EDITORIALS
27.PfaffM: Differences in health care spending across countries: Statistical evidence. JHealthPolit Poficy Law 1990;15:1-68. 28.Schieber6J, Poullier J-P, Greenwald LM: Health care systems in twenty-four countries.HealthAff1991;19:29-31. 29,BrennerG, Schneider M: The 1987revision of physician fees in 6ermany. Health Aft I991;10:147-156. 3D.CanadaCenter for Health Information: Hospital statistics (preliminary annual report, 1989-1990).Ottawa, Canada, 1992.
Public Policy and the Emergency Department See related articles, p 1208, 1236, and 1266. INTRODUCTION
The current issue of Annals addresses several i m p o r t a n t aspects of the role of public policy relative to emergency medicine. Emergency medicine plays an integral and pivotal r01e in the definition, structure, and function of the health care system. In this regard, it is essential that emergency physicians and emergency medicine organizations play an active and formative role in the rapidly changing health care environment. I appreciate this opportunity to provide my views on some of the policy issues raised in the c u r r e n t articles by Cross, Mitchell and Remmel, and Weil. PRESSURE ON DEPARTMENT
THE
EMER6ENCY
Mr Cross provides a concise and informative review of the law relative to the evolving responsibility of the ED in providing care. The point is well made that despite Supreme Court decisions such as Youngberg v Romeo (457 US 307), which held that the State has no constitutional duty to p r o vide treatment, provisions of the Consolidated Omnibus Budget and Reconciliation Act (COBRA) of 1986, as amended, placed just such a responsibility to evaluate all patients 0n hospital EDs. I agree with the author that "the hospital ED should not become the default setting for general medical practice, simply because we lack the political will to act"; however, I do not concur with the expressed opinion that it would be wise policy to "remove all economic incentives and disincentives from the clinical decision making process so that physicians ...are absolutely free to make decisions based solely upon the medical evidence." Virtually all key policy issues relating to emergency medicine deal with the concept of quality. Politicians and health care administrators are interested in obtaining value for dollars spent, while providers are increasingly concerned that cost-containment activities are adversely affecting access and the subsequent ability to provide quality care. The debate over the a p p r o p r i a t e level of utilization and quality is based in the fundamental a p p r o a c h to medical care services. Physicians have traditionally assumed a "maximalist" a p p r o a c h to services whereby the patient is to receive any and all services that could possibly be of benefit.i P r i o r to diagnosis-related groups (DRGs) and the prospective payment system instituted in 1983, hospital services were reimbursed on a cost-plus basis, which provided an incentive for hospitals to encourage physicians to perform all relevant tests and procedures. Many health
OCTOBER1992 21:10
ANNALS OF EMERGENOY MEDICINE
economists point to this system as one of the p r i m a r y factors in the enormous increases in health care spending over the past 25 years. U n d e r the DRG prospective payment system, hospitals have a strong incentive to minimize the length of stay and have focused on an "optimalist" a p p r o a c h to medical care. Optimalists believe strongly in the concept of diminishing marginal utility of medical care, and believe that at some point in the treatment process additional tests and procedures or time in the hospital are not worth the additional cost. Dr David Eddy, director of the Center for Health Policy at Duke University, has assisted the American College of Emergency Physicians in the development of clinical practice guidelines (ACEP's "clinical policies"). In 1986, Dr Eddy pointed out in a Health Affairs article that medicine is still an inexact art and that we lack the empirical research foundation of efficacy and effectiveness for many commonly accepted medical practices and procedures. 2 Without an adequate research foundation, the policy of encouraging physicians to do everything possible for their patients lacks credibility in an era of escalating cost containment. I believe there will be mounting pressure on all physicians, including those of us in emergency medicine, to provide the scientific justification for the treatments we prescribe. LEVELS
OF
UNCOMPENSATED
CARE
Drs Mitchell and Remmel provide a retrospective analysis of ED billing data in Florida. The authors found an overall collection rate of 59% and estimated that uninsured patients comprised about 20% of the sample. The descriptive statistics are interesting, although s t a n d a r d errors or confidence intervals were not reported. The study may lack national validity because F l o r i d a is not typical of many states, particularly with r e g a r d to the p r o p o r t i o n of Medicare recipients. The study provides evidence of a high degree of participation by emergency physicians in the Medicare and Medicaid programs. I agree with the policy conclusion of the authors that emergency physicians contribute significantly to the care of elderly and indigent patients. The authors estimated that 21% of patient visits were coded as either "extended" or "comprehensive" under the pro-1992 CPT emergency codes. The overall estimate of patients who were thought to be emergent or urgent "supporting the need for acute care in the emergency department" was 40%. The Inspector General of the Department of Health and Human Services estimated that more than one-half to two-thirds of Medicaid ED visits are for nonemergencies, 3 and some policy makers may conclude from the Mitchell and Remmell article that the Inspector General's estimate is accurate and that 60% of the patients in the study could have been treated in an alternative ambulatory care setting. UNIVERSAL
ACCESS
Dr Weil provides a very interesting and informative article dealing with the potential impact of universal insurance coverage on the ED. The author predicts the following m a j o r effects of universal coverage on the ED: • ED volumes will decline with p r o b a b l e consolidation of emergency services into fewer EDs; remaining EDs may experience cutbacks in staffing and support services.
1240/93
EDITORIALS
• Net collection percentages for emergency services will increase. Resource-based relative value system (RBRVS) payment mechanisms will be adopted by all payers with maintenance of the base conversion factor. • Universal coverage will improve access for the currently uninsured, resulting in the proliferation of alternative ambulatory facilities and competition for these patients. • There will be continued and increased emphasis on managed care plans. Although I agree with some of the conclusions reached by Weil, I believe his assessment of the impact of universal care does not fully explore the potential consequences for the specialty of emergency medicine.
THE UNINSURED The author makes the important point that the u n i n s u r e d are not a static group of 37 million as is often depicted in the media, but rather represent a highly dynamic population of individuals who experience "spells" of u n i n s u r e d periods with varying frequency and duration. Swartz and McBride of the U r b a n Institute utilized data from the Survey of Income and Program Participation and found that half of all uninsured spells end in less than four months, while only 15% last longer than 24 months. Also, people who are employed either part-time or full-time are highly likely to have short u n i n s u r e d spells, while individuals who are unemployed are more likely to have long u n i n s u r e d spells. The majority (70%) of spells of u n i n s u r a n c e lasted less than one year. 4 Nelson and Short found that 63 million Americans experienced at least one month without health insurance during a 28-month period in 1985-1987. 5
UNIVERSAL COVERAGE AND EMERGENCY MEDICINE I would like to explore the conclusions reached by Weil as well as expand the scope of possible benefits and consequences for emergency medicine of a universal insurance scheme. Likelihood of Universal Coverage I concur with Weil that many important pieces are now in place for the passage of some type of universal coverage for all citizens. It is truly a national disgrace that the United States is the only developed country except South Africa that does not provide basic health insurance coverage for all citizens. There are influential policymakers and commentators who treat this fact as some kind of inadvertent oversight, like leaving the light on in the closet. It is important to u n d e r s t a n d that this situation did not occur by accident. As long as the average tax-paying citizen was not adversely affected by the deficiencies in our health care system, there was no great public interest in reform. One public official once noted, "Americans d o n ' t mind throwing someone overboard, they just d o n ' t want to hear the splash." When was the last time you heard of a march on Washington by the u n i n s u r e d or Medicaid recipients? As John Kingdon noted, 6 public policy does not occur in a vacuum. In order for change to occur, there must be a clearly defined problem, a solution available, and the appropriate political climate to ensure support or at least
94/1241
acquiescence of important political constituencies. Reform of the American health care system is now clearly on the public agenda, and I believe that there will be major changes in our policy approach to health care within the near future. Virtually every proposal for health care reform includes the provision for universal coverage in some format, and concerns about affordability and availability of insurance coverage are now prominent in the public consciousness. I m p a c t o n E U Vn I u m e Weil posits that ED volumes will decline as a result of the interaction of several factors, including increased competition for newly insured patients, expansion of managed care plans, and cost-containment activities directed at channeling patients from the ED to alternative ambulatory care settings. I believe that there will be major emphasis on reducing the current levels of E]D use. There is little doubt that the ED is not the most efficient place to provide primary care, and evidence from studies such as the article by Mitchell and Remmel indicates that perhaps less than half of patients who visit EDs have conditions classifiable as emergent or urgent. The Health Care Financing Administration and private third-party payers are cognizant of the potential cost savings of redirecting a significant proportion of emergency patients into ambulatory care settings. A c c e s s t e C a r e Weil makes the common policy error of equating insurance coverage to access. Providing "a broad range of physician and hospital benefits" does not ensure that patients have access to care. Penchansky pointed out that access involves five major factors: availability, accessibility, accommodation, affordability, and acceptability. 7 For example, an inner-city patient with an insurance card but no transportation to a physician willing or able to care for the patient's needs is no better off than an individual who lacks insurance coverage. An argument could be made that although there is no universal insurance program per se, all Americans currently have some form of universal access--EDs. A universal insurance scheme, coupled with major efforts to redirect patients from hospital EDs, could have the u n i n t e n d e d effect of reducing access to certain underprivileged segments of society. Although Weil is not in favor of such cost-sharing approaches as deductibles and copayments as a method of cost containment, such measures are an almost constant element of insurance plans in the United States and would be a likely component of universal insurance. A major finding of the RAND Health Insurance Experiment was that cost sharing had a significant effect on the use of medical services; individuals who pay all or part of the cost of medical care use up to one third fewer services. 8 With regard to the u n i n s u r e d and access issues, an even more important finding of the RAND study was that patients in cost-sharing insurance schemes reduced the n u m b e r of appropriate and necessary services to the same degree as reduction of services for less serious conditions. Cost sharing decreased the likelihood of medical contact for most chronic conditions, and the cost-sharing effect was greatest for poor children. 9
ANNALS OF EMERGENCY MEBICINE
2 1 : 1 0 OCTOBER.1992
EDITORIALS E D C 011 e c t i 0 n R a t e Well paints a favorable picture for emergency physicians relative to increased remuneration, based on the assumption that there will be no fundamental change in the RBRVS conversion factor, even though patient volume will goup because of expansion of coverage to the uninsured. Why would policymakers be willing to grant a windfall in income to hospital and emergency physicians to provide services for the uninsured? Adding universal coverage to the system without a downward adjustment in the overall conversion factor would result in much higher expenditures for services that are currently being provided. A much more likely scenario is that the q u i d p r o quo for universal insurance will be an overall reduction in the conversion factor for physician fees. It is not difficult to envision a situation u n d e r universal insurance whereby emergency physicians see fewer but sicker patients in a reduced n u m b e r of EDs for fees that are lower than currently paid for such services. In such a situation, the net collection percentage of emergency physicians could decline. However, I am optimistic about the opportunities for emergency physicians to influence such decisions, to help bring about positive and a p p r o p r i a t e changes in the health care environment. As the safety net for our society, emergency physicians are widely perceived in a positive light by the public and pohcymakers. Through diligent and intensive activities to influence policy, emergency physicians could experience an environment of increased respect and compensation under universal insurance coverage. Ambulatory Visit Groups Although not addressed by any of the current authors, any discussion concerning the future effect of insurance reform on emergency medicine is not complete without reference to the potential consequences of ambulatory visit groups, which are currently u n d e r active consideration by policymakers in Washington. Ambulatory visit groups are similar in concept t o DRGs of the prospective payment system for hospitals. The basic idea is for insurance companies to pay a single global fee for ambulatory visits, such as for an ankle sprain. At the extreme, a hospital would receive a single payment for each ED ambulatory visit, inclusive of physician fees. Implementation of ambulatory visit groups could have dramatic consequences for emergency medicine. Private fee-fox-service billing might cease to exist, and emergency physicians could essentially become employees of hospitals. With a single bundled fee, how much would the radiologist receive for reading the ankle film? How much would go for supplies and overhead of the hospital, and how much of the fee would be left for the emergency physician? Hospitals would have incentives to provide ambulatory services on the most costefficient basis, with use of physician extenders and strong pressure to reduce patient t u r n a r o u n d times in the ED. CONCLUSION
There is an ancient Chinese curse, "may you live in interesting times." These are indeed interesting times for emergency medicine. No less than 35 proposals are currently u n d e r active consideration to provide basic reform of the American health care system. Virtually all of these proposals would have a significant impact on the specialty.
OCTOBER1992
21:10
ANNALSOF EMERGENCY MEDICiNE
Emergency medicine plays an integral role in the health care system of the United States. Emergency physicians represent the "front line" operalization of many policy concepts relative to access, quality of care, and cost containment; emergency medicine is uniquely poised to play a significant role in public health policy, including the development and implementation of a universal insurance plan. The uninsured have not been a b a n d o n e d by society; they seek and receive refuge in EDs. Robert M Williams, MD, FACEP 1. Donabedian A: The quality of care: How can it be assessed? JAMA 1988;260:1743-1747. 2. Eddy B: Success and challenges of medical decision making. Health,4ff 1986(Summer);5:30-34. 3, Department of Health and Human Services, Office of the Inspector 6eneral, March 1992, OEI-Of-90-0018& 4. Swartz K, McBride TD: Spells without health insurance: Distributions of durations and their link to point-in-time estimates of the uninsured. Inquiry 1990(Fa]E);27:281-288. 5. Nelson C, Short K: Health Insurance Coverage 1986-88. Washington, DC, Bureau of the Census, US Department of Commerce, Current Population Reports, Household Economic Studies, Series P-70, No. 17, 1990. 6. Kingdon JW: Agendas, Alternatives and Public Peficies. Boston, Little, Brown and Co, 1984. 7. Penchansky DBA, Thomas JW: The concept of access: Definition and relationship to consumer satisfaction. Med Care 1981;19:127-140. 8. Keeler EB, Ralph JE: How cost-sharing reduced medical spending of participants in the Health Insurance Experiment. JAMA 1983;249:2220. 9. Lohr et al: The Rand health insurance experiment. Med Care 1986(suppl);24:S51-S85.
Dr Williams is a Pew Fellow and doctoral student in health policy at the University of Michigan, Ann Arbor. He is writing his doctoral dissertation on the resource-based relative value system Medicare Fee Schedule.
The Effectiveness of 911 See related article, page 1173. It's too b a d that only one state in the union, North Carolina, is sophisticated enough with its emergency medical services (EMS) system and that the personnel working with the EMS office are knowledgeable enough to do in-depth analyses. If each state was as advanced, the EMS system in this country would p r o b a b l y be several years ahead of where it is today. We would have fewer controversies such as pneumatic antishock garment, endotracheal tube at the basic level, or even what the content of the emergency medical technician basic training p r o g r a m should be. We would be doing only those procedures that work and are p a r t i c u l a r l y cost effective, and would delete those that d o n ' t work. I suspect that by doing so we could really save a great deal of money and many lives. The money alone that we would save would p r o b a b l y pay for the research. The title of an article in this issue of Annals, "A Population-Based, Multivariate Analysis of the Association Between 911 Access and Per-Capita County Trauma Death Rates," is deceptive. The authors propose to r e p o r t on the value of 911 access, which they do in an excellent manner, but the title does not identify that the article also identifies several other components of the system that have been questioned as to their effectiveness. The authors have found that one of the major components for which we have chosen to spend money, the 911 system,
1242/95
27.PfaffM: Differences in health care spending across countries: Statistical evidence. JHealthPolit Poficy Law 1990;15:1-68. 28.Schieber6J, Poullier J-P, Greenwald LM: Health care systems in twenty-four countries.HealthAff1991;19:29-31. 29,BrennerG, Schneider M: The 1987revision of physician fees in 6ermany. Health Aft I991;10:147-156. 3D.CanadaCenter for Health Information: Hospital statistics (preliminary annual report, 1989-1990).Ottawa, Canada, 1992.
Public Policy and the Emergency Department See related articles, p 1208, 1236, and 1266. INTRODUCTION
The current issue of Annals addresses several i m p o r t a n t aspects of the role of public policy relative to emergency medicine. Emergency medicine plays an integral and pivotal r01e in the definition, structure, and function of the health care system. In this regard, it is essential that emergency physicians and emergency medicine organizations play an active and formative role in the rapidly changing health care environment. I appreciate this opportunity to provide my views on some of the policy issues raised in the c u r r e n t articles by Cross, Mitchell and Remmel, and Weil. PRESSURE ON DEPARTMENT
THE
EMER6ENCY
Mr Cross provides a concise and informative review of the law relative to the evolving responsibility of the ED in providing care. The point is well made that despite Supreme Court decisions such as Youngberg v Romeo (457 US 307), which held that the State has no constitutional duty to p r o vide treatment, provisions of the Consolidated Omnibus Budget and Reconciliation Act (COBRA) of 1986, as amended, placed just such a responsibility to evaluate all patients 0n hospital EDs. I agree with the author that "the hospital ED should not become the default setting for general medical practice, simply because we lack the political will to act"; however, I do not concur with the expressed opinion that it would be wise policy to "remove all economic incentives and disincentives from the clinical decision making process so that physicians ...are absolutely free to make decisions based solely upon the medical evidence." Virtually all key policy issues relating to emergency medicine deal with the concept of quality. Politicians and health care administrators are interested in obtaining value for dollars spent, while providers are increasingly concerned that cost-containment activities are adversely affecting access and the subsequent ability to provide quality care. The debate over the a p p r o p r i a t e level of utilization and quality is based in the fundamental a p p r o a c h to medical care services. Physicians have traditionally assumed a "maximalist" a p p r o a c h to services whereby the patient is to receive any and all services that could possibly be of benefit.i P r i o r to diagnosis-related groups (DRGs) and the prospective payment system instituted in 1983, hospital services were reimbursed on a cost-plus basis, which provided an incentive for hospitals to encourage physicians to perform all relevant tests and procedures. Many health
OCTOBER1992 21:10
ANNALS OF EMERGENOY MEDICINE
economists point to this system as one of the p r i m a r y factors in the enormous increases in health care spending over the past 25 years. U n d e r the DRG prospective payment system, hospitals have a strong incentive to minimize the length of stay and have focused on an "optimalist" a p p r o a c h to medical care. Optimalists believe strongly in the concept of diminishing marginal utility of medical care, and believe that at some point in the treatment process additional tests and procedures or time in the hospital are not worth the additional cost. Dr David Eddy, director of the Center for Health Policy at Duke University, has assisted the American College of Emergency Physicians in the development of clinical practice guidelines (ACEP's "clinical policies"). In 1986, Dr Eddy pointed out in a Health Affairs article that medicine is still an inexact art and that we lack the empirical research foundation of efficacy and effectiveness for many commonly accepted medical practices and procedures. 2 Without an adequate research foundation, the policy of encouraging physicians to do everything possible for their patients lacks credibility in an era of escalating cost containment. I believe there will be mounting pressure on all physicians, including those of us in emergency medicine, to provide the scientific justification for the treatments we prescribe. LEVELS
OF
UNCOMPENSATED
CARE
Drs Mitchell and Remmel provide a retrospective analysis of ED billing data in Florida. The authors found an overall collection rate of 59% and estimated that uninsured patients comprised about 20% of the sample. The descriptive statistics are interesting, although s t a n d a r d errors or confidence intervals were not reported. The study may lack national validity because F l o r i d a is not typical of many states, particularly with r e g a r d to the p r o p o r t i o n of Medicare recipients. The study provides evidence of a high degree of participation by emergency physicians in the Medicare and Medicaid programs. I agree with the policy conclusion of the authors that emergency physicians contribute significantly to the care of elderly and indigent patients. The authors estimated that 21% of patient visits were coded as either "extended" or "comprehensive" under the pro-1992 CPT emergency codes. The overall estimate of patients who were thought to be emergent or urgent "supporting the need for acute care in the emergency department" was 40%. The Inspector General of the Department of Health and Human Services estimated that more than one-half to two-thirds of Medicaid ED visits are for nonemergencies, 3 and some policy makers may conclude from the Mitchell and Remmell article that the Inspector General's estimate is accurate and that 60% of the patients in the study could have been treated in an alternative ambulatory care setting. UNIVERSAL
ACCESS
Dr Weil provides a very interesting and informative article dealing with the potential impact of universal insurance coverage on the ED. The author predicts the following m a j o r effects of universal coverage on the ED: • ED volumes will decline with p r o b a b l e consolidation of emergency services into fewer EDs; remaining EDs may experience cutbacks in staffing and support services.
1240/93
EDITORIALS
• Net collection percentages for emergency services will increase. Resource-based relative value system (RBRVS) payment mechanisms will be adopted by all payers with maintenance of the base conversion factor. • Universal coverage will improve access for the currently uninsured, resulting in the proliferation of alternative ambulatory facilities and competition for these patients. • There will be continued and increased emphasis on managed care plans. Although I agree with some of the conclusions reached by Weil, I believe his assessment of the impact of universal care does not fully explore the potential consequences for the specialty of emergency medicine.
THE UNINSURED The author makes the important point that the u n i n s u r e d are not a static group of 37 million as is often depicted in the media, but rather represent a highly dynamic population of individuals who experience "spells" of u n i n s u r e d periods with varying frequency and duration. Swartz and McBride of the U r b a n Institute utilized data from the Survey of Income and Program Participation and found that half of all uninsured spells end in less than four months, while only 15% last longer than 24 months. Also, people who are employed either part-time or full-time are highly likely to have short u n i n s u r e d spells, while individuals who are unemployed are more likely to have long u n i n s u r e d spells. The majority (70%) of spells of u n i n s u r a n c e lasted less than one year. 4 Nelson and Short found that 63 million Americans experienced at least one month without health insurance during a 28-month period in 1985-1987. 5
UNIVERSAL COVERAGE AND EMERGENCY MEDICINE I would like to explore the conclusions reached by Weil as well as expand the scope of possible benefits and consequences for emergency medicine of a universal insurance scheme. Likelihood of Universal Coverage I concur with Weil that many important pieces are now in place for the passage of some type of universal coverage for all citizens. It is truly a national disgrace that the United States is the only developed country except South Africa that does not provide basic health insurance coverage for all citizens. There are influential policymakers and commentators who treat this fact as some kind of inadvertent oversight, like leaving the light on in the closet. It is important to u n d e r s t a n d that this situation did not occur by accident. As long as the average tax-paying citizen was not adversely affected by the deficiencies in our health care system, there was no great public interest in reform. One public official once noted, "Americans d o n ' t mind throwing someone overboard, they just d o n ' t want to hear the splash." When was the last time you heard of a march on Washington by the u n i n s u r e d or Medicaid recipients? As John Kingdon noted, 6 public policy does not occur in a vacuum. In order for change to occur, there must be a clearly defined problem, a solution available, and the appropriate political climate to ensure support or at least
94/1241
acquiescence of important political constituencies. Reform of the American health care system is now clearly on the public agenda, and I believe that there will be major changes in our policy approach to health care within the near future. Virtually every proposal for health care reform includes the provision for universal coverage in some format, and concerns about affordability and availability of insurance coverage are now prominent in the public consciousness. I m p a c t o n E U Vn I u m e Weil posits that ED volumes will decline as a result of the interaction of several factors, including increased competition for newly insured patients, expansion of managed care plans, and cost-containment activities directed at channeling patients from the ED to alternative ambulatory care settings. I believe that there will be major emphasis on reducing the current levels of E]D use. There is little doubt that the ED is not the most efficient place to provide primary care, and evidence from studies such as the article by Mitchell and Remmel indicates that perhaps less than half of patients who visit EDs have conditions classifiable as emergent or urgent. The Health Care Financing Administration and private third-party payers are cognizant of the potential cost savings of redirecting a significant proportion of emergency patients into ambulatory care settings. A c c e s s t e C a r e Weil makes the common policy error of equating insurance coverage to access. Providing "a broad range of physician and hospital benefits" does not ensure that patients have access to care. Penchansky pointed out that access involves five major factors: availability, accessibility, accommodation, affordability, and acceptability. 7 For example, an inner-city patient with an insurance card but no transportation to a physician willing or able to care for the patient's needs is no better off than an individual who lacks insurance coverage. An argument could be made that although there is no universal insurance program per se, all Americans currently have some form of universal access--EDs. A universal insurance scheme, coupled with major efforts to redirect patients from hospital EDs, could have the u n i n t e n d e d effect of reducing access to certain underprivileged segments of society. Although Weil is not in favor of such cost-sharing approaches as deductibles and copayments as a method of cost containment, such measures are an almost constant element of insurance plans in the United States and would be a likely component of universal insurance. A major finding of the RAND Health Insurance Experiment was that cost sharing had a significant effect on the use of medical services; individuals who pay all or part of the cost of medical care use up to one third fewer services. 8 With regard to the u n i n s u r e d and access issues, an even more important finding of the RAND study was that patients in cost-sharing insurance schemes reduced the n u m b e r of appropriate and necessary services to the same degree as reduction of services for less serious conditions. Cost sharing decreased the likelihood of medical contact for most chronic conditions, and the cost-sharing effect was greatest for poor children. 9
ANNALS OF EMERGENCY MEBICINE
2 1 : 1 0 OCTOBER.1992
EDITORIALS E D C 011 e c t i 0 n R a t e Well paints a favorable picture for emergency physicians relative to increased remuneration, based on the assumption that there will be no fundamental change in the RBRVS conversion factor, even though patient volume will goup because of expansion of coverage to the uninsured. Why would policymakers be willing to grant a windfall in income to hospital and emergency physicians to provide services for the uninsured? Adding universal coverage to the system without a downward adjustment in the overall conversion factor would result in much higher expenditures for services that are currently being provided. A much more likely scenario is that the q u i d p r o quo for universal insurance will be an overall reduction in the conversion factor for physician fees. It is not difficult to envision a situation u n d e r universal insurance whereby emergency physicians see fewer but sicker patients in a reduced n u m b e r of EDs for fees that are lower than currently paid for such services. In such a situation, the net collection percentage of emergency physicians could decline. However, I am optimistic about the opportunities for emergency physicians to influence such decisions, to help bring about positive and a p p r o p r i a t e changes in the health care environment. As the safety net for our society, emergency physicians are widely perceived in a positive light by the public and pohcymakers. Through diligent and intensive activities to influence policy, emergency physicians could experience an environment of increased respect and compensation under universal insurance coverage. Ambulatory Visit Groups Although not addressed by any of the current authors, any discussion concerning the future effect of insurance reform on emergency medicine is not complete without reference to the potential consequences of ambulatory visit groups, which are currently u n d e r active consideration by policymakers in Washington. Ambulatory visit groups are similar in concept t o DRGs of the prospective payment system for hospitals. The basic idea is for insurance companies to pay a single global fee for ambulatory visits, such as for an ankle sprain. At the extreme, a hospital would receive a single payment for each ED ambulatory visit, inclusive of physician fees. Implementation of ambulatory visit groups could have dramatic consequences for emergency medicine. Private fee-fox-service billing might cease to exist, and emergency physicians could essentially become employees of hospitals. With a single bundled fee, how much would the radiologist receive for reading the ankle film? How much would go for supplies and overhead of the hospital, and how much of the fee would be left for the emergency physician? Hospitals would have incentives to provide ambulatory services on the most costefficient basis, with use of physician extenders and strong pressure to reduce patient t u r n a r o u n d times in the ED. CONCLUSION
There is an ancient Chinese curse, "may you live in interesting times." These are indeed interesting times for emergency medicine. No less than 35 proposals are currently u n d e r active consideration to provide basic reform of the American health care system. Virtually all of these proposals would have a significant impact on the specialty.
OCTOBER1992
21:10
ANNALSOF EMERGENCY MEDICiNE
Emergency medicine plays an integral role in the health care system of the United States. Emergency physicians represent the "front line" operalization of many policy concepts relative to access, quality of care, and cost containment; emergency medicine is uniquely poised to play a significant role in public health policy, including the development and implementation of a universal insurance plan. The uninsured have not been a b a n d o n e d by society; they seek and receive refuge in EDs. Robert M Williams, MD, FACEP 1. Donabedian A: The quality of care: How can it be assessed? JAMA 1988;260:1743-1747. 2. Eddy B: Success and challenges of medical decision making. Health,4ff 1986(Summer);5:30-34. 3, Department of Health and Human Services, Office of the Inspector 6eneral, March 1992, OEI-Of-90-0018& 4. Swartz K, McBride TD: Spells without health insurance: Distributions of durations and their link to point-in-time estimates of the uninsured. Inquiry 1990(Fa]E);27:281-288. 5. Nelson C, Short K: Health Insurance Coverage 1986-88. Washington, DC, Bureau of the Census, US Department of Commerce, Current Population Reports, Household Economic Studies, Series P-70, No. 17, 1990. 6. Kingdon JW: Agendas, Alternatives and Public Peficies. Boston, Little, Brown and Co, 1984. 7. Penchansky DBA, Thomas JW: The concept of access: Definition and relationship to consumer satisfaction. Med Care 1981;19:127-140. 8. Keeler EB, Ralph JE: How cost-sharing reduced medical spending of participants in the Health Insurance Experiment. JAMA 1983;249:2220. 9. Lohr et al: The Rand health insurance experiment. Med Care 1986(suppl);24:S51-S85.
Dr Williams is a Pew Fellow and doctoral student in health policy at the University of Michigan, Ann Arbor. He is writing his doctoral dissertation on the resource-based relative value system Medicare Fee Schedule.
The Effectiveness of 911 See related article, page 1173. It's too b a d that only one state in the union, North Carolina, is sophisticated enough with its emergency medical services (EMS) system and that the personnel working with the EMS office are knowledgeable enough to do in-depth analyses. If each state was as advanced, the EMS system in this country would p r o b a b l y be several years ahead of where it is today. We would have fewer controversies such as pneumatic antishock garment, endotracheal tube at the basic level, or even what the content of the emergency medical technician basic training p r o g r a m should be. We would be doing only those procedures that work and are p a r t i c u l a r l y cost effective, and would delete those that d o n ' t work. I suspect that by doing so we could really save a great deal of money and many lives. The money alone that we would save would p r o b a b l y pay for the research. The title of an article in this issue of Annals, "A Population-Based, Multivariate Analysis of the Association Between 911 Access and Per-Capita County Trauma Death Rates," is deceptive. The authors propose to r e p o r t on the value of 911 access, which they do in an excellent manner, but the title does not identify that the article also identifies several other components of the system that have been questioned as to their effectiveness. The authors have found that one of the major components for which we have chosen to spend money, the 911 system,
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