IOM panel seeks lead federal agency on emergency care

It also recommends a five-year demonstration project to help states better coordinate emergency care. Physicians hope the report leads to action.

By Kevin B. O’Reilly — Posted July 10, 2006

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An exhaustive, 900-page series of Institute of Medicine reports released in June has confirmed what physicians have complained about for years: Emergency departments are overcrowded, underfunded, short of on-call specialists, poorly equipped for pediatric care, and woefully unprepared to handle the surge in patients that a major terrorist attack, disease outbreak or natural disaster would bring.

Emergency physicians hailed the findings.

"It's an external organization that has looked at my world and validated what we've been saying about emergency medicine for years," said Frederick C. Blum, MD, president of the American College of Emergency Physicians. "We sometimes get the sense that nobody's listening to us."

A. Brent Eastman, MD, chief medical officer of Scripps Health in San Diego and a member of the 40-expert IOM panel that released the reports, said there is a crisis in emergency care and that the reports are a "crucial first step in addressing this crisis."

The reports, which focus separately on hospital-based emergency care, pediatric emergency care and emergency medical services, were prepared over two years at a cost of $3 million and recommend:

  • Creating a lead federal agency within Health and Human Services to consolidate functions related to emergency care that are scattered across multiple agencies.
  • Appropriating $50 million for hospitals that provide large amounts of uncompensated care.
  • Enacting an $88 million demonstration program over five years to encourage states to create a more coordinated, regionalized and accountable emergency care system.
  • Giving the Emergency Medical Services for Children program $37.5 million annually for five years.
  • Developing Centers for Medicare & Medicaid Services incentives to discourage boarding and diversion of ED patients.
  • Conducting a study on research gaps in emergency care and potentially creating an HHS center to devise a strategy to close those gaps.
  • Improving research on the most effective and appropriate pre-hospital emergency medical services.

Physicians call for action

Since last fall, ACEP has pushed unsuccessfully for Congress to pass legislation that would increase Medicare reimbursement for emergency care by 10%, create incentives for hospitals to move ED patients more quickly to inpatient rooms, and bring emergency physicians and nurses under the umbrella of the Federal Tort Claims Act, which established a fund to pay litigation costs.

AMA Trustee Steven J. Stack, MD, a Memphis, Tenn., emergency physician, said, "Congress must act now to heal the emergency care system." Part of that fix, Dr. Stack said, should be to stop the scheduled 4.7% Medicare reimbursement cuts. With a recent survey of AMA members showing that 45% of them would decrease or stop seeing new Medicare patients if cuts go into effect, "more Medicare patients will face limited access to regular physicians and be forced to seek emergency care instead."

The IOM didn't address Medicare's physician pay formula in its report. On medical liability, the IOM recommended that another commission be formed to look solely at that politically contentious issue.

"They're punting, and maybe appropriately so, because [medical liability] is such a huge issue, much bigger than emergency care," said Steven Krug, MD, head of emergency medicine at Children's Memorial Hospital in Chicago and also chair of the American Academy of Pediatrics' committee on pediatric emergency medicine.

Dr. Krug applauded the IOM reports, especially the recommendation to increase funding for the Emergency Medical Services for Children program, which he said has been very successful in improving pediatric emergency care training and technological readiness.

"I think they hit a home run," Dr. Krug said of IOM's expert panel. "It remains to be seen whether those recommendations actually translate into action. I hope so."

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Code red

Here are some of the Institute of Medicine's major findings in recent reports concluding that the U.S. emergency care system needs an overhaul to be prepared to handle a major manmade or natural disaster:

  • Emergency department visits grew by 26% between 1993 and 2003, but during the same 10-year stretch the number of EDs declined by 425 and the number of hospital beds dropped by 198,000.
  • Patients are sometimes boarded in EDs for up to 48 hours waiting for an inpatient bed.
  • Ambulances were diverted 501,000 times in 2003 due to lack of available beds -- an average of once a minute.
  • Emergency medical services received only 4% of Homeland Security Dept. first-responder funding in 2002 and 2003.
  • Children account for 27% of ED visits, but only 6% of EDs have all the necessary equipment to handle pediatric emergencies.

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