At the base of the problem is the use of the Medicare fee schedule as the underlining basis of a system of fair reimbursement. Medicare rates themselves typically cover only approximately 40-45% of most ED charges. In addition, the insurance industry underpays and/or incorrectly pays physicians, as evidenced by the stream of class action settlements in the last several years. Hundreds of millions of dollars have been paid, years after the fact, due to inaccurate historical payments made to physicians. EM cannot afford any more “catch-up” settlements for claims improperly paid years ago. Today, ACEP is battling payers like AnthemWellpoint in compliance disputes arising after their original class action settlements. These are instances where payers are reverting to pre-settlement protocols. The development of a system of fair reimbursement must necessarily include a fall-back adjudication system for correcting erroneous payments, but the impetus must first be the establishment of fair payments the first time they are paid, or the specialty will absorb substantial additional costs while the insurance industry rests on accumulating interest for unpaid and/or under-paid claims. Instead, emergency medicine needs a charge-based system, one that accounts for expenses with no ties to any governmental reimbursement methodology.
Emergency physicians are treating an increasingly more severely ill and/or injured population. According to CMS, critical care codes increased almost 11% between 2005 and 2007. The April 2009 GAO study showed a 4% increase in severity of ED patients classified as “Urgent” through “Immediate” between 2001 through 2006. This classification mirrors CPT codes 99284 through 99291.
Very important here is to consider two key facts about Medicare patients. First, currently the highest reimbursement from a Medicare carrier is $238.08 for a level five service (CPT 99285). Second, the April 2009 GAO study shows the average length of stay for Medicare patients is 242 minutes, or 4.03 hours. That means that for taking care of some of the highest acuity ED patients, EPs get paid $59.08/hour. Even if lower acuity patients are seen in different facilities in the future, the facts remain that EM is continuously treating increasingly higher acuity patients over time.
What are the conditions under which EPs provide services? EM is not only dealing with fewer EDs, as reported in the 2008 CDC Report, but it is also servicing more patients. For the period 1996 through 2006, the ED visit volume rose 32%. EM has responded to these challenges with solutions such as increased and staggered coverage, physician-directed triage protocols, creative use of mid-level providers and direct physician involvement in electronic chart design. And yet, the 2009 National Report Card on the State of Emergency Medicine still gave the specialty a C-minus overall. According to the April 2009 GAO study, the issues facing EDs are centered on diversion, increased wait times, boarding and lack of inpatient beds. These are not issues over which EM has control; in fact, within the broader healthcare milieu impinging on EDs, it is not a stretch to consider the halls of America’s EDs, and the physicians managing them, as veritable models of efficiency in an otherwise extremely chaotic environment. EM continues to serve patients 24/7, with no one turned away. EM today also serves as the pivotal channel for an increasing number of hospital admissions. The ED is not only the safety net of America’s healthcare system; it is the only net supporting the entire system. According to CMS’s Physician Quality Reporting Initiative (PQRI), EM ranks in the top tier across all medical specialties.
As the government moves increasingly toward an emphasis on quality, outcomes, and pay-for-performance, I suggest this is evidence of these indices for EM. Granted this is not necessarily an argument for evidence based outcomes, but it certainly suggests an increasing level of patient satisfaction with their treatment and outcomes. The results would be far different if patients were not receiving quality care along with the expected and proper outcomes.
Emergency physicians serve their communities through continual EMS education and training programs. They are strong voices against domestic violence; they have been instrumental in legislation for seat belts, child car seats, motorcycle helmets, and restrictions and penalties for drunk drivers. Emergency physicians are the true gatekeepers of America’s healthcare system, and integral to the fabric of American society. And yet, according to a recent EPM poll, nearly 30% of EPs wish they had chosen a different career.
If you take a look at the facts surrounding emergency medicine (see inset), the evidence is simply overwhelming in support a substantial increase in reimbursement for emergency physicians. Today’s reimbursement environment, however, shows the exact opposite trend. One state after another is raising the issue that would ban balance billing by non-contracted EPs, which would result in a severe revenue hit for EM. Although balance billing may not be the best solution for maintaining the financial viability of America’s EDs, today it remains the only solution. EM must be very strong in its insistence on fair reimbursement. The specialty is the critical centerpiece of the entire healthcare system and it is imperative that physicians support measures to either preserve balance billing in the short run, or define fair reimbursement for the immediate future. This must be a daily effort in dealing with payers and negotiating contracts. It is truly a process of educating the payer community of the central place and role of EM in the structure and efficient function of the healthcare system.