation’s capitol. We discussed the popular legislation to repeal the IPAB (Independent Payment Advisory Board), which is gathering cosponsors in both the House and the Senate, and the growing momentum of HR 5 (the HEALTH Act), which would improve the medical liability climate for all providers. However, our discussions focused on the regulatory issues which will be the focus of the Action Fund’s work.

At the Centers for Medicare and Medicaid Services (CMS), excitement abounds over the potential of Accountable Care Organizations (ACOs). These groups of providers would assume responsibility for a defined population of Medicare beneficiaries and work to provide high-quality care while reducing overall costs. If the ACO succeeds at these dual goals, Medicare would then share the cost savings in part with the provider network.

CMS has yet to finalize the rules for how these systems will work, and they remain controversial amongst providers. Many are concerned about the millions of dollars in start-up costs required to form an ACO. Smaller physician-based groups (rather than large hospital systems, like the Mayo Clinic) may find it impossible to raise the capital required to become an ACO and may never reap the shared savings necessary to pay back their initial investment. The rise of ACOs may pressure the two-thirds of emergency physicians working in practice groups contracted with hospitals to instead become hospital employees. In addition, the 65 quality measures used to determine the quality of care provided may be added to existing quality measures already in place, and the burden on physicians to report dozens of measures may become unmanageable.

ACEP has already produced a comment letter for review by CMS while they consider the final rules for ACOs. However, our leverage as a specialty is improved by the formation of the Action Fund. Through the Action Fund, multiple organizations (including ACEP, EMRA, AAEM, SAEM, ACOEP, and many practice groups) can speak to critical regulatory organizations like CMS with one voice—requesting a role for emergency physicians in ACOs, optimal ability for physician groups to join ACOs, and minimally burdensome quality reporting requirements.

Other potential changes to Medicare reimbursement were also discussed, including the national pilot program on Payment Bundling which will begin in 2013, the latest in Value Based Payment, and the evolution of the Physician Quality Reporting System (PQRS). While reporting quality measures will yield financial incentives (0.5% increase in payments) through 2014, penalties will be initiated in 2015 (-1.5% of your Medicare reimbursement for failing to participate). The good news is emergency medicine has established a great track record of participation and has the highest participation percentage of all specialties, with 63% of eligible practitioners submitting data. We must, however, continue our efforts to ensure that these quality measures offer a reasonable and evidence-based assessment of the excellent care we provide.

A recent flawed measure has been introduced which penalizes emergency physicians for frequently obtaining brain CTs on Medicare patients with an atraumatic headache. Unfortunately, there is no high-quality evidence to define the appropriate usage of brain CT on patients over age 65 with acute headache, so this measure is not evidence-based. In addition, the measure analyzes the utilization rate of brain CT, instead of analyzing the appropriate usage of this imaging in a given patient population. For these reasons, ACEP and the Action Fund will continue to work with CMS to modify or eliminate this measure from their quality reporting system.

Several new quality measures for emergency medicine have been recently proposed, including the use of anticoagulation for acute PE; pregnancy test for female abdominal pain patients; ultrasound determination of pregnancy location for pregnancy patients with abdominal pain; and Rhogam for Rh(-) pregnant women at risk of fetal blood exposure. ACEP and emergency physicians were instrumental in the development of these measures, which provide a reasonable analysis of the quality of care we provide in the ED. Working as a team on the Action Fund, we can continue to promote evidence-based quality measures and fair reimbursement for emergency physicians.

Early in residency, many of these issues may seem like part of a distant future, but the legislation and regulations being established now will shape our employment environment for decades into the future. Will ACOs put independent physician groups out of business? Will you be expected to report hundreds of quality measures to the government by 2025? EMRA is representing your future interests with our seat at the table on the Action Fund.

All of the members of the Action Fund agree that your training is important; the group identified issues of emergency medicine workforce, training, and education as a top issue for the Fund in the coming year. The Action Fund will be seeking ways to influence regulators to expand GME funding and increase the availability of residency-trained emergency physicians to serve emergency patients nationwide. As your Legislative Advisor, I am excited to represent emergency medicine residents at this critical time in healthcare.

While the 2012 elections may still be a year away, campaign season has already begun. The action is heating up in Iowa, with frequent visits by the Republican frontrunners, and even President Obama finding time to check in on the Midwest. While they speak of big changes for the future, the past year has been devoted to crisis-driven legislation, with our divided government seemingly only able to make a decision with a deadline hours away on critical financial issues. This focus on the immediate crisis (first the federal budget, then the debt ceiling) has taken legislators’ time and attention away from the ongoing crises facing medicine: medical liability reform and threats to Medicare reimbursement.

As advocates of emergency physicians and emergency patients, we have promoted HR 157. This legislation would improve liability protection for emergency physicians and on-call physicians providing emergency care and would thus improve emergency patients’ access to specialists. In addition, we have continued to advocate for a long-term fix to the Sustainable Growth Rate (SGR), the formula used to calculate Medicare physician reimbursement. Without a legislative patch, the SGR mandates a 29.4% cut in Medicare’s payments to physicians on January 1, 2012.

These critical legislative issues were addressed at the first meeting of the Emergency Medicine Action Fund in Washington, D.C. on July 14. Representatives from each of the 18 groups that hold seats on the Board of Governors attended the inaugural meeting. President Nathan Deal and I attended as your EMRA representatives. Each of the other five stakeholder organizations (American Academy of Emergency Medicine, Association of Academic Chairs of Emergency Medicine, American College of Osteopathic Emergency Physicians, Emergency Department Practice Management Association and Society for Academic Emergency Medicine) was also represented, along with ten groups and coalitions who made large donations to the Action Fund.

ACEP’s Washington, D.C. staff partnered with our health policy consultants to provide an overview of the legislative and regulatory scene from our nation’s capitol. We discussed the popular legislation to repeal the IPAB (Independent Payment Advisory Board), which is gathering cosponsors in both the House and the Senate, and the growing momentum of HR 5 (the HEALTH Act), which would improve the medical liability climate for all providers. However, our discussions focused on the regulatory issues which will be the focus of the Action Fund’s work.

At the Centers for Medicare and Medicaid Services (CMS), excitement abounds over the potential of Accountable Care Organizations (ACOs). These groups of providers would assume responsibility for a defined population of Medicare beneficiaries and work to provide high-quality care while reducing overall costs. If the ACO succeeds at these dual goals, Medicare would then share the cost savings in part with the provider network.

CMS has yet to finalize the rules for how these systems will work, and they remain controversial amongst providers. Many are concerned about the millions of dollars in start-up costs required to form an ACO. Smaller physician-based groups (rather than large hospital systems, like the Mayo Clinic) may find it impossible to raise the capital required to become an ACO and may never reap the shared savings necessary to pay back their initial investment. The rise of ACOs may pressure the two-thirds of emergency physicians working in practice groups contracted with hospitals to instead become hospital employees. In addition, the 65 quality measures used to determine the quality of care provided may be added to existing quality measures already in place, and the burden on physicians to report dozens of measures may become unmanageable.

ACEP has already produced a comment letter for review by CMS while they consider the final rules for ACOs. However, our leverage as a specialty is improved by the formation of the Action Fund. Through the Action Fund, multiple organizations (including ACEP, EMRA, AAEM, SAEM, ACOEP, and many practice groups) can speak to critical regulatory organizations like CMS with one voice—requesting a role for emergency physicians in ACOs, optimal ability for physician groups to join ACOs, and minimally burdensome quality reporting requirements.

Other potential changes to Medicare reimbursement were also discussed, including the national pilot program on Payment Bundling which will begin in 2013, the latest in Value Based Payment, and the evolution of the Physician Quality Reporting System (PQRS). While reporting quality measures will yield financial incentives (0.5% increase in payments) through 2014, penalties will be initiated in 2015 (-1.5% of your Medicare reimbursement for failing to participate). The good news is emergency medicine has established a great track record of participation and has the highest participation percentage of all specialties, with 63% of eligible practitioners submitting data. We must, however, continue our efforts to ensure that these quality measures offer a reasonable and evidence-based assessment of the excellent care we provide.

A recent flawed measure has been introduced which penalizes emergency physicians for frequently obtaining brain CTs on Medicare patients with an atraumatic headache. Unfortunately, there is no high-quality evidence to define the appropriate usage of brain CT on patients over age 65 with acute headache, so this measure is not evidence-based. In addition, the measure analyzes the utilization rate of brain CT, instead of analyzing the appropriate usage of this imaging in a given patient population. For these reasons, ACEP and the Action Fund will continue to work with CMS to modify or eliminate this measure from their quality reporting system.

Several new quality measures for emergency medicine have been recently proposed, including the use of anticoagulation for acute PE; pregnancy test for female abdominal pain patients; ultrasound determination of pregnancy location for pregnancy patients with abdominal pain; and Rhogam for Rh(-) pregnant women at risk of fetal blood exposure. ACEP and emergency physicians were instrumental in the development of these measures, which provide a reasonable analysis of the quality of care we provide in the ED. Working as a team on the Action Fund, we can continue to promote evidence-based quality measures and fair reimbursement for emergency physicians.

Early in residency, many of these issues may seem like part of a distant future, but the legislation and regulations being established now will shape our employment environment for decades into the future. Will ACOs put independent physician groups out of business? Will you be expected to report hundreds of quality measures to the government by 2025? EMRA is representing your future interests with our seat at the table on the Action Fund.

All of the members of the Action Fund agree that your training is important; the group identified issues of emergency medicine workforce, training, and education as a top issue for the Fund in the coming year. The Action Fund will be seeking ways to influence regulators to expand GME funding and increase the availability of residency-trained emergency physicians to serve emergency patients nationwide. As your Legislative Advisor, I am excited to represent emergency medicine residents at this critical time in healthcare.

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