ED bill would address access, funding

Washington -- Emergency physicians are taking another crack at pushing legislation they say is vital for tackling a growing access and readiness crisis in the nation's emergency departments.

Rep. Bart Gordon (D, Tenn.) last month introduced the Access to Emergency Medical Services Act of 2007, which is endorsed by the American College of Emergency Physicians. Sen. Debbie Stabenow (D, Mich.) has prepared a Senate companion bill but has not introduced it yet.

The bipartisan legislation seeks to ameliorate some problems identified in a landmark Institute of Medicine report series in June 2006, which characterized EDs as overcrowded, underfunded and unprepared to respond to disasters. Lawmakers introduced similar legislation in the previous Congress, but the bills never received floor consideration in either chamber.

This year's version would require hospitals to report statistics to the Dept. of Health and Human Services on how long they took on average to move patients from the ED to inpatient beds -- giving an indication of how much each hospital engages in patient boarding in the ED. Hospitals would not be allowed to participate in Medicare unless they provided this information, which HHS would make publicly available.

Emergency physicians from Albuquerque, N.M., to Rochester, N.Y., are complaining that excessive boarding by hospitals is making a critical situation even more dire, said Nick Jouriles, MD, an emergency physician in Akron, Ohio, and an ACEP vice president. A hospital that boards a patient in the ED to free up an inpatient bed cuts down on the capacity of the emergency department and imposes an added strain on the physicians who work there.

While the situation is manageable for physicians such as Dr. Jouriles, who typically must deal with boarding times in his ED of three or four hours, conditions are much worse for departments that care for boarded patients for three or four days at a time, he said. In the extreme cases, patient boarding helps take up more beds than the ED has in the first place, forcing physicians to take care of patients in hallways and other areas not designed for treatment. He fears that the situation is becoming more prevalent.

"The physicians who are worse off say, 'Two years ago we were where you are now,' " he said. "I can see that if we don't get this fixed, it's going to be here as well."

In addition to wreaking havoc on the facility's disaster preparedness level by drastically reducing its surge capacity, such a situation can lead to substandard care for any patient who comes to the ED, said Linda L. Lawrence, MD, an emergency physician in Fairfield, Calif., and president-elect of ACEP.

"We're talking about patients laying in the hallway, having to use bedpans and get part of their exams there," she said. "Is that the kind of care and privacy and dignity that we should be providing our patients? I don't think so."

Dr. Lawrence and Dr. Jouriles anticipate that the prospect of the government publicly releasing boarding information would give hospitals an incentive to improve their records. Currently, more incentives exist for hospitals to continue boarding, whether to free up more beds for higher-paying elective surgery patients or to deal with nursing shortages in certain departments.

Medicare reform in, tort reform out

Patient boarding is only part of the problem facing struggling EDs.

The legislation also seeks to bolster the care given to ED patients by including a 10% Medicare rate boost to emergency department physicians starting in 2008. This add-on, which would apply to any Medicare patient covered by the umbrella of the Emergency Medical Treatment and Active Labor Act, would be on top of whatever payment increase the AMA and other physician organizations might obtain by pushing congressional action this year.

The relatively modest payment adjustment would allow EDs to invest in more manpower and medical technologies to handle emergency situations in the way that people expect they will, Dr. Jouriles said.

"We're hoping this small amount of money will at least shine the light on the fact that we need to reorganize our priorities to match what the American people want with what we're actually doing," he said.

Emergency department physicians are not the only ones who would benefit from the new pay rate. Medical specialists, many of whom say they are being forced to reconsider their ED on-call status due to insufficient reimbursement levels combined with ballooning medical liability costs, also would get the payment add-on for care provided in the emergency setting.

The version of the bill from the last Congress would have taken a further step on the medical liability side by proposing added legal protections for physicians who provided care under EMTALA. But with the change in party control on Capitol Hill, ACEP felt that this issue no longer had broad enough support with congressional leaders, Dr. Lawrence said. Democratic lawmakers in general are opposed to capping medical liability damages.

But the liability issue is not completely going away. The bill calls for a special commission to examine the problems identified in the IOM reports and recommend legislative changes to Congress. The panel, which would include emergency physician representatives, could propose legal revisions in its final report.