ACEP’s 2000 goal: Access for the uninsured

Prudent layperson standard also pushed

The most important issue facing emergency medicine this year is access to emergency services for both the insured and uninsured, emphasizes Michael T. Rapp, MD, FACEP, current president of the American College for Emergency Physicians (ACEP) in Dallas and an ED physician at the department of emergency medicine at Arlington (VA) Hospital. Here are several issues that will affect you in 2000:

Lack of universal health coverage.

"Many people feel that the problem of the uninsured having access to health care should be the next fundamental issue that ACEP devotes attention to, after prudent layperson legislation is resolved," reports Rapp. An ACEP council voted to hold a conference this year to evaluate that issue.

As the number of uninsured patients continues to grow, care in the ED is affected, Rapp says. "Because of our failure to have universal health care coverage, there is an impact on the insured when they seek ED care. If we had universal health coverage, EDs would operate more efficiently."

Passage and enforcement of legislation requiring all health plans to use the prudent layperson standard.

ACEP will continue to pursue this issue aggressively, says Rapp. "We’re at a stage right now when we have complete acceptance of this standard nationally. We’ve gotten it accepted in federal programs and at the state level." (See story on federal legislation that requires health plans to use the prudent layperson definition of an emergency, p. 7.)

Prudent layperson definition standards have now been adopted in 28 states, he notes. "The next frontier is making sure those laws are adequately enforced. In some instances, the provisions are not being implemented properly." Although prudent layperson definition requires that payment be based on the patient’s presenting symptom, some payers in states that have passed legislation still evaluate the claim based on the eventual diagnosis, he explains.

ACEP chapters working on prudent layperson enforce ment include Maryland, Florida, New York, Michigan, and Washington, he says. If there is a problem with enforcement of prudent layperson legislation in your state, contact one of your state’s ACEP chapters or the national office, he suggests. "Even though the standard is clear and state laws have been passed, some payers are either not aware of this or choose to ignore it."

Education about fraud and abuse laws.

It’s important that regulations be understood clearly, so physicians aren’t reluctant to put in a valid claim for fear of being accused of fraudulent activity, says Rapp. "Managers need to make sure your documentation is adequate to get the reimbursement you are entitled to."

The government has allocated resources into Medicare fraud enforcement, which creates a much greater danger for physicians in general, he maintains: "The Office of Inspector General has created compliance guidelines, so it’s advisable for anybody who puts in a claim for payment to be familiar with these and be aware of potential penalties." Penalties can include fines of up to $10,000 per occurrence, he stresses.

ACEP has developed an information paper on compliance issues for guidance of physicians, which is available on its Web site (www.acep.org).

Ambulatory patient classifications (APCs).

There is a concern about what effect the proposed switch to APCs for outpatient services will have on emerging trends in emergency medicine, such as observation units, Rapp explains. (For the latest information on APCs, see story, p. 9.)

There is a question about whether EDs will be reimbursed for observation under APCs, he notes. "This is an important area of growth in emergency medicine, and there needs to be an adequate financing mechanism to do this. Otherwise, it will be hampered."

If the ED physician is responsible for the care and evaluation of a patient over a longer period of time, hospitalization can be avoided, but there needs to be reimbursement for this service, stresses Rapp. "If there isn’t, EDs will want to tend to keep a patient briefly and admit them to the hospital, which would be a bad trend in the long run."

• Evaluation of patient satisfaction tools.

ACEP’s practice and research committee is evaluating patient satisfaction survey tools and reviewing the methodology used, he reports. The issue is that patient satisfaction tools are increasingly used by hospitals as a means to evaluate the various services provided, he explains. "As a result, ED physician groups and individual physicians are increasingly being evaluated this way. Poor survey results can result in the hospital terminating a contract or groups terminating individual physicians, even if there are no specific quality concerns otherwise raised."

It is important that those tools be accurate and statistically valid measures of customer satisfaction, he stresses; in addressing physician performance, they also need to focus on areas the physician can control.

Preparation of physicians for managing the ED.

There is a trend toward physician management of the ED, says Rapp. Physicians are more commonly being given responsibility for overall management of the entire ED, including nursing and registration, he explains. "We find a lot of physicians are actually going to get a MBA, which is probably not necessary to manage an ED. But clearly something more is needed than the training given in residency programs where mainly clinical information is taught."

ACEP is developing an extended course that would teach physicians management skills, including budgeting and human resources, he says.

Development of a bill of rights for physician.

ACEP is developing an ED physician’s bill of rights because most physicians work under contract unless they are directly employed by the hospital. "It will basically outline what the rights of physicians should be and address contract issues such as due process," says Rapp. In many contracts, physicians can be terminated without any reason given. "It’s not commonly done, but the possibility makes people feel insecure," he says. "It would be better if physicians were not subject to arbitrary termination."

A formal policy statement would allow physicians to ask employers if they adhere to the ACEP ED physician bill of rights and use the tool to evaluate potential employment opportunities, he explains.

Evaluation of telephone advice.

ACEP’s Emergency Practice Committee is evaluating telephone advice. "This is frequently offered by EDs as a program to help managed care companies, so we are considering the quality issues raised by such activity," he says.

Improvement of access to reimbursement data.

ACEP is working to make reimbursement information more accessible on its Web site, he says. "It’s the best way to get information out because it’s constantly changing."

ACEP’s reimbursement staff field frequent questions on proposed changes in CPT coding requirements, which could be posted on the Web site, he says.

Formation of a new medical/legal committee.

ACEP has formed a new committee to help members analyze medical and legal issues that arise, such as fraud and abuse and the anti-kickback law. Information papers on key medical legal issues will be developed.

Michael Rapp, MD, FACEP, Arlington Hospital, Department of Emergency Medicine, 1701 N. George Mason Drive, Arlington, VA 22205. Telephone: (703) 558-6169. Fax: (703) 558-5355. E-mail: mrapp@ acep.org.