4th Edition Editors-in-Chief Nathaniel R. Schlicher, MD, JD, FACEP EMRA Legislative Advisor, 2008-2010 Associate Director, TeamHealth Patient Safety Organization Regional Director of Quality, CHI Franciscan Health Emergency Departments President, Washington Chapter of ACEP Alison Haddock, MD, FACEP EMRA Legislative Advisor, 2010-2012 Director of Health Policy: Advocacy Assistant Professor, Baylor College of Medicine Division of Emergency Medicine Chair, ACEP State Legislative–Regulatory Committee Disclaimer The statements and opinions expressed in this book are provided as guidelines and should not be construed as EMRA policy unless specifically referred to as such. EMRA disclaims any liability or responsibility for the consequences or any actions taken in reliance on those statements or opinions. The materials contained herein are not intended to establish policy or procedure. Get Involved If you'd like to become more involved in advocacy issues, please join the EMRA Health Policy Committee. Follow @EMadvocacy on Twitter and sign up for the committee at emra.org/committees-divisions/EMRA-Committee-and-Division- Application. Copyright © 2016. EMRA Emergency Medicine Residents’ Association. All rights reserved. All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means without written permission from the copyright owner. Printed in the USA. ISBN: 978-1-929854-42-4. Additional copies of this publication are available from Emergency Medicine Residents’ Association P.O. Box 619911 Dallas, TX 75261 972-550-0920 emra.org ii Advocacy Handbook: ¬ EMRA US Acute Care Solutions is proud to offer an educational grant to support the Emergency Medicine Advocacy Handbook, 4th edition, furthering the tradition of promoting this and other EMRA activities. Our commitment to EMRA is grounded in the belief that emergency medicine residency training is the gold standard for the practice of the specialty. We take pride in hiring emergency medicine residency-trained physicians, and we are pleased to support residents throughout their training. The Emergency Medicine Advocacy Handbook is important because the practice of medicine is a business — yet there are fewer and fewer business models that put the physician at the center of the decision-making process. Therefore, participation in the legislative and policymaking arena is absolutely essential to delivering the highest level of patient care. We are pleased to help provide a key resource to create an informed, proactive voice for emergency medicine. With best wishes, US Acute Care Solutions www.usacs.com | 800.828.0898 4535 Dressler Road NW Canton, OH 44718 Chapter ¬ iii Publisher Emergency Medicine Residents’ Association P.O. Box 619911 | Dallas, TX 75261 972.550.0920 emra.org EMRA Board of Directors Ramnik Dhaliwal, MD, JD President Alicia Kurtz, MD President-Elect Matt Rudy, MD Immediate Past President Abigail Cosgrove, MD Secretary/Editor, EM Resident Nida F. Degesys, MD Speaker of the Council Tiffany Jackson, MD Vice-Speaker of the Council Alison Smith, MD, MPH ACEP Representative Nick Governatori, MD Academic Affairs Representative Leonard Stallings, MD RRC-EM Liaison Christian Dameff, MD Informatics Coordinator Jasmeet Dhaliwal, MD, MPH Legislative Advisor Zachary Jarou, MD Membership Development Coordinator Ashley Guthrie, DO Member-at-Large Sean Ochsenbein Medical Student Council Chair iv Advocacy Handbook: ¬ EMRA Preface to the Fourth Edition Eight years ago a plucky group of young residents believed that every resident should be educated about the importance of health policy and determined to do something about it by writing the first edition of the EMRA Advocacy Handbook. Now as an aged attending, nothing has diminished my belief that advocacy is at the core of what we do as emergency physicians. If anything, the past decade has stoked the fires of passionate advocacy in many physicians. If we, the house of medicine, are to survive and thrive in this evolving health care world, we must once more take up the mantle of leadership. With constant barrages of attack from regulators, insurers, well-meaning hospital administrators, and a lay public that demands low cost with high technology results, the challenges that we face are real. Merely clocking in and out on our shifts is not enough. Every day we advocate for our patients in our clinical shifts, and now we must carry that forward into the rest of our practices. The role of health care navigator and ardent champion of the health care resources is one that emergency medicine physicians were born to play. We care for everyone, regardless of ability, providing care in a resource-deprived setting. When my 400 bed hospital did not have ophthalmologists on staff, the ED providers stepped in to cover the need for inpatient consults. When the State Legislature looked for savings in the health care system, they came to the ED providers as the canary in the coal mine of health care to help them find savings. When insurers ask where dollars can be saved, they often start with the ED, but rapidly find with education that it is the complex medical patients that we help manage that cost the system. At the intersection of the changes that are happening in health care lies the emergency department. We must rise to the occasion. We must be knowledgeable and passionate advocates as emergency physicians. When others say it cannot be done, we show them every day what is possible. When others point fingers to the ED as the source of all waste, we generate solutions that fix problems, not blame providers or patients. We are the creative, hard-working, backbone of the health care system that is always there, no matter the time of day or ability to pay. I hope you find this handbook to be a valuable resource in your advocacy, and I hope it inspires you to make it a regular part of your medical practice. I look forward to seeing you out there on the advocacy trail. Nathan R. Schlicher, MD, JD, FACEP Chapter ¬ v vi Advocacy Handbook: ¬ EMRA Table of Contents ACCESS 1. Access to Coverage and Care .................................................1 Kristen Cadden Swann, MD; Archana Shah, MD, MBA; J. Akiva Kahn, MD 2. Utilization of Emergency Services ............................................. 9 Jason Bischof, MD; Andrew G. Little, DO 3. The Impact of EMTALA .......................................................13 Kenneth W. Dodd, MD; Ramnik S. Dhaliwal, MD, JD 4. Emergency Department Crowding and Boarding ...............................19 Anuja Trivedi, DO, MPH; Jessica Best, MD, MS 5. “Non-Emergent Visits” and Challenges to the Prudent Layperson Standard ......23 Kevin Davey, MD; Jordan Celeste, MD 6. High Cost, High Need: Patients with Frequent ED Visits ........................27 Theresa E. Tassey, MD, MS; Aaran Drake, MD PAYMENT 7. Introduction to Payment Issues ..............................................33 B. Bryan Graham, DO; Jordan Celeste, MD 8. Reforming Fee-for-Service: Paying for Performance ............................39 Erik A. Berg, MD; Jesse Schafer, MD 9. Delivery System Reform .....................................................45 Kenneth Perry, MD; Mark Shankar, MD; Emmagene Worley, MD 10. “Big Data” in EM Payment ....................................................51 Teresa Proietti, DO; Melanie Stanzer, DO; Chet Schrader, MD, FACEP 11. Fair Payment and Balance Billing ............................................57 Jasmeet S. Dhaliwal, MD, MPH; Michael Granovsky, MD, CPC, FACEP, David McKenzie, CAE, ACEP, Reimbursement Director 12. The Evolving Regulatory Environment ........................................63 Natalie Kirilichin, MD; Ben Karfunkle, MD WORKFORCE 13. Graduate Medical Education Funding ........................................69 Michael Boyd, MD; Puneet Gupta, MD 14. Physician Shortage and Workforce Challenges ................................ 77 Bradley Burmeister, MD; Nathan VanderVinne, MPH, MSIII 15. Advanced Practice Providers in the ED .......................................83 Elizabeth Davlantes, MD; Allen F. Wang 16. Controversies in Board Certification ..........................................89 Leigh Avera, DO; Aurore Richard, DO; Nathan Deal, MD Chapter ¬ Table of Contents vii PRACTICE CHALLENGES 17. Medical Liability Reform .....................................................95 Lucy Yang Hormberg, MD, JD; Cedric Dark, MD, MPH, FACEP, FAAEM 18. The Corporate Practice of Medicine Doctrine ................................ 103 David D. Wagner, MD, JD 19. Technology in Patient Care ................................................. 109 Patrick Olivieri, MD; Nupur Garg, MD 20. Telemedicine ..............................................................113 Nupur Garg, MD; Adnan Hussain, MD 21. Regionalization of Emergency Medicine .....................................117 Sara R. Paradise, MD; Andrew I. Bern, MD, FACEP 22. Palliative and End-of-Life Care ...............................................123 Ross Cohen, DO; Ronnie Kuo Ren, MD; Chadd K. Kraus, DO, DrPH, MPH 23. Mental Health in the ED .................................................... 129 Thiago C. Halmer, MD, MBA; Veronica T. Tucci, MD, JD, FAAEM 24. Community Paramedicine and EMS Policy Issues ..............................137 Grace Zhang; Richard M. Pescatore, DO, EMT-HP 25. Substance Use and Abuse in the ED .........................................141 Brittany C.H. Koy, MD 26. Social Determinants of Health .............................................. 149 Joshua M. Enyart, DO; Dennis Hsieh, MD, JD ADVOCACY ESSENTIALS 27. How a Bill Becomes a Law ................................................. 155 David G. Reid, DO; Jason Bowman, MSIV 28. Getting to Know Your Legislator .............................................163 Tiffany D. Jackson, MD; Jonathan W. Meadows, MS, MPH, CPH 29. Getting Involved in the House of Medicine ....................................171 Marcus Holmes, DO; Melanie Stanzer, DO; Chet Schrader, MD, FACEP; Heidi Knowles, MD, FACEP 30. Health Services Research ...................................................177 Elizabeth A. Samuels, MD, MPH; Brandon C. Maughan, MD, MHS, MSHP Appendix References ...................................................................183 viii A dvocacy Handbook: ¬ EMRA