19 September 2009

Feeling Wonkish

Kids are sleeping and I've the house to myself, but I am feeling too lazy to practice karate so (what else?) I decided to flip through the 543 proposed amendments to the Senate Finance Health Reform Bill.

So there'll be lots of attention to Amendment 261-- "Schumer/ Cantwell C2: Establish Public option as passed by HELP Committee," as well as the classic Amendment 250 -- "Wyden C3: Exchange plans as good as Members of Congress."  But I thought I'd be a tad more provincial and see what's in the cards (possibly) that might affect Emergency Medicine.

Most notable, I suppose, are the Stabenow amendments 71-73. which seem to replicate the "Access to Emergency Services Act" language.  Stabenow D-6:
This amendment first establishes the United States Bipartisan Commission on Access to Emergency Medical Services to: (1) identify and examine factors in the health care delivery, financing, and legal systems that affect the effective delivery of screening and stabilization services furnished in hospitals that have emergency departments pursuant to the Emergency Medical Treatment and Labor Act; and (2) make specific recommendations to Congress within eighteen months of enactment with respect to federal programs, policies, and financing needed to assure the availability of such screening and stabilization services and the coordination of state, local, and federal programs for responding to disasters and emergencies.
Ok, a commission, that's nice.  And it touches on boarding in the ER as well:
Second, this amendment directs CMS to convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing, and other relevant disciplines to develop boarding and diversion standards for hospitals and guidelines, measures, and incentives for implementation, monitoring, and enforcement of such standards.
And also Stabenow D-7:
This amendment would provide a 5% Medicare reimbursement bonus for services provided by an emergency room physician or by an on-call specialist for services performed in an emergency room
This is significant because it's the first time (to my knowledge) there has been a funding source identified for this provision.  It should help to keep the on-call rosters full, to a limited degree.  Also also Stabenow D-8:
This amendment would eliminate the payment reduction for emergency room physicians and for services provided by on-call specialists in an emergency room that the Chairman‘s Mark identifies as an offset for the primary care/general surgery bonus.
Hmm. A carve-out for EM from the primary care bonus.  Sure, it's good for me, but I am not sure it's good policy.  Probably won't pass anyway.  Cantwell has what seems like a significant addition (D-2):
Hospitals committed to starting new osteopathic or allopathic residency training programs in one of eight medical specialties or a combination of specialties (family medicine, internal medicine, emergency medicine, obstetrics/gynecology, general surgery, preventive medicine, pediatrics, or behavioral and mental health) could secure start-up funding to offset the initial costs of starting such programs.
Not EM specific, but at least a little effort to address the physician workforce issue.  Menendez has a good point in the insurance regulation portion (C-6):
Each health care plan and health care insurance issuer offering coverage in the exchange shall provide enrolled individuals coverage for emergency services without regard to prior authorization or the emergency care provider‘s contractual relationship with the health plan. Further, enrollees may not be charged co-payments or cost-sharing for emergency services furnished out-of-network that are higher than in-network rates.
This is important.  It's hellish dealing with authorizations in the ED.  Kyl (C-24) has an interesting carve-out for ER docs (and specialists in the ER) with regard to malpractice:
This amendment would regulate lawsuits for health care liability claims related to the provision of services provided in the emergency room.
  • Set a statute of limitations of three years after the date of manifestation of injury or one year after the claimant discovers the injury, with certain exceptions.
  • Require a court to impose sanctions for the filing of frivolous lawsuits.
  • Limit noneconomic damages in a civil medical liability lawsuit to $250,000 from any provider or health care institution, not to exceed $500,000 from all providers and health care institutions. It would also make each party liable only for the amount of damages directly proportional to such party's percentage of responsibility.
  • Allow the court to restrict the payment of attorney contingency fees and limit the fees to a decreasing percentage based on the increasing value of the amount awarded.
  • Prescribe qualifications for expert witnesses.
  • Require the court to reduce damages received by the amount of collateral source benefits to which a claimant is entitled.
  • [and more]
I like it, but again, I see no reason why these common-sense provisions should be restricted to the ER only.

Bear in mind that all of these are just proposed amendments, not part of the actual bill itself.  Many (I daresay most) will not be incorporated into the actual bill.  Though the democrats are better than the republicans were in accepting minority amendments, it's relatively unlikely that many of them will be accepted.  It's also worth noting, I suppose, a couple of key points in the Chairman's Mark itself:
Page 17: Definition of Four Benefit Categories.
Four benefit categories would be available: bronze, silver, gold and platinum. No policies could be issued in the individual or small group market (other than grandfathered plans) that did not meet the actuarial standards described below. All health insurance plans in the individual and small group market would be required, at a minimum, to offer coverage in the silver and gold categories.
All plans must provide preventive and primary care, emergency services, hospitalization, physician services (and lots more)

So emergency services must be included in all health insurance plans.  Kinda common sense, but good to see it clearly defined.
Page 93: National Pilot Program on Payment Bundling.
The Secretary would be required to develop, test and evaluate alternative payment methodologies through a national, voluntary pilot program that is designed to provide incentives for providers to coordinate patient care across the continuum and to be jointly accountable for the entire episode of care starting in 2013.[...]
The pilot program may cover the following services: acute care inpatient hospitalizations; physician services delivered inside and outside of the acute care hospital setting; outpatient hospital services, including emergency department visits...
Not liking this so much.  Bundling seems like such a great idea, but when the ER docs' fee is bundled in with the hospitals' fees, well then you get a sticky situation.  How much does each party get? Who decides?  How can physicians retain any financial independence from their partner hospitals in this sort of model?  There's an old saying that "democracy is three wolves and a sheep voting on what to have for lunch." It's not entirely apt, but in this case the ER docs would be the sheep.

The other thing that I gained from reading this is a real appreciation of how tricky lawmaking really is.  This bill, after modification to some greater or lesser degree in committee, will need to be merged with the HELP committee bill and then (one hopes) with the House bill.   That's a real challenge!  Sure, there will be the big partisan battles, but all the little line items are the hard parts, I think. When you come to a provision like, say the Stabenow amendments, which have no clear partisan bias and a marginal effect on cost -- and bear in mind that there may be hundreds and hundreds of these in each bill -- how do you decide which are worthy of keeping, and which get tossed?  Presumably you can't keep them all, and many are probably in direct conflict.  Unless the advocate for a particular bill is at the conference table, it's gotta become a little arbitrary.

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