YEAR-END REPORT - 2019 Published 23-Dec-2019 HPTS Issue Brief 12-23-19.6 Health Policy Tracking Service - Issue Briefs Healthcare Providers & Facilities Emergency Care Authored by David J. Steiner, J.D., a contributing writer and member of the Ohio bar. 12/23/2019 I. Introduction Several medical organizations have urged key Congressional committees to consider potential unintended consequences that may threaten access to care as they attempt to find legislative solutions to protect patients from surprise medical bills. The American College of Emergency Physicians has applauded the fact that the Secretary of the Department of Health and Human Services Alex Azar has publicly expressed his support of the Acute Unscheduled Care Model. New Hampshire-based Dartmouth-Hitchcock Health will partner with West Health, a family of nonprofit and nonpartisan organizations. The two entities will engage in a $4.5 million research collaboration to create an innovative “Geriatric Emergency Department.” According to a recently released study by Elevate's Center for the New Middle Class, surprise medical bills are a hardship for many Americans, regardless of their credit score. The research found that eight in ten non-prime consumers (those with credit scores under 700), and six in ten prime consumers (with credit scores over 700) have experienced some level of financial hardship due to medical bills in the last five years. A recently published study found that, among Medicare beneficiaries receiving emergency department care in the United States, mortality within 30 days of an ED visit has declined in recent years, especially for the highest-severity patients. These declines occurred as fewer patients were admitted and were instead sent home. The American College of Emergency Physicians recently issued a press release condemning the unintended effects of a state law in California that was passed to protect patients from surprise medical bills. These unintended effects were addressed in a study conducted in that state after the passage of the bill. II. General ER news Medical provider groups set to publish updated joint guidelines for pediatric emergency care The American College of Emergency Physicians (ACEP), the American Academy of Pediatrics (AAP), and the Emergency Nurses Association (ENA) will publish the updated joint guidelines titled “Pediatric Readiness in the Emergency Department.” These guidelines will recommend ways that health care providers can ensure every injured or critically ill child receives the best care possible in an emergency setting. The organizations published the joint policy statement online in Annals of Emergency Medicine on November 1, 2018. The joint statement is a revision of the 2009 policy statement and highlights recent advances in pediatric emergency care that may be incorporated into all emergency departments that care for children. The statement focuses on the importance of evidence-based guidelines and includes additional recommendations for quality improvement plans focusing on children and disaster preparedness. According to Vidor Friedman, MD, FACEP, president of ACEP, “The joint recommendations help improve and standardize care delivery for children of all ages in the emergency department, create best practice benchmarks for emergency departments and strengthen pediatric patient safety efforts.” According to the 2014 National Hospital Ambulatory Medical Care Survey, there were approximately 5,000 emergency departments in the United States. Of more than 141 million emergency department visits, approximately 20 percent were for children younger than 15 © 2020 Thomson Reuters. No claim to original U.S. Government Works. -1- years. Approximately 83 percent of children in need of emergency care go to a community emergency department versus a pediatric emergency department. Colleen Kraft, MD, MBA, FAAP, President of the American Academy of Pediatrics, also commented on the guidelines, stating that, “Children have unique needs that are heightened during serious or life-threatening emergencies. It's imperative that all hospitals have the medications, equipment, policies, resources, education and training, and capable staff to provide effective emergency care for children of all ages.” AAP, ACEP, and ENA routinely work together to “optimize high-quality, family-centered care of children in emergency departments.” In 2013, the three groups worked with the federal EMS for Children Program to start the National Pediatric Readiness Project (NPRP), which is intended to ensure pediatric readiness of emergency departments. ENA President Jeff Solheim, MSN, RN, CEN, TCRN, CFRN, FAEN, FAAN, also commented on the updated guidelines. Mr. Solheim stated that, “The delivery of pediatric care should reflect an awareness of unique pediatric patient safety concerns. ENA, AAP and ACEP are working together to maintain and improve the quality of care that pediatric patients receive in hospitals and emergency departments. These updated recommendations are intended to serve as a resource for clinical and administrative leadership of emergency departments as they strive to improve their readiness for children of all ages,” said ENA President Jeff Solheim, MSN, RN, [FN1] CEN, TCRN, CFRN, FAEN, FAAN. Emergency Nurses Association supports recently passed federal bills intended to combat opioid crisis The Emergency Nurses Association (ENA) recently commended Congress and President Trump for passing bipartisan legislation intended to combat the opioid crisis. The SUPPORT for Patients and Communities Act incorporates several bills, including two supported by ENA, which are designed to provide immediate assistance to help stop the deadly impact of opioid drugs, which claimed the lives of approximately 49,000 Americans in 2017. According to ENA President Jeff Solheim, MSN, RN, CEN, TCRN, CFRN, FAEN, FAAN, “The opioid epidemic has strained an already overburdened emergency care system in the United States. This, coupled with the challenges of watching how addiction negatively impacts our patients and their loved ones, makes the opioid crisis very personal for emergency nurses. We applaud any legislation, such as ALTO, that will help control this very real problem.” The SUPPORT Act includes the ALTO ED Act and key provisions of the POWER Act, which are two ENA-backed bills for which the association strongly advocated because of their intended impact on how emergency departments treat patients struggling with opioid- use. The ALTO ED Act was sponsored by Representative Bill Pascrell, D-N.J., in the House and Senator Cory Booker, D-N.J., in the Senate. It requires the Department of Health and Human Services to run a demonstration program in which grants would be awarded to hospitals and emergency departments to develop, study, and improve alternative pain management protocols with the goal of reducing unnecessary opioid use in emergency departments. The POWER Act was introduced by Representative David McKinley, R-W.Va., in the House and Senator Shelley Moore Capito, R- W.Va., in the Senate. The POWER Act authorizes federal funds to help health care facilities (including emergency departments) and key state agencies and local organizations develop protocols for discharging patients after a non-fatal overdose. These protocols are intended to improve coordination of community-based treatment for those patients. 2018 ENA President-elect Patricia Kunz Howard, PhD, RN, CEN, CPEN, TCRN, NE-BC, FAEN, FAAN commented on these legislative efforts. She stated that, “Alternatives to opioids is vitally important to reduce the tragedies associated with opioid addiction. The Emergency Nurses Association supports alternative measures to manage pain without the use of opioids.” The ENA is a professional nursing association “dedicated to defining the future of emergency nursing through advocacy, education, [FN2] research, innovation, and leadership.” It boasts a membership of over 43,000 members worldwide. Emergency medicine organization speaks out against new Blue Cross & Blue Shield policy in Mississippi The Mississippi Chapter of the American College of Emergency Physicians (MS-ACEP) and the national organization ACEP recently spoke out against a policy change that Blue Cross & Blue Shield of Mississippi (BCBS-MS) implemented that makes patients pay for all the costs of an emergency visit if the insurer decides that the decision to seek care in an emergency department did not “align with the diagnosis severity.” Philip Levin, MD, FACEP, president of MS-ACEP, commented on the policy, stating that, “This bad policy violates Federal and State laws that require insurance coverage for emergency care to be based on the patient's presenting symptoms and not on their final diagnosis.” Dr. Levin further noted that, “Emergency physicians treat patients every day with symptoms identical to those of life-threatening conditions, such as severe headache or abdominal pain. Some of these patients go home, some have serious issues and need medical procedures, and some need to be admitted to the hospital. Health insurance companies can't expect patients to know which symptoms are life-threatening and which are not, and patients shouldn't be punished financially because of it.” © 2020 Thomson Reuters. No claim to original U.S. Government Works. -2- Dr. Levin also stated that he believes the new policy is dangerous because people in Mississippi who truly need emergency care may now not seek it out because they may be afraid of receiving a large bill. The “prudent layperson” standard has been the guideline in state and federal law for over 20 years in determining whether an emergency visit is justified. The standard requires that insurance coverage be based on a patient's symptoms, not their final diagnosis. ACEP contends that anyone who seeks emergency care suffering from symptoms that may be an emergency should not be denied coverage even if the final diagnosis does not turn out to be immediately life-threatening. The BCBS-MS policy violates this standard, according to ACEP and MS-ACEP. Anthem Blue Cross Blue Shield has implemented a similar policy in several states such as Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia has filed a federal lawsuit against Anthem in that state to force them to reverse the policy. According to an ACEP poll, more than 4 in 10 Americans report delaying or avoiding emergency care in the past two years out of concerns about the cost of co-pays, co-insurance, and deductibles. Nearly half of the poll respondents who delayed or avoided care said their medical condition worsened as a result. Vidor Friedman, MD, FACEP, president of ACEP, noted that, “Some health plans have a long history of not paying for emergency care. For years, they have denied claims based on final diagnosis instead of symptoms. Emergency physicians successfully fought back against these outrageous policies. Now, as the future of health care is debated again, insurance companies are trying to reintroduce the practice. We cannot let them.” ACEP is a national medical specialty society representing emergency medicine. It has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. It also has a Government Services Chapter that represents emergency physicians employed [FN3] by military branches and other agencies of the government. Three studies examine availability of pediatric areas in emergency departments Three recently published studies in the December issue of Academic Emergency Medicine found that many emergency departments lack a pediatric area or pediatric emergency care coordinator (PECC). The studies also conclude that an intervention can increase use of PECCs. Alexandra Camargo of Massachusetts General Hospital in Boston and colleagues surveyed all 5,273 U.S. emergency departments in the United States to characterize emergency care in 2015. The researchers found that 10 percent of general emergency departments reported having a pediatric area, and 16 percent of all U.S. emergency departments reported having a PECC. The researchers also found that a pediatric area was more likely for larger emergency departments with higher numbers of visits and those in the Northeast or South. They also found that seventy-five percent of general emergency departments with a pediatric area had a PECC. Monica Brova, M.P.H., of the Boston University School of Public Health and her colleagues surveyed 130 of the 337 emergency departments that reported receiving pediatric telemedicine. 107 of these emergency departments completed the survey. Of those 107, 90 and 83 percent confirmed the use of telemedicine in 2016 and 2017, respectively. Of the emergency departments that discontinued the use of telemedicine, technical reasons and scheduling concerns were the main reported reasons for discontinuation. The most frequently reported challenges by the emergency departments using pediatric telemedicine were process concerns and technological concerns (30 and 14 percent, respectively). In a separate study, Carlos A. Camargo Jr., M.D., of Harvard Medical School in Boston and his colleagues surveyed 73 Massachusetts emergency departments annually from 2014 to 2018. In Massachusetts, a grassroots effort established a PECC in every Massachusetts emergency department. The researchers in Dr. Camargo's study found an increase in the percentage of emergency departments with an appointed PECC over time, increasing from approximately 30 percent from 2014 to 2016 to approximately 85 and 100 percent during the years of 2017 and 2018. According to a statement from Dr. Camargo, “We believe an intervention like this one could have similar results elsewhere, and we [FN4] have started to replicate the project in a few volunteer states.” Emergency physicians group issues proposed framework to protect ER patients from surprise bills The American College of Emergency Physicians (ACEP) recently released a framework of proposed solutions to protect emergency patients from bills as a result of insurance companies deciding that certain trips to the emergency department were non-emergent and therefore not covered. According to Vidor Friedman, MD, FACEP, president of ACEP, “By oath and by law, emergency physicians will treat any patient, regardless of their ability to pay. In fact, that federal law, the Emergency Medicine Treatment and Labor Act (EMTALA) actually forbids emergency care providers from discussing with the patient any potential costs of care or details of their particular insurance coverage © 2020 Thomson Reuters. No claim to original U.S. Government Works. -3- until they are screened and stabilized. Patients can't choose where and when they will need emergency care and they should not be punished financially for having emergencies.” Dr. Friedman states that this framework of proposed solutions is intended to ensure that patients are removed from the middle of billing issues that frequently arise relating to insurance coverage of emergency care. ACEP's proposed solutions include: • Prohibit balance billing — When a patient receives out-of-network emergency care, the provider will make no demand for payment from the patient. • Streamline the process to ensure patients only have a single point of contact for emergency medical billing and payment — Under ACEP's proposal, insurers will directly pay any coinsurance, copay, and deductible for emergency care to the provider, and can then collect back these amounts from the patient. This will put an end to patients receiving and having to reconcile the multiple, confusing bills and explanation of benefits that result from the many providers who often need to be involved in a single emergency episode. • Ensure the patient responsibility portion for out-of-network emergency care is no higher than it would be in-network — When facing an emergency, patients or their family members don't have time to try and figure out where their care will be in-network, so they shouldn't be punished financially for being unable to do so. Under current law, while copays and coinsurance must be the same for emergency patients whether they are in- or out-of-network, deductibles can be much higher—often double! We think that needs to change. • Require insurers to more clearly convey beneficiary plan details — This would include printing the deductible on each insurance card. While a simple step, it can help patients understand the limits of their insurance coverage and reduce the surprise when they later get a bill. • Require insurers to more clearly explain their rights related to emergency care — Policyholders deserve to have this in plain, easy-to- understand clear language. • Take the Patient Out of Insurer-Provider Billing Disputes — ACEP wants to prevent provider/insurer billing disputes. To expedite and [FN5] simplify this process, ACEP is calling for the creation of an arbitration process to settle network issues. Veterans rights group sues VA again relating to reimbursement of emergency medical expenses On January 1, 2019, the National Veterans Legal Services Program (NVLSP) filed a class action lawsuit in the U.S. Court of Appeals for Veterans Claims (CAVC), accusing the U.S. Department of Veterans Affairs (VA) of sending false information throughout 2018 to tens of thousands of veterans who had applied for VA reimbursement of emergency medical expenses they incurred at non-VA facilities. The lawsuit claims that the VA has a practice and policy of falsely informing these veterans that they cannot qualify for any reimbursement if they have partial coverage for their emergency medical expenses under a health plan contract. The NVLSP claims that this representation is inaccurate because it directly violates the binding decision issued by the CAVC in 2016 in Staab v. Shulkin. The NVLSP claims that the Staab case invalidated a VA regulation because it prohibited reimbursement if the veteran had partial coverage under a health care plan. NVLSP Executive Director Bart Stichman commented on the litigation, stating that, “By misinforming so many veterans of their eligibility for reimbursement of non-VA medical expenses, the VA is once again failing to live up to its obligations to those who served our country. The Staab decision in 2016 could not have been clearer. How VA officials could allow these false boilerplate letters to be sent to tens of thousands of veterans seeking reimbursement lies beyond my comprehension. This campaign is a systemic deception by the VA that must be stopped.” Mr. Stichman further noted that, “The mere inclusion of the language advising veterans that they are not eligible for reimbursement if they have coverage through a third-party health plan obviously has a chilling effect. It discourages veterans from pursuing and appealing their claims, leaving them to have to bear the unnecessary burden of paying thousands of dollars in health care expenses.” This is the second time in three months that NVLSP has filed a class action lawsuit in the CAVC claiming that the VA has systematically and improperly mishandled tens of thousands of reimbursement claims. On October 30, 2018, NVLSP filed a class action on behalf of veteran Amanda Wolfe and other veterans challenging the regulation adopted by the VA in January 2018. Ms. Wolfe's lawsuit suggests that the regulation violates the law because it prohibits reimbursement for those emergency medical expenses that the veteran must pay as a deductible or coinsurance payment under the veteran's health care plan. In its recently filed lawsuit, NVLSP represents petitioner, Peter E. Boerschinger, who seeks to represent the tens of thousands of other veterans who also received an allegedly inaccurate VA correspondence about the reimbursement criteria. As part of this lawsuit, the NVLSP also seeks to compel the VA to provide corrected information to all veterans who received the allegedly inaccurate communications and to reinstate their reimbursement claims. According to Mr. Stichman, “The new math employed by the VA raises serious concerns about whether veterans will be left holding the bag on all or most of their medical expenses. This is no way to treat our brave men and women who selflessly defended our country.” © 2020 Thomson Reuters. No claim to original U.S. Government Works. -4- The National Veterans Legal Services Program (NVLSP) is an independent, nonprofit veterans service organization that “strives to ensure that our nation honors its commitment to its 22 million veterans and active duty personnel by ensuring they have the benefits they have earned through their service to our country.” NVLSP offers training for attorneys and other advocates, connects veterans and active duty personnel with pro bono legal help when seeking disability benefits, publishes a guide on veteran benefits, and represents [FN6] and litigates for veterans and their families before the VA, military discharge review agencies, and federal courts. CMS announces new payment model for emergency ambulance services; intended to reduce costs for Medicare beneficiaries The U.S. Department of Health and Human Services (HHS) and Center for Medicare and Medicaid Innovation (Innovation Center) recently announced a new payment model for emergency ambulance services that intends to allow Medicare Fee-For-Service (FFS) beneficiaries to receive the most appropriate level of care at the right time and place with the potential for lower out-of-pocket costs. The Center for Medicare and Medicaid Innovation tests innovative payment and service delivery models to lower costs and improve the quality of care. According to HHS Secretary Alex Azar, “This model will create a new set of incentives for emergency transport and care, ensuring patients get convenient, appropriate treatment in whatever setting makes sense for them. Today's announcement shows that we can radically rethink the incentives around care delivery even in one of the trickiest parts of our system. A value-based healthcare system will help deliver each patient the right care, at the right price, in the right setting, from the right provider.” The new model, the Emergency Triage, Treat and Transport (ET3) model, will allow participating ambulance suppliers and providers to partner with qualified health care practitioners to deliver treatment in place (either on-the-scene or through telehealth) and with alternative destination sites (such as primary care doctors' offices or urgent-care clinics) to provide care for Medicare beneficiaries following a medical emergency for which they have accessed 911 services. This model seeks to engage health care providers across the care continuum to more appropriately and effectively meet beneficiaries' needs. The model is predicted to also encourage development of medical triage lines for low-acuity 911 calls in regions where participating ambulance suppliers and providers operate. The ET3 model will have a five-year performance period, with an anticipated start date in early 2020. CMS Administrator Seema Verma commented on the new model, stating that, “The ET3 model is yet another way CMS is transforming America's healthcare system to deliver better value and results for patients through innovation. This model will help make how we pay for care more patient-centric by supporting care in more appropriate settings while saving emergency medical services providers precious time and resources to respond to more serious cases.” Currently, Medicare primarily pays for unscheduled, emergency ground ambulance services when beneficiaries are transported to a hospital emergency department (ED). This system incentivizes transporting all beneficiaries to the hospital even when an alternative treatment option may be more appropriate. The ET3 model will address this incentive and test two new ambulance payments, while continuing to pay for emergency transport for a Medicare beneficiary to a hospital emergency department or other destination covered under current regulations: • payment for treatment in place with a qualified health care practitioner, either on-the-scene or connected using telehealth; and • payment for unscheduled, emergency transport of Medicare beneficiaries to alternative destinations (such as 24-hour care clinics) other than destinations covered under current regulations (such as hospital EDs). The ET3 model is intended to encourage high-quality provision of care by enabling participating ambulance suppliers and providers to earn up to a 5% payment adjustment in later years of the model based on their achievement of key quality measures. The quality measurement strategy aims to avoid adding more burden to participants, including minimizing any new reporting requirements. Qualified health care practitioners or alternative destination sites that partner with participating ambulance suppliers and providers would receive payment as usual under Medicare for any services rendered. The model will use a phased approach through multiple application rounds to maximize participation in regions across the country. In an effort to ensure access to model interventions across all individuals in a region, CMS will encourage ET3 model participants to partner with other payers, including state Medicaid agencies. CMS plans to release a Request for Applications in Summer 2019 to solicit Medicare-enrolled ambulance suppliers and providers. In an effort to implement the triage lines for low-acuity 911 calls, CMS anticipates in Fall 2019 issuing a Notice of Funding Opportunity for a limited number of two-year cooperative agreements. This Opportunity would be available to local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic locations where ambulance suppliers and providers have been selected to participate. A previous White Paper by the U.S. Departments of Health and Human Services and Transportation found that Medicare could save approximately $560 million per year by transporting individuals to doctors' offices rather than a hospital emergency department. Moreover, accounting for avoided inpatient hospitalizations and opportunities for treating in place could lead to further savings and quality of care improvements. Thus, according to CMS, “there is great opportunity for improvement in care quality and reduction in costs to the Medicare program through innovation in emergency medical services (EMS).” © 2020 Thomson Reuters. No claim to original U.S. Government Works. -5- With the support of local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches, ambulance suppliers and providers will triage people seeking emergency care based on their presenting needs. The model also aims to ensure Medicare Fee-For-Service beneficiaries receive the most appropriate care, at the right time, and in the right place. The model is intended to help make EMS systems more efficient and provide beneficiaries broader access to the care they need. Beneficiaries who receive treatment from alternative destinations may also save on out-of-pocket costs. An individual can always choose to be brought to an emergency department if he or she chooses. According to a fact sheet issued by CMS, The ET3 model aims to reduce expenditures and preserve or enhance quality of care by: • Providing person-centered care, such that beneficiaries receive the appropriate level of care delivered safely at the right time and place while having greater control of their healthcare through the availability of more options; • Encouraging appropriate utilization of services to meet health care needs effectively; and • Increasing efficiency in the EMS system to more readily respond to and focus on high-acuity cases, such as heart attacks and strokes. The ET3 Model has a five-year performance period. The anticipated start date is January 2020, and the performance period for all participants (regardless of start date) will end at the same time. Therefore, only applicants selected through the first RFA will participate [FN7] [FN8] for the full five years. Texas lawmakers introduce legislation addressing surprise bills from emergency care providers Texas state Senator Kelly Hancock (R-North Richland Hills) recently proposed legislation to prevent surprise medical billing of consumers in Texas. The bill, called SB 1264, and its companion legislation introduced by Rep. Trey Martinez Fischer (D-San Antonio), would allow medical providers and facilities to directly trigger an existing Texas Department of Insurance (TDI) balance bill mediation program for payment negotiations with health insurance companies. The proposed bill would also prohibit insurance companies from sending surprise balance bills to consumers. According to Senator Hancock, Chairman of the Senate's Business and Commerce Committee, “Thousands of Texans receive unexpected, and frankly unreasonable, surprise medical bills every year. Mediation works when it's available and has saved Texas patients more than $30 million in out-of-pocket health care expenses. But they're still getting stuck in the middle of payment negotiations, with no choice over care or control over costs. It's time to change that.” Senator Hancock first established the TDI surprise bill mediation program in 2009 after a constituent brought the issue to his attention. HB 2256 (81R) created a process for patients to dispute surprise charges greater than $1,000 from certain out-of-network providers working at in-network facilities. Hancock later helped pass SB 481 (84R) and SB 507 (85R), which expanded the program's availability and coverage. Currently, mediation protections address surprise balance bills greater than $500 from all emergency providers, including freestanding emergency departments, and all out-of-network providers working at a network facility. Under state law, these types of “balance bills” are required to include a consumer disclosure statement with instructions for contacting TDI's mediation help line. However, Hancock contends that many patients don't know “if, when, or how” to request state assistance with a medical billing dispute. Bob Jackson, state director of AARP Texas, noted that, “Texans are fed up with surprise medical bills, and consumers deserve to be held harmless from the anguish and shock that they encounter due to billing disputes between insurers and medical providers. The landmark legislation sponsored by Senator Kelly Hancock and Representative Trey Martinez Fischer to end surprise medical billing is great news for patients throughout Texas.” SB 1264 also includes a provision to allow federally-regulated, self-funded health benefit plans to opt into the state protections afforded [FN9] under the bill. These plans represent over 40% of the Texas health insurance market. U.C. San Diego opens emergency unit for seniors U.C. San Diego Health has opened an emergency unit specializing in treating seniors requiring emergency health care. The Gary and Mary West Emergency Department at UC San Diego Health in La Jolla is the first in California to treat qualifying patients over the age of 65 in a dedicated space customized for geriatric emergency care. Vaishal Tolia, MD, MPH, medical director of the Department of Emergency Medicine at UC San Diego Health, commented on the opening of the unit, stating that, “Although we have been delivering specialized senior emergency care for more than two years, the new physical space allows older adults to be cared for in an environment that better meets their needs than a traditional emergency room setting. We are very excited to provide this unprecedented service to our senior patients and their caregivers.” The accredited geriatric emergency department features architectural design elements for older patients, such as carefully calibrated lighting and improved acoustics, safety and comfort. The waiting room has chairs with high backs and sturdy arms and legs to assist seniors in sitting and standing. The 11 new SECU patient rooms include sound-absorbing walls and ceilings to reduce ambient noise, a variable lighting system that orients patients to the actual time of day, and contrasting colors between walls and floors and between toilet and chair seats and floors to improve mobility and reduce fall risk. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -6- According to Ted Chan, MD, chair of the Department of Emergency Medicine at UC San Diego Health, “Senior patients face common complications, such as being at a high risk for falls and cognitive and memory problems. All patients in the SECU are treated by a team with special training in geriatric medicine, including pharmacists to manage medications and social workers to ensure a smooth transition home upon discharge. Our goal with the SECU is to lower hospital admissions and re-admissions in this patient population.” Other features of the SECU include a nursing station visible from all patient rooms and a private lounge to offer caregivers a place to relax when visits last longer than planned. The SECU also has on its walls original artwork from local San Diego surf artist Aaron Chang. The new unit was funded by an $11.8 million grant from Gary and Mary West. The grant enables research initiatives between UC San Diego Health and the West Health Institute to identify, evaluate, and disseminate best practices in geriatric emergency care. Patty Maysent, CEO, UC San Diego Health, noted that, “Gary and Mary West are incredible philanthropists with large and generous hearts for seniors. Their gift to UC San Diego Health paves the way to innovative care in emergency medicine with the opening of the SECU. Our dedicated staff has worked tirelessly over the past few years to make this vision a reality. As we start the New Year, we are grateful for the opportunity to continue providing outstanding care to our community in all of its diversity.” Shelley Lyford, president and CEO of West Health, also commented on the opening, observing that, “Seniors in San Diego now have an emergency department with processes and enhancements to provide a better and more dignified experience during an extremely vulnerable time. Through our collaboration with UC San Diego Health, we are leading the way to wider adoption of geriatric emergency departments across the nation, ultimately improving outcomes and quality of life for seniors before, during and after a medical crisis.” West Health is funded by philanthropists Gary and Mary West, and is a family of nonprofit and nonpartisan organizations that are “dedicated to lowering health care costs and enabling seniors to successfully age in place with access to high-quality, affordable health [FN10] and support services that preserve and protect their dignity, quality of life, and independence.” Report predicts continued rise in urgent care market due to increased availability and higher insurance coverage rates According to a recently released report, The U.S. urgent care market is predicted to reach $30.6 billion by 2025, representing a 6.2% compound annual growth rate (CAGR) during the relevant period. Factors likely to drive the market during this period include an increase in incidence of chronic diseases, rising affordability of emergency care, and increasing demand for cost-effective treatment for older adults. Other factors that may contribute to the high growth within this market include increasing investments by service providers, increased recognition of these facilities, and the need to provide affordable care. Assuming it remains in place, the continued increase in numbers of people with insurance coverage as a result of the Patient Protection and Affordable Care (PPAC) Act is also expected to assist in the growth of the U.S. urgent care market. Business deals such as partnerships, collaborations, mergers, and acquisitions are also expected to increase the scope of the urgent care market. For example, CityMD acquired STAT Health in June 2018 in an attempt to expand its services to 100 locations in New York City. The report concludes that traditional hospitals are increasing their interest in urgent care (UC) centers to “maintain the balance between emergency and primary care in hospitals.” Many urgent care centers now have tools for diagnosis, blood testing, screening, and radiology. Moreover, companies and the U.S. government (in collaboration with UC centers) often organize wellness programs, and the use of telemedicine is now occurring at many urgent care centers, which allow for consultation for certain acute conditions. Additional key findings from the report suggest: • In the U.S., an injury is one of the major causes of death among children and is subsequently anticipated to increase demand for urgent care. According to the Centers for Disease Control and Prevention (CDC), in 2016, about 32,074,270 injuries were reported in the country; • By application, acute respiratory infection accounted for the largest share in the market in 2017 due to treatment at low cost for infections such as asthma, bronchitis, cough, nausea, and sore throat; • The hospital-owned segment, supported by joint ventures with hospitals, accounted for the largest share in the market and is anticipated to maintain its dominance over the forecast period due to easy follow-up with specialists and physicians; and • Some of the key players are Concentra, Inc.; Urgent Care MSO, LLC; American Family Care; CareNow; City Practice Group of New York; CareSpot; Fast Pace Urgent Care; Centra Care; Physicians Immediate Care; Intermountain Healthcare; Aurora Health Care; [FN11] Urgent Team; Prohealth; MD Now; Hometown Urgent Care; NextCare Holdings, Inc.; and MedSpring. Emergency physician group issues statement in response to insurer UnitedHealth's analysis of out-of-network billing Vidor Friedman, MD, FACEP, president of the American College of Emergency Physicians (ACEP), recently issued a statement in response to a UnitedHealth Group analysis of out-of-network billing. Dr. Friedman noted that: Insurers like UnitedHealth Group, yet again, prefer to shift the blame for their increasingly narrow networks to physicians. These same insurance companies are less likely to mention that right now they actually benefit each time a patient receives out-of-network care, © 2020 Thomson Reuters. No claim to original U.S. Government Works. -7- because the patient will often pay more of the total bill from their own pocket, due to higher out-of-network deductibles, before the insurance company ever chips in. The reality is that while overtly taking steps to keep physicians out-of-network, insurers are shifting blame to physicians and, even worse, shifting more and more costs to their own beneficiaries. Unfortunately, these unscrupulous tactics by insurers such as UnitedHealth are not new, as noted by a federal judge who recently found that a UnitedHealth subsidiary was “deceptive” and “evasive” in efforts that can hinder access to care. Patients must be protected, and this must stop. ACEP is working with bipartisan members of the House and Senate to protect patients and end “surprise billing.' By oath and by law, emergency physicians will treat any patient, regardless of their ability to pay. ACEP is the national medical specialty society representing emergency medicine. It has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter of the organization represents emergency physicians employed by military branches and other government agencies. One proposal in ACEP's Framework for Protecting Emergency Patients involves leveling deductibles for out-of-network emergency care so that they are no higher than those for in-network care. In this scenario, patients or their family members facing a medical emergency who do not have time to figure out where their care will be in-network would not be financially penalized for receiving out of network emergency care. According to ACEP, UnitedHealth's analysis references out-of-network emergency physicians “opting out” of emergency department's health plan networks, “as though insurers have no agency in such negotiations and contracting between insurers and providers only involves one party.” ACEP also contends that the company's brief fails to acknowledge that, under the Affordable Care Act, commercial insurers have the ability to apply a higher deductible for out-of-network emergency care. As such, insurers such as UnitedHealth benefit when they “opt out” of bringing emergency physicians into their plan networks, especially in light of out-of-network deductibles of $5,000 - $10,000 being increasingly common. ACEP currently calls for insurers to serve as a single point of contact to the patient for medical billing and payment, which would potentially help patients avoid confusion from having to deal with multiple bills and explanations of benefits that result from the many providers who often need to be involved in a single emergency care experience. The organization also stated that, “ACEP welcomes a discussion about steps that can be taken to protect and inform patients, take patients out of the middle of provider/insurer billing disputes, and puts an end to patients being surprised by how little their insurance [FN12] covers.” CDC report shows emergency department visits on the rise; nonurgent visits decreasing According to new data from the Centers for Disease Control and Prevention (CDC), emergency department visits reached a record high of 145.6 million patients in 2016, which is the most recent year for which data is available. These numbers represent an increase from approximately 137 million visits in 2015. The CDC data also show that 4.3 percent of emergency patients went to the emergency department with nonurgent medical symptoms in 2016, which a represents a decrease from 5.5 percent in 2015. The CDC data did not include freestanding emergency departments or urgent care centers. According to the American College of Emergency Physicians, wait times continue to improve as well. Over one-third (39 percent) of patients wait less than 15 minutes to see a provider and almost three-quarters (72 percent) of patients are seen in less than one hour. Vidor Friedman, MD, FACEP, president of the American College of Emergency Physicians, commented on these figures, noting that, “Emergency physicians are uniquely qualified to provide essential care that patients can't get anywhere else. Nearly two-thirds of visits occur after business hours, when other doctors' offices are closed. Millions of patients rely on emergency physicians for rapid diagnosis and treatment of acute illness, while emergency departments are increasingly viewed as a hub for care and care transitions.” Illness rather than injury is the most common reason for which patients seek emergency care, and the most frequently seen patients are children or senior citizens. Patients age 15 or younger comprised 18.8 percent (27.4 million) of emergency visits in 2016, and patients age 65 or older made up 15.9 percent (23.1 million) of emergency visits that same year. Stomach pain (12.5 million visits, 8.6 percent) and chest pain (7.5 million visits, 5.2 percent) were the two most common reasons patients sought emergency care in 2016. Injuries accounted for 42.2 million emergency visits (29 percent). The leading causes of injury were falls (10.5 million visits, 23 percent of injury visits) and motor vehicle crashes (3.7 million visits, 8.1 percent of total injury visits). Heart disease was the leading principal diagnosis group among the diseases that most commonly resulted in hospital admission from the emergency department. Nearly 60 percent of emergency care was delivered outside of traditional “business hours” (8am-5pm), and, 69 percent of hospital inpatients are processed through the emergency department. There was no change in the percentage of care delivered during traditional business hours (41 percent) between the years of 2015 and 2016. Dr. Friedman further commented on the report, stating that, “Emergency physicians are proud to provide care to anyone, anytime. Emergency care is growing more complex and some of the larger trends that will impact emergency department planning and © 2020 Thomson Reuters. No claim to original U.S. Government Works. -8- resource discussions include the rising number of elderly patients, preventing and treating opioid abuse, and the role of the emergency department in treating and managing patients with mental illness.” Other highlights of the CDC report included: • Median time to see a physician or other provider decreased to 17 minutes. The median visit length is about 180 minutes, which includes time with the physician or other provider, or other clinical services; • In 2016, 15.8 percent of patients arrived at the emergency department by ambulance, representing about 24 million ambulance transports; • Hospital admission or transfer resulted from 17.4 million visits. A patient admitted to the hospital from the emergency department will stay in the hospital an average of 4.5 days; • There were 2.2 million emergency visits by patients living in nursing homes, one-third of which resulted in hospital admission; • More than 5.5 million patients visited the emergency department with a primary diagnosis of mental disorder. Of those, 2.4 million visits involved a mental health professional seeing a patient in the emergency department. Patient visits resulting in hospital admission for mental health issues reached more than 2.1 million, which is 5,930 patient visits every day; • The number of homeless patients increased from 0.6 percent to 1 percent of total emergency visits; • The most frequent source of payment was Medicaid or CHIP (37.7 percent of visits), followed by private insurance (31.8 percent), [FN13] Medicare (21.6 percent) or no insurance (8.4 percent). Man sent home from hospital comes back and opens fire on emergency room; injures nurse A man who sought mental health care the day before and was turned away came back and shot a nurse inside a South Carolina hospital emergency room recently. Authorities took the man's gun on Tuesday of that week and told his girlfriend that it was OK to bring him back Friday for additional treatment. The man then went back to the emergency room with another gun on Wednesday and randomly opened fire, wounding a nurse. The shooting at the Regional Medical Center in Orangeburg, S.C. led to the wounded nurse having surgery. He was in critical condition after the surgery. Authorities took the gunman into custody after the shooting and shut down the emergency room while they investigated. According to Orangeburg County Sheriff Leroy Ravenel, the shooter will be charged with assault and battery with intent to kill. According to Democratic Rep. Gilda Cobb-Hunter of Orangeburg, the shooter's girlfriend had brought him to the mental health facility after calling deputies and mental health providers on Tuesday requesting help. They discovered he was armed, took his gun, and told the girlfriend that they did not have to admit him. Cobb-Hunter noted that, “They took his weapon yesterday. They told the girlfriend, ‘Bring him back Friday, he is OK right now.’ They went home yesterday. He came back this morning to be seen with another gun.” Cobb-Hunter requested prayers for the nurse fighting for his life, as well as the shooter. She noted, “We ask for prayer for the shooter [FN14] as well, because with mental challenges there are always demons that one is fighting.” Poll finds that majority of Americans of all political affiliations favor government protection against surprise out of network medical bills According to a recently conducted poll, three-quarters of the public (including a majority of Republicans) are in favor of the federal government protecting patients from receiving surprise medical invoices after they are unknowingly treated by doctors or medical facilities that are out of their insurance network. This issue often arises in the context of emergency department visits. Four in 10 American adults under age 65 claimed that they or a family member received an unexpectedly high invoice for a procedure, test, or doctor's visit they thought would be better covered by their insurer within the past two years. Approximately half of those respondents noted that the high bill occurred because the medical provider was not in their insurance network. The poll was conducted by the Kaiser Family Foundation between April 11-16, 2019 among 1,203 adults. The margin of error is +/-3 percentage points. Some states have placed limits on what out-of-network doctors and facilities can charge or have provided mechanisms for mediating the bills. Many of these protections, however, do not apply to millions of Americans who receive their health insurance through their employer. Some members of Congress have discussed potential protections, such as limiting out-of-network payments in emergency care to a price that is a set amount above what Medicare pays. The poll found between 76% and 78% of the public want the federal government to take action on this issue. Support among Democrat respondents was between 88% and 91%, and Republican support for government action ranged from 60% to 62%. There was also no consensus among the respondents on who should absorb the extra costs for which patients are currently responsible: 43% of the public said insurance companies should cover the extra costs from the bills, while 47% said doctors or providers should absorb it. Only 5% of the respondents said the provider alone should absorb all the cost. Democrats were somewhat more likely than independents or Republicans to suggest that insurers should absorb the full cost. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -9- Approximately half of the respondents characterized surprise billings as a top priority for Congress, although other health care issues received even more support. The poll found 64% of the public said lawmakers should concentrate on protecting the Affordable Care [FN15] Act's guarantees relating to preexisting medical conditions, and 68% prioritized lowering prescription drug costs. Paper by center-right think tank questions effectiveness of initiatives to reduce ER usage A recently released paper by the American Action Forum (AAF) discusses how recent initiatives to reduce emergency room usage may be ineffective and have negative health consequences for patients. The AAF claims to “proudly leads the center-right on economic and fiscal policy issues. It combines timely analysis and modern communications strategies to promote innovative, free-market solutions to build a stronger, more prosperous future.” Some of the main topics discussed in the paper include: • Insurers and state Medicaid programs have, over the past several years, implemented a variety of financial incentives to discourage, for potentially non-emergent health concerns, the use of emergency departments (EDs) in favor of other care settings, such as physicians' offices, urgent care centers, and retail clinics. • Some insurers have attempted to increase such deterrence by implementing a policy of retroactive review for ED claims with certain discharge diagnoses and potentially denying coverage for those visits determined to be “inappropriate.” • There are concerns that such policies may inadvertently discourage appropriate use of EDs, resulting in individuals not getting needed care in a timely manner. Furthermore, this policy may disproportionately impact minority populations. • Several studies indicate that the primary reason for using an ED for potentially non-emergent health concerns is a lack of access to primary care providers. An alternative solution to manage ED usage better, therefore, may be to increase access to alternative care settings, particularly in the evening and on weekends, and to provide transportation assistance to such locations. The paper discusses the need to address increased emergency department (“ED”) use, noting that it is more expensive to treat an individual in an ED compared with the cost at a doctor's office, urgent care center, or retail clinic. It also noted that private insurers cover approximately half of all ED expenditures despite privately insured individuals accounting for only 35-40 percent of all ED visits. It should also be noted, however, that EDs only accounts for about two percent of national health expenditures. According to the paper, “As with most health policy challenges, there is no silver bullet to solve the health expenditure crisis; the problem likely requires a multitude of smaller changes. One such change includes decreased use of low-value care—services for which the costs outweigh the benefits they provide.” The paper goes on to discuss why someone may pursue care at an ED even though it may cost more to the patient. These reasons potentially include proximity and the ability to get to one location versus another, as well as the ability to obtain an appointment at a time that is possible for the patient. Insurers and states also often use higher cost sharing ratios for care received in the ED. The paper, however, noted that, “Multiple studies, however, have found these policies to be largely ineffective, particularly for lower-income individuals, which may seem counter- intuitive. The primary reason these policies fail to alter people's behavior amounts to the fact that most people do not use EDs when they have expedient and affordable access to other sources of care and/or when they do not believe their medical concern is an emergency that needs immediate attention.” Research has shown that ED utilization tends increase during times when physician offices are generally closed. One study found that 75 percent of ED visits among children in 2012 were at night or on a weekend, and that (regardless of insurance status) actual or perceived lack of access elsewhere was the most common reason given for visiting an ED for non-urgent conditions. Put simply, “Most people go to EDs for care when they feel they have no other option. As a result, there may not truly be enough inappropriate use for [FN16] this type of financial lever on its own to substantially reduce ED visits.” Emergency physicians group and residents group release joint statement against Trump Administration's rule expanding conscience protections for medical providers Vidor Friedman, MD FACEP, president of the American College of Emergency Physicians (ACEP), and Omar Maniya, MD, MBA, president of the Emergency Medicine Residents' Association (EMRA), recently issued a joint statement in response to a final rule issued by the Department of Health and Human Services (HHS). The rule expands “conscience protections” for providers who refuse to administer certain types of care based on religious belief or moral conviction. Dr. Friedman and Dr. Maniya believe that this rule is “worrisome and dangerous for patients.” ACEP and EMRA released the following joint statement: Emergency physicians will care for any patient that needs emergency medical treatment. Denying emergency care or delaying emergency services based on race, religion, sexual orientation, gender identity, ethnic background, social status, type of illness, or ability to pay, is unethical and dangerous. Refusing to care for patients who require emergency medical attention could violate federal law and stands in stark contrast to the sworn oath and fundamental principle of emergency care: we must treat or stabilize anyone who visits the emergency department, anytime. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -10- ACEP and EMRA are concerned that these types of exemptions may run afoul of the Emergency Medical Treatment and Labor Act (EMTALA), fail to recognize the unique and vital nature of emergency medicine, and open the door to discrimination by institutions or individuals that are expected to prioritize patient care and safety ahead of personal beliefs.” ACEP is the national medical specialty society representing emergency medicine. ACEP is headquartered in Dallas, Texas and has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by different military branches and other government agencies. EMRA, founded in 1974, is the largest and oldest independent resident organization in the world. It is the “voice of emergency medicine [FN17] physicians-in-training” and has a membership over 16,000 residents, medical students, and alumni. California health information exchange awarded $4.9 million grant to connect ambulances to statewide health data network; concept expected to expand to additional communities in future Manifest MedEx, California's nonprofit health data network, has been selected by the state's Emergency Medical Services Authority (EMSA) for $4.9 million in grant funding to develop and implement interoperable health information exchange between emergency ambulance service providers and hospitals. Manifest MedEx will work together with six local EMS agencies, 13 EMS providers, and 16 hospitals to cover eight counties (Riverside, San Bernardino, Fresno, Tulare, San Joaquin, Merced, Amador, Stanislaus, Calaveras) and more than 7.6 million Californians following the Office of the National Coordinator's model for Search, Alert, File, Reconcile (SAFR) capabilities under this grant. By connecting EMS providers and their emergency department partners through SAFR, the nonprofit network will enable data-informed emergency care in the field, real-time notification to hospitals of incoming patients, and seamless data transfer between electronic patient care records and hospital electronic health records. Beginning with a two-year program, this work is designed to create capabilities that can be scaled to other California communities in the future. Manifest MedEx is California's largest nonprofit health data network. According to the organization, “Manifest MedEx delivers real-time information to help healthcare providers care for millions of patients every day. Together, we are transforming the healthcare landscape across the state, supporting California as a leader in affordable, proactive, and compassionate medical care.” According to Erica Galvez, Chief Strategy Officer of Manifest MedEx “Ambulance service is an incredibly critical point for patient communication. On transport, patients may be unconscious and unable to communicate their serious allergies and medical history details. On arrival to the emergency department, providers need access to details from paramedics to act safely and quickly.” Galvez further noted that, “Manifest MedEx is honored to be selected by EMSA as a trusted partner for seamlessly delivering life-saving health information when California patients are at their most vulnerable.” Over 400 healthcare organizations in California currently participate in Manifest MedEx, including the recent additions of Health Net, Scripps Health, and AHMC Healthcare. The network delivers real-time notifications of hospital admit, discharge, transfer (ADT) activity, as well as up to seven years of searchable medical record history to assist healthcare leaders improve patient care and reduce costs. MedEx is currently offering some hospitals a $60,000 bonus for participants that sign on before May 31, 2019, as part of the statewide [FN18] Cal-HOP program. U.S. House set to introduce bipartisan legislation addressing surprise medical bills; includes several provisions about ER care Representatives Raul Ruiz, M.D. (D-CA), Phil Roe, M.D. (R-TN), Joseph Morelle (D-NY), Van Taylor (R-TX), Ami Bera, M.D. (D- CA), Larry Bucshon, M.D. (R-IN), Donna Shalala (D-FL), and Brad Wenstrup (R-OH) recently released an outline of the bipartisan “Protecting People from Surprise Medical Bills Act.” This bill is intended to protect patients from “unfair and expensive surprise medical bills,” and is expected to be introduced in its final form in the coming weeks. According to Dr. Ruiz, “For too many middle-class families, receiving an unexpected and very expensive bill from an out-of-network provider is devastating and can lead to severe anxiety, depression, and financial ruin. This must end. That's why I will soon introduce the bipartisan Protecting People from Surprise Medical Bills Act, legislation that will ban these bills and keep families out of the middle by using a fair, evidence-based, independent, and neutral arbitration system to resolve payment disputes between insurers and providers. As an emergency doctor, patients come first and must be protected. I look forward to working as a bipartisan team to get this critical legislation signed into law.” The bill will include a prohibition on Surprise Balance Billing. Out-of-network (OON) providers will no longer be permitted to balance bill a patient for unanticipated out-of-network care, which includes the following situations: • Emergency care in both in-network and out-of-network facilities; • Scheduled anticipated care with unanticipated out-of-network providers; • Out-of-network after-emergency care when a patient cannot travel without medical transport; and © 2020 Thomson Reuters. No claim to original U.S. Government Works. -11- • Out-of-network imaging or lab services when ordered by an in-network provider. The patient will not be liable to pay the insurer any amount in excess of the applicable in-network cost-sharing amount and deductible, and the insurer or provider shall not bill any such excess payment. Entities who violate the ban and balance bill a patient will be subject to civil monetary damages if the patient has not been reimbursed the amount that they were balanced billed within 30 days of the entity being made aware of the error. Under the proposed law, the plan/issuer will pay the provider a commercially reasonable rate within 30 days. If either party is dissatisfied with that amount, they will have 30 days to privately settle on a payment amount. If no agreement between the parties is met, either party may trigger the independent dispute resolution (IDR) process. The Secretaries of HHS and Labor will establish an IDR process for resolving disputes between health plans and out-of-network providers for emergency services or unanticipated care rendered to enrollees. The patient will be completely removed from the process and will only be billed for their in-network cost-sharing rates. The IDR is “baseball style,” where the arbiter will select either the initial provider charge or the payment that the plan initially paid the provider, whichever they deem to be more reasonable. If the parties reach a settlement prior to completion of the arbitration process, then they split the costs of the process. Any payment owed by one party to the other must be made within 15 calendar days. HHS will be required to maintain a database of arbitrators (which may be delegated to the American Arbitration Association or to a state that already undertakes a similar function) who are qualified to resolve billing disputes of this nature and are unbiased and free from actual or potential conflicts of interest. Providers will be allowed to submit multiple claims of identical code(s) from a single site of service for simultaneous consideration under the arbitration process. The dates of service for these claims shall occur within 60 days of each other. Once arbitration is requested, the arbitration process shall be completed within sixty (60) days; this timeframe includes 30 days for both parties to submit information and data and 30 days for the arbiter to render a decision. Providers/issuers may submit supporting documents, and the IDR entity shall consider: • The usual and customary cost of the service, which is defined as 80th percentile of charges for comparable services for that specialty in the geographical area in which the services were rendered, determined through reference to an independent medical claims database; • If previously contracted, the history of commercial network contracting between the plan and the provider, including the prior in- network rates; • The training and specialization of the provider, as well as the characteristics of the practice setting (including the acuity level and cost intensity); • The provider's quality and outcome metrics; • The circumstances and complexity of the case, including time of the service; • The physician's usual charge for comparable services with regard to patients in health care plans in which the physician is not participating; • If there is a wide discrepancy between what the plan is attempting to pay this OON provider vs. other OON providers and between what the provider is charging for this OON patient vs. other OON patients; • Individual patient characteristics; and • Other economic and clinical circumstances relevant to the case. The final judgment of the arbitrator on the reasonable amount shall be binding and enforceable in any court with subject matter jurisdiction, and not subject to appeal unless it is determined that fraudulent or corrupt actions have been taken by any of the parties involved in the IDR process. Under the bill, a health plan/issuer will be required to clearly print in-network and out-of-network deductible amounts on insurance cards distributed to the beneficiaries. Furthermore, a patient will not be held responsible for out-of-network costs if the patient could not have reasonably known they were out-of-network because insurers were not compliant with transparency requirements. For example, if a patient checks the website and verifies with the plan that they are in-network, they cannot be balance billed if that turns out to be untrue. Republican Representative Roe also commented on the draft bill, noting that, “I am proud to be working with my friend and colleague Rep. Raul Ruiz on finding a solution to the widespread problem of surprise billing. For too long, these bills have negatively impacted patients and families across our nation causing financial stress when working out how to pay for costly, unexpected bills.” Roe further noted that, “The legislative principles we have laid out will rely on reasonable payment metrics and a system of arbitration between medical providers and insurers to compensate providers for care, instead of leaving patients on the hook for costly surprise bills. With around 180 million Americans receiving their health care coverage from an employer in a large group plan controlled by the Employee Retirement Income Security Act (ERISA), it is time they have some peace of mind that a surprise bill won't financially wipe © 2020 Thomson Reuters. No claim to original U.S. Government Works. -12- them out. Similar laws have proven successful in New York and Maryland for state-based plans, and I am hopeful these principles will soon lead to legislation that will be the solution we need to help protect patients.” Representative Wenstrup also weighed in on the legislation, stating that, “Patients must be protected from unanticipated medical bills when they cannot pick the doctor; these bills cause more stress and less healing. By providing a clear backstop for disagreements between providers and insurers, we can protect patients while maintaining the balance in our health care system that ensures access to [FN19] care.” Poll finds 81 percent of Americans think surprise billing costs should fall on insurance companies A recently released poll found that 81 percent of Americans believe the responsibility for the costs associated with surprise billing should fall upon health insurance companies rather than hospitals and doctors. The poll was conducted by Morning Consult between May 31 and June 1, 2019. Many voters (especially those in smaller communities) are concerned about the effect of rate setting. Sixty-three percent of Americans are worried about the impact rate setting could have on small communities that already face hospital and doctor shortages. Sixty- seven percent believe Congress must protect access to health care for Americans living in rural communities. Sixty-nine percent of respondents favored independent third-party resolution of rate disputes over allowing the government to set rates. According to Vidor Friedman, MD, FACEP, president of ACEP, “The American College of Emergency Physicians (ACEP) stands with the majority of Americans in favor of independent dispute resolution, which takes patients out of the middle and establishes a fair, efficient process to resolve differences between insurers and providers. Independent dispute resolution is a proven and market-based process that ensures that all stakeholders come to the table to negotiate in good faith.” Other findings from the poll include: • Fifty-four percent of Americans with health insurance who experienced a surprise medical bill says it's because their insurance company did not cover the medical treatment they received. • Eighty-one percent of Americans say that, given that in most emergency situations patients are not able to choose their provider, insurance companies should pay for emergency services. [FN20] • Sixty-three percent of Americans support Congress stepping in to establish insurance network standards. Emergency physicians group supports bipartisan Protecting People From Surprise Medical Bills Act The American College of Emergency Physicians (ACEP) officially supports bipartisan legislation recently introduced by Representatives Raul Ruiz (D-Calif.) and Phil Roe (R-Tenn.) with 32 original cosponsors. The bill is intended to protect patients from surprise medical bills. Vidor Friedman, MD, FACEP, president of ACEP, commented on the legislation, noting that, “The “Protecting People From Surprise Medical Bills Act' truly takes patients out of the middle of disputes between insurers and medical providers. This bill goes further than any other legislative proposals to encourage transparency from insurance providers and make sure that patients understand the limitations of their insurance.” Dr. Friedman continued his statement in support of the bill: This bill makes certain that a patient only pays the in-network amount for emergency care, whether the care delivered was in- or out- of-network. ACEP strongly supports the bill's provision that extends this important protection to the patient's deductible – bringing down the amount a patient must pay out of their own pocket before their insurance kicks in. This key provision will encourage health plans to expand their networks for emergency care – helping to address the root cause of “surprise bills,” narrow insurance networks. With the introduction of this bill, ACEP is optimistic a solution is in sight that will allow Congress to protect patients from surprise bills while avoiding unintended cost consequences or massive disruption of our health system. We are eager to continue working with bipartisan members of the House and Senate on measures that hold patients harmless, provide a level playing field for providers in network or in billing negotiations with insurers, and continue to enable emergency physicians to treat anyone, anytime, anywhere, regardless of their insurance status or ability to pay. We thank Reps. Ruiz, Roe, and all of the bipartisan cosponsors for recognizing the need for a policy remedy that more directly addresses the root cause of surprise bills, which is inadequate insurance networks.” ACEP is the national medical specialty society representing emergency medicine. ACEP has 38,000 emergency physician members. [FN21] Michigan study finds potentially significant savings by reducing over-testing in emergency rooms Researchers associated with the University of Michigan found excessive imaging testing being performed in the emergency department. The doctors involved in the study were the program directors of the Michigan Emergency Department Improvement Collaborative (MEDIC), a physician-led statewide quality network connecting a diverse set of unaffiliated emergency departments with the goal of improving quality and reducing low-value emergency care throughout Michigan. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -13- The researchers and a team of emergency physician MEDIC clinical champions from hospitals and health systems across Michigan used data from MEDIC to review opportunities to safely reduce over-testing in emergency departments. They found that the emergency departments could save approximately $3.8 million annually if these MEDIC sites were to collectively [FN22] improve to a benchmark standard. Kaiser Family Foundation reviews occurrences of potential surprise medical bills and concerns of Americans over such bills The Kaiser Family Foundation (KFF) recently conducted an analysis addressing the potential frequency of surprise medical bills associated with emergency room visits and hospital stays in the United States healthcare system. KFF first defined the term “surprise medical bill,” noting that such bills arise in different scenarios: • When an insured person inadvertently receives care from an out-of-network provider; • When a patient lacks the ability to select the emergency room, treating physicians, or ambulance providers that treat the patient; or • When a patient receives planned care at an in-network facility but later finds out that a provider treating the patient does not participate in her health plan's network. The common thread in all of these situations is that the patient is not in a position to choose the provider or to determine the insurance network status of the provider. The KFF analysis used claims data from large employer plans to estimate the incidence of out-of-network charges associated with hospital stays and emergency visits that could lead to a surprise bill. They found that, for people in large employer plans in 2017, 18% of all emergency visits and 16% of in-network hospital stays had at least one out-of-network charge associated with the care. The analysis also reviewed state and federal policies intended to address surprise billing. For people with large employer coverage, emergency visits and in-network inpatient stays were both more likely to result in at least one out-of-network charge in Texas, New York, Florida, New Jersey, and Kansas. These charges were less likely (for people with large employer coverage) in Minnesota, South Dakota, Nebraska, Maine, and Mississippi. Surprise medical bills are often generated when a patient owes the difference in cost-sharing levels between in-network and out-of- network services. For example, a preferred provider health plan (PPO) might require a patient to pay 20% of allowed charges for in- network services and 40% of allowed charges for out-of-network services. In some plans, an out-of-network service might not be covered at all. They are also generated by balance billing. Health insurers usually negotiate discounted charges with network providers and require them to accept the negotiated fee as payment-in-full. Network providers are then prohibited from billing plan enrollees the difference between the allowed charge and the full charge. Out-of-network providers are free to bill this balance, which often results in surprise medical bills. The analysis found that 38% of Americans are “very worried” and 29% are “somewhat worried” about being able to afford their own or a family member's unexpected medical bills. Moreover, 39% of insured nonelderly adults said they received an unexpected medical bill in the past 12 months, including one in ten who claimed that the bill was from an out-of-network provider. Of those respondents who received an unexpected bill, half say the amount they were expected to pay was less than $500 overall, and 13% stated that the unexpected costs were $2,000 or more. According to the KFF study, over three-quarters of Americans want the federal government to take action to address the problem of surprise medical bills. The public appears to be less interested in the details of how protections against these medical bills are accomplished. However, respondents were divided over who should bear the cost of the surprise bills between providers, insurers, or both. In reaching their estimates of potential surprise medical bills, KFF analyzed large employer claims data from IBM's MarketScan Research Database. This database contains information provided by large employers about claims and encounters for nearly 19 million individuals. KFF then examined situations that were likely to result in a surprise out-of-network billing. The analyzed database, however, only included paid claims, not denied claims. As such, it may not reflect claims for services provided by out-of-network providers if the group plan denied those out-of-network claims. Moreover, the MarketScan database reflected only the amount of allowed charges under a plan. It cannot provide estimates of the dollar amounts of surprise bills. In emergency settings, patients are often unable to ensure that they go to an in-network emergency room. The Affordable Care Act (ACA) provides partial protection for patients receiving out-of-network emergency care. It requires all non-grandfathered health plans to cover out-of-network emergency services and to apply the in-network level of cost sharing to such services. Health plans are also required to pay a reasonable amount for the out-of-network emergency services. The ACA does not prohibit balance billing by facilities or providers for emergency care. Patients can receive surprise bills for emergency care from the emergency room facility and from providers who treat the patient in the emergency room. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -14- The rate of out-of-network billing for emergency care for people with large employer coverage varied from state to state. Approximately a quarter or more of emergency visits in Texas (38%), New Mexico (29%), New York (28%), California (26%), Kansas (24%), and New Jersey (24%) resulted in at least one out-of-network charge in 2017. The rate in other states, however, was small: Minnesota (3%), South Dakota (4%), Nebraska (4%), and Alabama (4%). Emergency visits in urban areas (18%) were somewhat more likely to result in at least one out-of-network charge than are visits in rural areas (14%). The data used in this analysis included large employers who are often self-insured and therefore not subject to current state protections. The majority of the potential surprise out-of-network emergency charges found in this study were from doctors and other out-of-network professionals (as opposed to from the hospital or emergency facility). Most people with large employer coverage use in-network emergency facilities. In 2017, 78% of emergency room visits by people with large employer coverage were at an in-network facility. [FN23] Study addresses underrepresentation of women and minorities in emergency medical services in the US According to a recently published study, women and minority groups are underrepresented in Emergency Medical Services (EMS) in the United States. Furthermore, significant improvements in workforce diversity are unlikely to occur in the near future. The 10-year study, which was published in Prehospital Emergency Care, reviewed 700,000 newly certified emergency medical technicians (EMTs) and paramedics. Dr. Remle Crowe, a Research Scientist at ESO in Austin Texas and lead author of the study, noted that, “A diverse healthcare workforce can reduce health disparities and inequities in the delivery of care to minority patient populations.” Despite the fact that EMS serves as an important entry point to the healthcare system for many diverse populations, few studies have focused on the gender, racial, and/or ethnic diversity of those entering the EMS workforce. Dr. Crowe and colleagues at The Ohio State University and the National Registry of EMTs reviewed the gender and racial/ethnic composition of the 588,337 EMTs and 105,356 paramedics who earned initial National EMS Certification from 2008 to 2017. Throughout the relevant period, fewer than a quarter of newly certified paramedics were female (between 20%-23%). Furthermore, the proportion of newly certified EMS professionals identifying as black remained near 5% among EMTs and 3% among paramedics. For Hispanics, the proportion rose from 10% to 13% among EMTs and from 6% to 10% among paramedics. Compared to the country's population in 2017, women and racial/ethnic minorities remained underrepresented among newly certified EMS professionals. These representation differences varied across geographic regions. In the Northeast there were 93% fewer newly certified EMTs who identified as black compared to the US population (4% vs. 11%) and the difference amounted to 138% for new paramedics (4% vs. 11%). Although efforts to increase diversity among healthcare professionals are generally increasing, the authors noted that few of these efforts have specifically focused on EMS recruitment. Dr. Crowe further noted that, “Diversity among EMS professionals is important for fomenting multicultural awareness, enhancing patient-provider communication, and improving equality in the delivery of care. However, we're unlikely to see substantial changes in the diversity of the EMS workforce in the near future. Women and racial/ethnic minority groups remain underrepresented among recent graduates, and the gaps are more pronounced among paramedics. This is particularly concerning as paramedics provide more critical invasive interventions and make complex, time-sensitive decisions regarding care.” The study suggests that improving EMS workforce diversity will require “coordinated national recruitment efforts to encourage underrepresented groups to pursue careers in EMS.” Examples of such practices include partnerships with schools (especially [FN24] elementary and middle schools), as well as community engagement initiatives involving youth classes and activities. Emergency care group applauds recent committee markup of surprise emergency bill federal legislation The American College of Emergency Physicians (ACEP) recently issued a statement in response to the July 17, 2019 Energy and Commerce Committee markup of federal legislation intended to address surprise emergency treatment bills. The statement reads as follows: We are pleased that the Energy & Commerce Committee is recognizing the value of including an independent dispute resolution (IDR) process as part of a surprise billing solution. The amendment from Representatives Ruiz (D-CA) and Bucshon (R-IN) that was voted on today is a big step in the right direction. Despite the life-saving treatment provided to millions of Americans each day, the median in- network amounts for an emergency physician's services are almost always less than $1,250. In order to ensure access to emergency care is protected, the qualifying threshold for using IDR must be lowered, or that process will remain out of reach on over 99% of the services provided by emergency physicians. We look forward to continuing to work with Congress on achieving a balanced approach.” © 2020 Thomson Reuters. No claim to original U.S. Government Works. -15- ACEP is the national medical specialty society representing emergency medicine. It has a membership of 38,000 emergency physicians. ACEP has already come out in support of the “Protecting People From Surprise Medical Bills Act.” Vidor Friedman, MD, FACEP, president of ACEP, commented on the Act, stating that, “The “Protecting People From Surprise Medical Bills Act' truly takes patients out of the middle of disputes between insurers and medical providers. This bill goes further than any other legislative proposals to encourage transparency from insurance providers and make sure that patients understand the limitations of their insurance.” ACEP also noted that, “With the introduction of this bill, ACEP is optimistic a solution is in sight that will allow Congress to protect patients from surprise bills while avoiding unintended cost consequences or massive disruption of our health system.” The organization states that it is “eager to continue working with bipartisan members of the House and Senate on measures that hold patients harmless, provide a level playing field for providers in network or in billing negotiations with insurers, and continue to enable [FN25] [FN26] emergency physicians to treat anyone, anytime, anywhere, regardless of their insurance status or ability to pay.” OIG report finds many non-VA emergency room claims for veterans inappropriately denied and rejected Veterans who receive emergency care at non-VA facilities can file for reimbursement of non-VA emergency care costs. If claims are denied or rejected by the VA, non-VA facilities and providers can bill the veterans for some or all the costs of the emergency care services provided. In September 2017, then Representative Tim Walz (Minnesota) expressed a concern about claims processors denying veterans' non-VA emergency care claims to meet production goals and receiving incentives such as high performance ratings and bonuses. The VA Office of Inspector General (OIG) conducted an audit to determine whether processors of non-VA emergency care claims inappropriately denied or rejected the claims, and, if so, whether the cause of these denials was pressure to meet production standards. The scope of the OIG's audit focused on non-VA emergency care claims-processing activities and oversight by the Office of Community Care (OCC) Claims Adjudication and Reimbursement Directorate (CAR) personnel nationwide. The audit included site visits to nine CAR locations. The audit team's findings in this report were drawn from: • Interviews with 182 staff and leaders; • Observations of claims-processing activities; • Survey responses from 435 CAR staff in every CAR region; • Assessments of a statistically selected sample of 180 denied and 60 rejected non-VA emergency care claims that were scanned or electronically received from April through September 2017; and • Reviews of relevant VA email records. The OIG discussed the following findings in its report: • A significant number of denied and rejected claims were inappropriately processed, some leading to wrongful denials and rejections; • OCC's CAR culture created pressure for timely production; • CAR lacked sufficient quality controls over denied and rejected claims; and • Additional barriers affected claims processing. VA personnel who process payments of claims for medical care obtained outside VA are from the CAR in the VA's Office of Community Care. The audit team's nationwide accuracy review found that an estimated 31 percent of denied or rejected non-VA emergency care claims were inappropriately processed by CAR staff. Moreover, denied and rejected claims could shift the financial burden of non-VA care from VA to the veteran. Under current regulations, a claim is “denied” because there is not a basis for a payment. A claim may also be “rejected,” which means that it cannot be decided until the claimant provides additional or corrected information. When CAR denies a claim, the claimant may have to pay out of pocket for his or her emergency care. During the period of April 1 through September 30, 2017, the billed amount of inappropriately processed claims that were either denied or rejected was approximately $716 million, affecting nearly 61,000 veterans. The audit team could not determine whether providers billed veterans for inappropriately processed claims that VA did not reimburse. The risk of undue financial burden remained for individuals who could ultimately be billed by the non-VA provider for their episode of emergency care. Although claimants can appeal denied claims, CAR was not effectively monitoring veterans' appeals of non-VA emergency care claims decisions. While not all claims-processing errors resulted in inaccurate decisions, the audit revealed that a portion of those denied and rejected claims should have been approved. The OIG estimated that about 17,400 veterans, with bills totaling at least $53.3 million, were negatively affected during the audit period. The OIG estimated that these errors could result in $533 million in improper underpayments to claimants over five years if corrective action is not taken. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -16- The audit found that the remaining processing errors are also significant, as claimants did not receive complete and accurate information regarding why their claims were not approved. As such, the procedural errors created a risk that claimants could not [FN27] effectively respond with necessary information to obtain claim approval and payment. Senate Committee on Veterans' Affairs Ranking Member Jon Tester (D-MT), House Committee on Veterans' Affairs Chairman Mark Takano (D-CA), Senate Committee on Veterans' Affairs Member Senator Jerry Moran (R-KS), and House Committee on Veterans' Affairs Ranking Member Dr. Phil Roe (R-TN) recently led a bipartisan, bicameral letter to VA following the OIG's report. In their letter, Members expressed their disappointment that VA has not done enough to improve its claim processing following a 2014 GAO report on the same matter and demanded that, “VA expeditiously and continuously implements the recommendations made by independent oversight bodies.” The letter addressed, among other issues, whether the VA is adequately staffed for reviewing these types of claims, how it intends to resolve these inappropriately processed claims, and whether incentives still exist for decision makers within the VA to deny valid emergency room claims. Other signatories to the letter were Senator Tammy Baldwin (D-WI), Senator Patty Murray (D-WA), Senator Bernard Sanders (I-VT), Senator Sherrod Brown (D-OH), Senator Richard Blumenthal (D-CT), Senator Joe Manchin III (D-WV), Senator Mazie Hirono (D-HI), Senator Kyrsten Sinema (D-AZ), Senator John Boozman (R-AR), Rep. Julia Brownley (D-CA), Rep. Chris Pappas (D-CT), Rep. Mike Levin (D-CA), Rep. Gregorio Sablan (D-MP), Rep. Gil Cisneros (D-CA), Rep. Anthony Brindisi (D-NY), Rep. Max Rose (D-NY), Rep. Conor Lamb (D-PA), Rep. Kathleen Rice (D-NY), Rep. Joe Cunningham (D-SC), Rep. Lauren Underwood (D-IL), Rep. Susie Lee (D- NV), Rep. Colin Allred (D-TX) Rep. Neal Dunn (R-FL), Rep. Jack Bergman (R-MI), Rep. Gus Bilirakis (R-FL), Rep. Aumua Amata Coleman Radewagen (R-AS), Rep. Jim Banks (R-IN), Rep. Andy Barr (R-KY), Rep. Daniel Meuser (R-PA), Rep. Mike Bost (R-IL), and [FN28] Rep. Chip Roy (R-TX). Medical professional organizations offer guidance to Congress on surprise medical bill legislation Several medical organizations have coalesced to urge key Congressional committees (including Ways and Means and Education and Labor) to consider potential unintended consequences that may threaten access to care as they attempt to find legislative solutions to protect patients from surprise medical bills. These physician societies, which represent over 300,000 physicians across multiple specialties, have set forth key policy considerations that they consider to be important in guiding any successful legislation. The involved groups include the American Association of Neurological Surgeons, American Association of Orthopaedic Surgeons, American College of Emergency Physicians, American College of Radiology, American College of Surgeons, American Medical Association, American Society of Anesthesiologists, American Society of Plastic Surgeons, College of American Pathologists, and Congress of Neurological Surgeons. The considerations set forth by the professional associations include: Limits are placed on patient responsibility Patients should be protected from surprise medical bills when they unknowingly receive services from out-of-network providers in in-network facilities, and should be out of any payment disputes between physicians and insurers that can arise. In such situations, patients should only be responsible for in-network cost-sharing, with balance billing prohibited. Such cost-sharing protection should apply to copays, coinsurance, and deductibles. Rate-setting is avoided A payment process for out-of-network care needs to be established that is keyed to the market value of physician services and that maintains a level-playing field for future in-network contract negotiations. A benchmarked rate would provide insurers with access to a discounted contract rate without providing physicians with the corresponding benefits of contracting in exchange. It then further erodes the value of the insurance coverage that policyholders have purchased by allowing insurers to shift even more costs to them in the form of higher deductibles and other cost-sharing. As physicians, we believe our patients benefit most when we are in network with as many insurers as possible. Upfront payment is ensured Any payment process for out-of-network care should ensure that timely (i.e. within 30 days of claim submission), upfront payment is made from the insurer that is of an amount that is commercially reasonable and in line with the services provided by the physician. If any guardrail(s) is specified around this upfront payment in legislation, it must be ensured that it will not disincentivize insurers from negotiating fair contracts to bring physicians in-network. HHS should provide annual reports to Congress regarding the impact of this payment process, or any such guardrails, on patient access to care, network adequacy, and insurer-provider negotiations. A robust independent dispute resolution avoids payment disputes from the start Legislation should provide for a robust independent dispute resolution (IDR) mechanism that incentivizes all parties to act fairly and reasonably from the start in setting charges and payment amounts, without ever needing to be invoked. Then for those circumstances where the insurer's up-front payment is insufficient (whether due to factors such as the complexity of the patient's medical condition, the © 2020 Thomson Reuters. No claim to original U.S. Government Works. -17- special expertise required, comorbidities, or other factors unique to that provider or geographic area), the IDR process itself will allow for a quick, efficient, and easy resolution, without the need for attorney involvement or costs to the federal government. Specifically, the groups suggest that an IDR process should: • Be accessible for all physicians who provide out-of-network care; • Use a “baseball-style” approach in which the IDR entity can select only between either party's final offers, and the non- prevailing party must bear the costs of the process; • Allow for “batching” of claims that involve identical plan or issuer and providers, the same or similar procedures, and that occur within reasonable timeframes, with consideration given to the size and resources of the individual or group providing those services; and • Require for certain criteria to be considered during the IDR process, including: the training, experience and specialization of the provider; the provider's quality and outcome metrics; the circumstances and complexity of the case(s) under dispute; commercially reasonable amounts for comparable services or items in the same geographic area; and demonstration of good-faith efforts (or lack of good faith efforts) made by the out of network provider or the plan to contract, and any prior negotiated rates. Allow for elective out-of-network care with patient consent Patients should have the opportunity to knowingly receive care from the out-of-network provider of their choice for elective services. Providers should be forthcoming with their network status during consultations with the patient, just as carriers should properly inform patients about which physicians are within their network. Following these discussions, patients who fully research their healthcare options and make an informed decision to choose an out-of-network provider should be able to receive a direct bill for that care. This encourages patient choice and empowers patients to determine what is best for their medical needs, while also fostering greater access to care. Network adequacy is strengthened Overly narrow network design by insurers has contributed significantly to the current problem. Therefore, strong oversight and enforcement of network adequacy is needed from both federal and state governments. Robust network adequacy standards include, but are not limited to, an adequate ratio of emergency physicians, hospital-based physicians, and on-call specialists and subspecialists to patients, as well as geographic and driving distance standards and maximum wait times. Insurer transparency is ensured Provider directories must be accurate and updated regularly by insurers to be useful to patients seeking care from in-network providers. In addition, insurers should be held to complying with the prudent layperson standard in existing law for determining coverage for emergency care, so that insured patients are not liable for unexpected costs simply because they were unable to accurately self- [FN29] diagnose ahead of time whether their symptoms were, in fact, due to an emergency medical condition. Research finds that surprise medical bills financially stress all consumers, even those who are middle class with good credit According to a recently released study by Elevate's Center for the New Middle Class (CNMC), surprise medical bills are a hardship for many Americans, regardless of their credit score. The research found that eight in ten non-prime consumers (those with credit scores under 700), and six in ten prime consumers (with credit scores over 700) have experienced some level of financial hardship due to medical bills in the last five years. The study also found that 54% of non-prime and 42% of prime consumers have delayed seeking medical treatment due to fear of high costs. Furthermore, a majority of those surveyed had health insurance, implying that lack of insurance was not a contributing factor to medical expense-related bills. Jonathan Walker, Executive Director of the CNMC, commented on the findings, noting that, “After visiting the emergency room, recovery should be the focus; financial recovery should not. Our research finds non-prime consumers are feeling these expenses more acutely, but we are seeing Americans across the board struggle with financial pain – on top of any physical pain – when recovering from an emergency medical expense. Moreover, they may forgo treatment altogether because of the financial burden.” Other key findings from the survey include: • Nearly half of non-prime consumers and almost one-third of prime consumers said a financial disruption due to surprise medical expenses could not be absorbed in the month it occurred; • When asked why medical expenses are disruptive, factors relating to insurance not covering claims, high deductibles, and high out-of- pocket costs are most commonly cited; • More than half of Americans surveyed reported an emergency room visit for someone in their household in the past five years, noting inpatient hospital treatment as the most financially disruptive, followed by emergency room visits; and • 72% of non-prime and 65% of prime consumers felt that surprise medical expenses in some way disrupted their household's finances. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -18- In conducting the research, CNMC compared the responses of 1,544 Americans with prime and non-prime credit scores. The research was conducted via an online panel from April 22 to May 23, 2019. Elevate's Center for the New Middle Class “conducts research, engages in dialogue, and builds cooperation to generate understanding [FN30] of the behaviors, attitudes, and challenges of America's growing “New Middle Class.”' Physicians group applauds HHS public support of emergency medicine-focused Medicare alternative payment model The American College of Emergency Physicians (ACEP) has applauded the fact that the Secretary of the Department of Health and Human Services (HHS) Alex Azar has publicly expressed his support of the Acute Unscheduled Care Model (AUCM). AUCM is the first emergency medicine-focused Medicare alternative payment model (APM), and was developed by ACEP and recommended by the Physician-Focused Payment Model Technical Advisory Committee (PTAC). Structured as a bundled payment model, the AUCM is intended to improve quality and reduce costs by allowing emergency physicians to accept some financial risk for the decisions they make around discharges for certain episodes of acute unscheduled care. As Medicare and other payers move away from fee-for-service toward more value-based care, the AUCM will potentially allow emergency physicians to play a leading role in managing this transition. In the HHS official response to PTAC, Secretary Azar asked the Centers for Medicare & Medicaid Services (CMS)' Innovation Center (CMMI) to look into incorporating core concepts of AUCM into the APMs it is developing. Secretary Azar specifically noted that AUCM is a “creative proposal…that focuses on the safe discharge of patients, follow-up care for 30 days post-ED visit, and hospitalizations or other avoidable post-ED visit events and their associated costs.” The Secretary also noted that he is “encouraged by submitters like ACEP who continue to help drive transformative innovation in American health care toward a value-based delivery system.” According to ACEP, “The Secretary's endorsement of the AUCM is an important step toward enhanced quality reporting and value- based care in emergency medicine and paves the way for emergency physicians to finally be in a Medicare APM that is meaningful to them and their patients. ACEP looks forward to working with CMMI as it carries out the HHS Secretary's request.” The American College of Emergency Physicians (ACEP) is a national medical society representing emergency medicine. ACEP represents its 40,000 emergency physician members. Secretary Azar also noted in his response that, “I agree with PTAC that ED providers can influence transitions of care from the hospital and serve as one critical link in broader efforts to deliver coordinated, value-based care.” Azar further stated that, “I am interested in exploring how the concepts in the AUCM model for care management by emergency physicians after an ED encounter could be incorporated into models under development at the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMS Innovation Center). We have further discussed care transitions with ACEP, and I have asked the CMS Innovation Center to assess how key mechanisms of action in this model could operate as a [FN31] component in a larger model dedicated to improving population health.” th Nonprofit physician coalition praises 100 co-sponsor of legislation addressing surprise medical bills The Out of the Middle Coalition recently applauded Representatives Raul Ruiz, MD, (D-Calif.) and Phil Roe, MD, (R-Tenn.) for reaching 100 cosponsors on their bipartisan proposal to address surprise medical bills. This legislation now enjoys more support than any other pending surprise medical billing legislation in the U.S. House of Representatives. Out of the Middle represents thousands of physicians across the United States who advocate on behalf of their patients and demand that Congress protect these patients from surprise medical bills “without letting insurance companies dodge their responsibility to cover their care.” According to the coalition, by reaching this co-sponsorship milestone of support for the Protecting People From Surprise Medical Bills Act (H.R. 3502), lawmakers are demonstrating widespread and growing interest in “advancing a balanced solution to the surprise medical billing problem.” This proposed solution removes patients from the middle of the process, and is intended to ensure that patients have access to health care services when and where they need them. It also is intended to provide a level playing field between physicians and insurers, as well as a fair process to resolve billing and payment disputes. The Out of the Middle Coalition “appreciates the leadership of these members of Congress in protecting our patients.” It also noted that, “We strongly encourage key committees tasked with addressing this issue, including the House Committee on Education and Labor and the House Committee on Ways and Means, to consider this particular legislation as the most equitable and common-sense solution to tackle surprise medical bills.” The Protecting People from Surprise Medical Bills Act is designed to address the root cause of surprise bills, which, according to the Coalition, is inadequate insurance networks. The bill is modeled after legislation currently in place in New York state, which has reduced complaints related to surprise bills, increased the number of in-network physicians, and reduced health care spending. The Coalition contends that H.R. 3502 includes “robust patient protections” that ensure individuals only pay in-network amounts for their care, regardless of whether the care provided was in or out-of-network. The bill also attempts to clarify for patients the limits of their © 2020 Thomson Reuters. No claim to original U.S. Government Works. -19- insurance coverage, safeguards access to emergency care, and preserves access to planned care by the physician of their choice. The bill also encourages transparency from health plans and establishes what the Coalition deems a “fair and efficient” payment dispute resolution process between physicians and insurers. This resolution process requires no patient involvement. The Coalition also noted that, “On behalf of the millions of patients we care for each day, the Out of the Middle Coalition celebrates this significant milestone and applauds the 100 co-sponsors for their leadership on this important patient protection issue.” Out of the Middle comprises the American Academy of Ophthalmology, American Association of Neurological Surgeons, American Association of Orthopaedic Surgeons, American College of Emergency Physicians, American College of Radiology, American Society of Anesthesiologists, College of American Pathologists, Congress of Neurological Surgeons and the National Association of Spine [FN32] Specialists. New Hampshire hospital partners with West Health in geriatric emergency department New Hampshire-based Dartmouth-Hitchcock Health (D-HH) will partner with West Health, a family of nonprofit and nonpartisan organizations dedicated to lowering health care costs to enable seniors to successfully age in place. The two entities will engage in a $4.5 million research collaboration to create an innovative “Geriatric Emergency Department” (GED). The GED is designed with protocols, resources, and specialized care areas to optimize the acute care of older adults. While most hospitals implementing GEDs have been urban or larger academic medical centers, the D-HH/West Health collaboration will be the first in the nation to focus on a largely rural population. According to D-HH CEO and President Joanne M. Conroy, MD, “Improving the delivery of care in rural areas is one of the strategic imperatives for Dartmouth-Hitchcock Health, as we grow to meet the needs of patients around the region. With our strong programs and passionate providers in Emergency Medicine and Geriatrics, along with our dynamic Connected Care Center, we are uniquely qualified for the development of a rural telehealth model of geriatric emergency care that this collaboration will enable.” Shelley Lyford, president and chief executive officer of West Health, also commented on the project, noting that, “This is the perfect union. Combining West Health's experience in geriatric care with Dartmouth-Hitchcock's pioneering work in telehealth and geriatrics will enable D-H to add geriatric emergency telecare to its already world-class telehealth portfolio. And seniors will be the beneficiaries of this important work.” Over the course of the three-year research collaboration, the West Health Institute will contribute expertise and $3 million in capital to establish Dartmouth-Hitchcock Medical Center in Lebanon (DHMC) as a center for geriatric emergency care. The collaboration plans to develop and implement protocols, resources, and specialized care areas within the Emergency Department at DHMC. The intent of these projects is to optimize the acute care of older adults. After DHMC earns accreditation from the American College of Emergency Physicians (ACEP) as a top-tier, Level 1 GED, it will offer its services (along with DHMC) as the “hub” to four “spoke” sites around the region through D-HH's Center for Telehealth. D-HH has committed an additional $1.5 million to the overall project cost. Scott Rodi, MD, interim section chief and regional director of emergency medicine at DHMC, commented that, “Seniors who seek treatment in EDs are often highly complex patients with various medical and social issues that are challenging for any ED, and can be especially challenging for rural hospitals with fewer resources. This partnership with West Health will enable us to work with our rural colleagues to provide specialized, senior-specific care to more patients throughout the region. It's another step forward in our vision to improve access to high-quality health care for all people, regardless of where they live.” This collaboration is expected to help evaluate the effectiveness and sustainability of using telemedicine to extend the reach of a GED to rural hospitals, and to “create opportunities to scale the concept to other rural facilities across Northern New England and throughout [FN33] the country.” National emergency medicine group addresses unintended consequences of California surprise medical bill law The American College of Emergency Physicians (ACEP) recently issued a press release condemning the unintended effects of a state law in California that was passed to protect patients from surprise medical bills. These unintended effects were addressed in a study conducted in that state after the passage of the bill. ACEP contends that a recent survey of California physicians “shows the state's law to solve surprise billing is not working as intended.” Some believe that the California model, which mirrors the rate setting (or benchmarking) proposals also under consideration in Congress, could potentially increase health care costs as much as 30 percent while also limiting patients' access to in-network physicians. ACEP is a national medical society representing emergency medicine doctors. ACEP has approximately 40,000 emergency physician members. California physicians who responded to the survey reported greater difficulty in contracting, and the majority of respondents are concerned that similar federal legislation could accelerate health care consolidation. Other findings in the recently released California survey include: © 2020 Thomson Reuters. No claim to original U.S. Government Works. -20- • 94 percent of responding physicians agree the congressional bills modeled after the California law will economically incentivize insurers to terminate contracts with physicians; • 88 percent of responding physicians said the California law allowed insurers to shrink physician networks, decreasing patient access to in-network physicians in their community; • 79 percent of responding physicians said the California law negatively impacted the availability of emergency and on-call physician specialists who respond to emergencies; and • 77 percent of responding physicians agree that the federal legislation will disproportionately harm rural areas. In New York, recent findings from the New York Department of Financial Services found that the state's attempt to stop surprise billing lowered in-network emergency physician payments by nine percent while also saving New York consumers more than $400 million in four years. According to Laura Wooster, MPH, Associate Executive Director of Public Affairs for ACEP, “California's experience is a warning sign that federal surprise billing proposals that include rate setting will endanger America's emergency care safety net while raising health care costs. Instead, Congress should model federal legislation after the fair and proven approach used in New York, which successfully protects patients from surprise bills while avoiding unintended consequences.” The New York-style model is similar to the approach included in HR 3502, the federal “Protecting People from Surprise Medical Bills Act.” ACEP contends that this model can lead to cost savings within the entire system, while still preserving access to care for patients. ACEP's press release argues that, “It's been proven to be efficient and fair to insurers and providers. And, by effectively utilizing independent dispute resolution (IDR), it lowered the cost of care, generated savings and nearly eliminated surprise bills.” Ms. Wooster also noted that, “It is hard to reconcile the findings from New York—which the New York Department of Financial Services based on its own data about the real-world impact of the law—with flawed third-party analyses, especially those promoted by insurance industry-supported researchers and others.” According to ACEP, “There are also significant issues with the Congressional Budget Office (CBO) analysis of surprise bill proposals, which is limited to a paraphrased recounting of an email from the agency to a Congressional office, rather than a full report. ACEP urges Congress to take a thoughtful approach and look to proven successes when considering the best solution to protect patients [FN34] without impacting access to care or driving up costs.” Study finds mortality among Medicare beneficiaries within 30 days of ER visit has declined A recently published study found that, among Medicare beneficiaries receiving emergency department (ED) care in the United States, mortality within 30 days of an ED visit has declined in recent years, especially for the highest-severity patients. These declines occurred as fewer patients were admitted and were instead sent home. The study was published in JAMA Internal Medicine, and was authored by a team of researchers led by Laura Burke, MD, MPH, an emergency medicine physician at Beth Israel Deaconess Medical Center (BIDMC), According to Dr. Burke, “It's important for policymakers and researchers to consider trends in emergency care from a broader perspective. Too often, people focus on ED visits as being very expensive and see the growing intensity of emergency care as wasteful or unnecessary – however, emergency physicians on the front lines know that appropriate intensity of care, such as running more tests and administering more treatments when indicated, can provide a lot of value to the health care system and, most importantly, to patients. They do so by providing timely diagnosis and treatment and often, preventing the need for a more expensive hospital admission. Our results also suggest that the evolving practice of emergency care may also be leading to better outcomes.” Dr. Burke and colleagues reviewed over 15 million ED visits in the United States among traditional Medicare beneficiaries from 2009 to 2016. They looked at how often patients were admitted to the hospital (opposed to being sent home), and whether this number was changing over time. They also examined whether the time trends (changes in mortality rates over time for Medicare beneficiaries using the ED) were similar across different types of hospitals. Burke and her colleagues found that mortality rates within 30 days of an ED visit improved by 23 percent from 2009 to 2016, a trend [FN35] that was greatest for the sickest patients. © Copyright Thomson/West - NETSCAN's Health Policy Tracking Service [FN1] . “Emergency Physicians, Pediatricians and Nurses Issue Recommendations on Emergency Care for Children,” November 1, 2018, available at: http://newsroom.acep.org/Emergency-Physicians-Pediatricians-and-Nurses-Issue-Recommendations-on-Emergency-Care- for-Children. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -21- [FN2] . “Emergency Nurses Association Praises Signing of SUPPORT Act,” October 24, 2018, available at: https://www.ena.org/press-room/ articles/detail/2018/10/24/emergency-nurses-association-praises-signing-of-support-act. [FN3] . “Blue Cross & Blue Shield Policy in Mississippi Puts Patients At Risk,” January 17, 2019, available at: http:// newsroom.acep.org/2019-01-17-Blue-Cross-Blue-Shield-Policy-in-Mississippi-Puts-Patients-At-Risk. [FN4] . “Many EDs Do Not Have Pediatric Area, Emergency Care Coordinator,” Health Day News, January 11, 2019, available at: https:// www.psychiatryadvisor.com/practice-management/many-eds-do-not-have-pediatric-area-emergency-care-coordinator/article/824021/. [FN5] . “ACEP Presents Framework To Protect Emergency Patients From Out-Of-Network Billing Issues,” January 28, 2019, available at: http://newsroom.acep.org/2019-01-28-ACEP-Presents-Framework-To-Protect-Emergency-Patients-From-Out-Of-Network-Billing- Issues. [FN6] . “VLSP Files Class Action Lawsuit Accusing VA of Disseminating False Information To Veterans,” January 2, 2019, available at: https:// www.nvlsp.org/news-and-events/press-releases/nvlsp-files-class-action-lawsuit-accusing-va-of-disseminating-false-informa. [FN7] . “HHS launches innovative payment model with new treatment and transport options to more appropriately and effectively meet beneficiaries' emergency needs,” February 14, 2019, available at: https://www.cms.gov/newsroom/press-releases/hhs-launches- innovative-payment-model-new-treatment-and-transport-options-more-appropriately-and. [FN8] . “Emergency Triage, Treat, and Transport (ET3) Model,” February 14, 2019, available at: https://www.cms.gov/newsroom/fact-sheets/ emergency-triage-treat-and-transport-et3-model. [FN9] . “Hancock Files Landmark, Bipartisan Legislation Preventing Surprise Medical Bills,” February 28, 2019, available at: https:// senate.texas.gov/members/d09/press/en/p20190228a.pdf. [FN10] . “UC San Diego Health Opens California's First Accredited Senior Emergency Care Unit Gary and Mary West Emergency Department First in Western Region to Receive Gold Accreditation,” January 10, 2019, available at: https://health.ucsd.edu/news/releases/Pages/2019-01-10-uc-san-diego-health-opens-californias-first-accredited-senior-emergency- care-unit.aspx. [FN11] . “U.S. Urgent Care Market Size, Share & Trends Analysis Report By Application (Acute Respiratory Infection, Injuries, Joint/Soft Tissue Issues), By Ownership, And Segment Forecasts, 2018 – 2025,” Research and Markets, December 2018, available at: https:// www.researchandmarkets.com/research/bgzw6k/united_states?w=4. [FN12] . “Insurers Take Steps to Keep Physicians Out-of-Network While Shifting Costs to Patients,” Mar 11, 2019, available at: http:// newsroom.acep.org/news_releases?item=122989. [FN13] . “ACEP: Emergency Visits Reach All-Time High,” April 5, 2019, available at: http://newsroom.acep.org/2019-04-05-ACEP-Emergency- Visits-Reach-All-Time-High. [FN14] . Associated Press, “Nurse Wounded in South Carolina Emergency Room Shooting,” Journal of Emergency Medical Services, April 11, 2019, available at: https://www.jems.com/articles/news/2019/04/nurse-wounded-in-south-carolina-emergency-room-shooting.html. [FN15] © 2020 Thomson Reuters. No claim to original U.S. Government Works. -22- . “Americans Overwhelmingly Want Federal Protections Against Surprise Medical Bills,” available at: https://khn.org/news/americans-overwhelmingly-want-federal-protections-against-surprise-medical-bills/. [FN16] . “Assessing Efforts to Curb Inappropriate Use Of the Emergency Room,” Tara O'Neill Hayes, March 29, 2019, available at: https:// www.americanactionforum.org/research/assessing-efforts-to-curb-inappropriate-use-of-the-emergency-room/. [FN17] . “Emergency Physicians: HHS Conscience Rule Puts Patient Safety At Risk,” May 3, 2019, available at: http://newsroom.acep.org/2019-05-03-Emergency-Physicians-HHS-Conscience-Rule-Puts-Patient-Safety-At-Risk. [FN18] . “California Ambulances Connecting to Statewide Health Data Network,” May 7, 2019, available at: https://www.manifestmedex.org/ california-ambulances-connecting-to-statewide-health-data-network/. [FN19] . “Reps. Ruiz, Roe Release Outline of Bipartisan Legislation with Reps. Morelle, Taylor, Bera, Bucshon, Shalala, and Wenstrup to Protect Patients, Prevent Surprise Medical Bills,” May 23, 2019, available at: https://ruiz.house.gov/media-center/press-releases/reps- ruiz-roe-release-outline-bipartisan-legislation-reps-morelle-taylor. [FN20] . “Patients Want Insurance Companies to Take More Responsibility for Surprise Bills, Poll Finds,” June 24, 2019, available at: http:// newsroom.acep.org/2019-06-24-Patients-Want-Insurance-Companies-to-Take-More-Responsibility-for-Surprise-Bills-Poll-Finds. [FN21] . “ACEP Supports “Protecting People From Surprise Medical Bills Act,” June 26, 2019, available at: http://newsroom.acep.org/Acep-Supports-Protecting-People-From-Surprise-Medical-Bills-Act. [FN22] . Kylie Urban, “Reducing Overtesting in the Emergency Department Could Save Millions,” June 27, 2019, available at: https:// labblog.uofmhealth.org/industry-dx/reducing-overtesting-emergency-department-could-save-millions. [FN23] . Karen Pollitz, Matthew Rae, Gary Claxton, Cynthia Cox, and Larry Levitt, “An examination of surprise medical bills and proposals to protect consumers from them,” June 20, 2019, available at: https://www.healthsystemtracker.org/brief/an-examination-of-surprise- medical-bills-and-proposals-to-protect-consumers-from-them/#. [FN24] . “US emergency medical services must do more to combat underrepresentation of women and minorities,” July 25, 2019, available at: https://newsroom.taylorandfrancisgroup.com/us-emergency-medical-services-must-do-more-to-combat-underrepresentation-of-women- and-minorities/. [FN25] . “ACEP Supports “Protecting People From Surprise Medical Bills Act,”' June 26, 2019, available at: http://newsroom.acep.org/Acep- Supports-Protecting-People-From-Surprise-Medical-Bills-Act. [FN26] . “ACEP Statement on House Energy and Commerce Markup of Surprise Billing Legislation,” July 17, 2019, available at: http:// newsroom.acep.org/news_releases?item=123007. [FN27] . “Non-VA Emergency Care Claims Inappropriately Denied and Rejected,” August 6, 2019, available at: https://www.va.gov/oig/pubs/ VAOIG-18-00469-150.pdf. [FN28] . “Senate, House Leaders Demand VA Fix Emergency Care Claims Errors Impacting an Estimated 60,800 Veterans,” August 12, 2019, available at: https://www.tester.senate.gov/?p=press_release&id=6939. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -23- [FN29] . “Providers to Congress: Protect Patients from Surprise Bills Without Compromising Access to Care,” September 6, 2019, available at: https://www.emergencyphysicians.org/press-releases/2019/9-6-2019-providers-to-congress-protect-patients-from-surprise- bills-without-compromising-access-to-care and at https://www.acep.org/globalassets/new-pdfs/advocacy/specialty-letter-to- waysmeansedlabor---09.04.2019.pdf. [FN30] . “Surprise Medical Expenses Are A Significant Source of Financial Stress For Middle Class Consumers,” October 9, 2019, available at: https://newmiddleclass.org/surprise-medical-expenses-are-significant-source-financial-stress-middle-class-consumers/. [FN31] . “HHS Endorses First Emergency Medicine-focused Medicare Alternative Payment Model Developed by ACEP,” October 11, 2019, available at: https://www.emergencyphysicians.org/press-releases/2019/10-11-19-aucm. [FN32] . “Bipartisan Solution to Surprise Medical Bills Reaches 100 Co-Sponsors,” October 17, 2019, available at: https:// www.outofthemiddle.org/news/bipartisan-solution-to-surprise-medical-bills-reaches-100-co-sponsors/. [FN33] . “Dartmouth-Hitchcock Health, West Health partner to create nation's first rural geriatric emergency department,” October 24, 2019, available at: https://vtdigger.org/2019/10/24/dartmouth-hitchcock-health-west-health-partner-to-create-nations-first-rural-geriatric- emergency-department/. [FN34] . “California Surprise Billing Law Overwhelmingly Favors Insurers, Limits Patient Access to Care,” November 7, 2019, available at: https://www.emergencyphysicians.org/press-releases/2019/11-7-19-california-surprise-billing-law-overwhelmingly-favors-insurers-limits- patient-access-to-care. [FN35] . “Retrospective study suggests emergency department physicians are improving both outcomes and efficiency of care,” November 4, 2019, available at: https://www.bidmc.org/about-bidmc/news/2019/11/burke-ed-mortality. Produced by Thomson Reuters Accelus Regulatory Intelligence 04-Feb-2020 © 2020 Thomson Reuters. No claim to original U.S. Government Works. -24-