The situation on Capitol Hill in Washington, D.C., in May was surreal. As we have been doing for more than 20 years, emergency physicians from ACEP made their annual trek to D.C. to meet with members of Congress and their staff and talk about the issues affecting the practice of emergency medicine during the ACEP Legislative Advocacy Conference and Leadership Summit (LAC). But for the first time in 14 years, something was different. Yes, for the first time in a very long time, members of Congress and staffers didn’t have to sheepishly lower their eyes and again try to explain why they still hadn’t fixed the flawed Sustainable Growth Rate (SGR) Medicare payment formula. Instead of more wringing of hands and gnashing of teeth, “thank you” and “you’re welcome” were shared many times across the halls of the Capitol. After 14 years and 17 temporary patches, the flawed SGR formula was finally gone. Although I tend to be a little more reserved than most, I was tempted to go skipping down the halls of the Capitol, arm in arm with ACEP President Mike Gerardi, MD, FAAP, FACEP; Gordon Wheeler, ACEP associate executive director for public affairs; and Peter Jacoby, MD, FACEP, chair of the National Emergency Medicine Political Action Committee (NEMPAC) Board of Trustees, singing, “Ding-dong! The SGR is dead!” So with the SGR gone, what did we talk about with members of Congress? Real policy issues for a change! Now that the issue of Medicare payments is off the table (at least temporarily until we have to figure out this MIPS, or merit-based incentive payment system, thing), we could actually talk with Congress about addressing the day-to-day real-world challenges that affect how we practice our craft.
Although the conference didn’t officially start until Monday, May 4, I want to give props to the Emergency Medicine Residents’ Association (EMRA) and the ACEP Young Physicians Section (YPS), who really started the action on Sunday with their Leadership and Advocacy Essentials program. This half-day session included great presentations in a “rapid-fire” 30-minute format from Jasmeet Dhaliwal, MD, MPH, EMRA’s legislative director who did an “Intro to Health Policy Basics talk;” Aimee Moulin, MD, who gave straightforward information with her “Stop the Madness! Treating Patients With Mental Illness in the ED” talk; and Paul Kivela, MD, MBA, FACEP, from the ACEP Board of Directors, closing the day with “The Roadmap to Getting Involved.”
Of the 537 attendees at the conference, emergency medicine residents were, as always, very well represented, comprising 25 percent of meeting attendees. One last point about the residents: For those of us who have been going to LAC for a long time, it is easy to feel comfortable with D.C. and the advocacy process. For residents and other first-timers, going to Capitol Hill to speak with members of Congress can be pretty intimidating. However, there are always plenty of more-seasoned attendees to help guide you through the process.
Highlights From This Year’s LAC
From a nuts-and-bolts perspective, this year’s meeting was reformatted with the first two days retitled the Legislative Advocacy Conference and the last day focused on professional development as the Leadership Summit.
This year’s meeting was full of informative presentations, including:
- “Quality Initiatives in the 21st Century—CEDR—ACEP’s Clinical Data Registry”
- “Psychiatric Patient Boarding Problems in the ED”
- “Medicare Policy—Intersection of Observation, 2-Midnight, and 3-Day Stay Rules”
- “Leadership Diagnostics : Symptoms and Cures”
- “How to Succeed in an Evolving Health System,” given by Steve Stack, MD who, in June, will become the first emergency physician to assume the Presidency of the American Medical Association (AMA)
Another new addition to the meeting this year was the Congressional Dine-Arounds. Sponsored by the NEMPAC, these were small dinners (only about 10 to 12 people) with members of Congress. Even with the House of Representatives not being in session, Jeanne Slade and the NEMPAC staff were able to arrange for dinners with the following members of Congress:
- Sen. Bill Cassidy (R-LA), who is a gastroenterologist
- Rep. Dutch Ruppersberger (D-MD)
- Sen. Ron Wyden (D-OR)
- Sen. Shelley Moore Capito (R-WV)
- Sen. Mark Kirk (R-IL)
- Sen. Chris Murphy (D-CT)
So with the Medicare Access and CHIP Reauthorization Act passed, the SGR formula gone, and MIPS coming, this year’s Hill visits focused more on policy issues rather than payment. There were four major issues that we brought to the Hill:
1. Liability Reform
A continued push for support of the Healthcare Safety Net Enhancement Act of 2015 (H.R. 836/S.884). This bill would provide for federal protection under the Federal Tort Claims Act for all services provided in the emergency department under the EMTALA federal mandate. The Federal Tort Claims Act already provides similar protection to those physicians practicing in the U.S. Public Health Service, in the Indian Health Service, and at federally qualified health centers. The bill provides for management of claims in federal court, with the U.S. government becoming the defendant, rather than the individual physician. Although the cases would be adjudicated in federal court, the actual damages/payments that an individual plaintiff would be granted remain state-specific where the case occurred.
2. Mental Health
Support of legislative efforts to provide resources for patients with mental illness and stop the practice of psychiatric boarding in the emergency department. The ongoing challenge of finding appropriate inpatient beds and/or outpatient treatment resources for patients with mental health disease is certainly not new to anyone in the ED. There was great anticipation of a bill to be introduced by Rep. Tim Murphy (R-PA), a clinical psychologist by training, that would provide federal help in a number of ways. Rep. Murphy had introduced a bill last year with a number of key initiatives, and the hope was that his bill this year would contain many of the same initiatives:
- Improve research, data collection, and coordination of existing mental health programs by creating an Undersecretary of Health for Mental Illness at the Department of Health and Human Services.
- Remove regulations that currently prohibit same-day billing under Medicaid for treatment of physical and mental health for the same patient in the same location on the same day.
- Give states the option to receive federal matching payments for care of adult patients with mental illness.
3. Funding for Emergency Medicine Research and Trauma Systems
Requested support for appropriation of funds within the FY 2016 budget to support the Office of Emergency Care Research (OECR) at the National Institutes of Health (NIH) and for ongoing support of grant funding that supports research on regionalization of care and trauma systems. OECR was established in 2011 within NIH to coordinate research on the specialty of emergency medicine. However, the office has never been funded directly, significantly limiting its effectiveness in producing research to improve the practice of emergency medicine. Requests for support of OECR in the amount of $28 million were made to support the following programs that have been authorized by Congress but never funded:
- Regionalization of emergency care pilot projects
- Trauma systems planning grants
- Trauma care center grants
- Trauma service availability grants
4. Graduate Medical Education (GME) Funding
Expansion of GME funding amounts and number of residency slots. In 2006, the Association of American Medical Colleges began increasing medical school enrollments in an attempt to meet the medical needs of the U.S. population and minimize projected physician shortages. This has resulted in a 30 percent increase in the number of medical students, with just over 20,000 matriculants to U.S. medical schools in 2014. However, the number of Medicare-funded residency training spots, using Direct Graduate Medical Education funding, has been capped since 1996 resulting in a mismatch, with more medical school graduates than residency spots. In the 2015 match, there were 1,700 total U.S. graduates of allopathic and osteopathic medical schools who were unmatched and did not find a residency spot. The request to members of Congress was to fund an additional 15,000 residency slots over the next five years in order to expand the physician workforce in anticipation of the aging and growing U.S. population.
It is always great to see a few hundred ACEP members come to Washington, D.C., each year for an amazing few days. But being a leader in your ED and being an advocate for EM and our patients is everyone’s responsibility. Next year’s meeting will be May 15–18, 2016. Will you be there?