IUEM Represents in Washington, D.C.

Written by Lauren Falvo, MD PGY3

advoDC2019From May 5th-8th, members of IUEM’s Advocacy Committee visited Washington, DC to attend ACEP’s Leadership and Advocacy Conference (LAC).

Residents (pictured above) representing included Tommy Eales PGY2; Lauren Falvo PGY3; Ashley Satorius PGY3; Jennica Siddle PGY3; and Emily Wagner PGY4 (EM-Peds).

We had excellent tutelage and guidance of faculty and Indiana Emergency Physicians: JT Finnell, IU faculty, serving as an ACEP Board of Directors member; Chris Ross, former Indiana Chapter of the American College of Emergency Physicians; Lindsay Weaver, IU faculty; and Jamie Shoemaker, community doctor from northeast Indiana.

Over 72 hours, emergency physicians, consultants, and politicians came together to discuss policies affecting emergency physicians and the patients we serve. LAC 2019 focused on two of the many important issues facing emergency medicine: mental health access and “surprise” billing.

Emergency departments serve as a haven for those with nowhere else to go. For patients in mental crises, close monitoring in a psychiatric care unit is the safest place to receive treatment and take steps towards healing. Due to budget constraints, there are limited inpatient beds and mental health resources across the state of Indiana and nationwide. As a result, these patients remain in the emergency department, sometimes for days, until beds are available. During this time, these patients are exposed to continuous stressful stimuli (unavoidable by nature of the emergency department), with limited access to psychiatric care. During their wait, those emergency beds can no longer be used to see the patients in the waiting room with medical complaints. Additionally, depending on the cause of their crises, these patients are required to have 1:1 sitters, which often means that one of our techs or nurses is pulled off the floor to stay in the room with the patient for the entirety of their shift. A prolonged stay in the emergency department is a disservice to our mental health patients, and a danger for our patients stuck in the waiting room. For more details regarding legislative efforts, please refer to House Bill HR2519 and Senate Bill S-1334.

ACEPbilling

ACEP on surprise billing (image from link)

“Surprise” billing, as it has become more colloquially known, but we prefer the more apt descriptions of “surprise coverage gap” is in part a consequence of discrepancies between in-network and out-of-network coverage that are not readily apparent to patients at the time of receiving care.

For example—a hypothetical patient, Sarah, may go to IU Methodist Hospital for a broken ankle. IU Methodist is considered in-patient with Sarah’s insurance plan. Sarah is evaluated by a nurse and physician and undergoes an x-ray, receives a splint, and goes home. She knows that she will owe a flat-fee copay for her visit, and that she will owe a portion of the cost of her x-ray; money that will go towards her deductible. However, 3 months later, Sarah gets an additional bill for several hundred dollars. While IU Methodist is in-network with her insurance company, the radiologist responsible for reading her x-ray could be a contracted employee who does not have an in-network agreement with her insurance company. Sarah is then expected to pay the bill for the radiology read, a medical service that she was not able to evaluate for or choose, in full, as her out-of-network deductible is far more than her in-network deductible. This is not the radiologist’s fault; they are providing the service they were hired to do, and do not necessarily have the negotiating power to obtain contracts with some of the larger insurance companies. However, Sarah is now left with an additional bill that she was not prepared for, and possibly cannot afford. Although there is not a current bill in the House or Senate to address this issue, emergency physicians have come to the Hill to discuss leveling the playing field by equalizing in-network and out-of-network deductibles to protect patients receiving emergent treatment. For a brief account of how states like New York are attempting to improve this healthcare issue, go to https://www.vox.com/health-care/2019/3/19/18233051/surprise-medical-bills-arbitration-new-york.

DCscooter2019

Additional highlights of Washington, DC included scootering around the Mall to visit some our most beloved non-Indianapolis monuments, meeting our caffeine fixes with cereal milk lattes at Milk Bar, and consuming copious amounts of Szechuan cuisine.

Thank you to Senator Mike Braun, Senator Todd Young, Representative Jackie Walorski, Representative Andre Carson and their respective legal aides, Reily Inman, Jaymi Light, Martin Schultz, and Ryan Shay for making time in their busy schedules to discuss healthcare concerns in Indiana. And thank you, IUEM and IUEM’s Advocacy Track for sponsoring residents to “have a seat at the table” of health policy!

 

We look forward to more opportunities like this to advocate for our patients with national decision makers. Join us next year!

Graduate Reflections through Art

We salute the hard work of our current third years in the Emergency Department in the past several years. They are role models for hard work, fun, and teaching. Good luck to you all!

Here we have a reflection from one of our IUEM advocacy track leaders and graduates, Kim Van Ryzin.

If you want to watch a video of her project see below!

https://www.facebook.com/plugins/video.php?href=https%3A%2F%2Fwww.facebook.com%2FIUHealth%2Fvideos%2F2309192982441208%2F&show_text=0&width=560“>Link to IU Health Art Project Video

Advocacy work can be approached in many different meaningful ways depending on one’s interests, the scale at which one wishes to work, and the cause chosen. As a physician, medicine provides a compelling field in which to advocate for diverse populations and causes. For example, some may choose to focus on large populations through work in health care policy, while others may choose to represent an individual’s or a family’s needs while working in the Emergency Department. Throughout my life, I have been fortunate to be able to participate in many different advocacy work opportunities. However, I have found myself the most inspired, fulfilled, and happiest being a member of Dr. Angi Fiege’s program, Rachel’s First Week (RFW).

Dr. Fiege and her family founded Rachel’s First Week in loving memory of their daughter, Rachel, who tragically died her first week of college due to a head bleed sustained after a fall while at a party. Rachel’s First Week is a grass-roots advocacy program aimed at facilitating a safe and successful transition for high school seniors through sharing Rachel’s story and teaching injury prevention and safety education. The Fiege family and friends honor Rachel by touching thousands of lives each year during a one hour presentation given at high schools and colleges across central Indiana. Rachel’s story and other difficult topics perhaps not otherwise touched on in the classroom (alcohol, drugs, depression) are discussed in order to give guidance on how to handle these potentially dangerous situations and to ultimately prevent this type of tragedy from happening again.

My work as a RFW presenter is an opportunity unique to IUEM and as greatly enriched my experience as a resident. Interacting with the students through presenting these difficult topics connected me to this population and the community. I felt energized and fulfilled after each presentation knowing I had made a positive impact on the lives of these students. I know my participation in RFW has even helped protect me against burn out through the joy and connection to community it has brought me. I believe by facilitating powerful advocacy experiences in residency, physicians may be more inclined to be active in advocacy as a staff physician. I know my involvement in RFW has ensured my continued involvement in advocacy work in the future. 

Finally, Dr. Fiege’s success with RFW encouraged me to pursue my own project, the Methodist Rotating Art Gallery, inspired by the experience of the loss of my father. After having experienced this type of loss in my own life, I could truly appreciate Dr. Fiege’s tenacity, strength, and deep love for Rachel demonstrated by her willingness to share Rachel’s story in order to prevent future tragedies. I am honored to support one of my mentors and friends, Dr. Fiege, by continuing to remember her daughter through our work with this population. I am so grateful Dr. Fiege has facilitated this opportunity for me and other residents. Being a member of RFW has been one of the best experiences of residency at IUEM and is certainly one in which I have made a positive impact on our community through education.​

  • written by Kim Van Ryzin, IUEM Graduate 2018

Rachael’s First Week 2017 and 2018

It’s not a mystery that college kids go to parties, drink fruity jungle juice, and do keg stands. What is more concerning is how many of those kids might let their friend “sleep off” a fall or landing on their side. As clinicians, we know this can be dangerous. Anyone under the influence of one too many rum and sodas does not have great insight and may not realize that falling from a height could lead to devastating injuries. This happens cringingly often, but does not have the spotlight or common knowledge amongst teenagers and early 20-somethings. Until now.

 

Rachael Fiege was your typical Indiana girl. She was outgoing and a friend to many. She had been a good student and star soccer player during high school. On her second night of college at IU, she and her friends went to their first college party. They knew to stay together and look out for each other throughout the night. She and her girlfriends were having a great time until she tumbled down a flight of stairs. Able to shake it off, Rachael’s friends encouraged her to lie down on the couch, checking on her a few times during the party. It wasn’t until the morning they realized she was no longer breathing. Her mother and critical care physician, Dr. Angie Fiege received the worst possible phone call any parent could ever hear. Her beautiful, vibrant daughter had died of an intracranial hemorrhage.

 

Rachael’s legacy has led to an important, expanding program, Rachael’s First Week (RFW). Angie started this with donations left in her daughter’s name, initially creating the program to inform high school seniors and college students in a non-confrontational that it’s ok to call 911 if you’re worried about a friend. Thanks to the Lifeline Law, if you’re under 21 and intoxicated and need to go to the hospital, you can dial 911 for you or your friend…and not see the inside of a jail cell. Angie started off small, gathering a few of Rachael’s friends and emergency medicine residents and students from IU, and went to her high school to have the first ever session. Now, RFW has reached out to thousands of high school and college students including other schools around Indianapolis, Indiana University, Marion University, and Butler University. The message is always well received.

 

“ Rachael’s First Week challenges young men and women to think about the choices they make, and always look out for each other, even strangers. The program encourages a change in culture from approaching college with risk-taking behaviors to one of fun using common sense and caring for friends and strangers alike.”

 

The format allows for anonymous questions to be sent in via text messaging, which really allows for candid discussion. They also cover drug use and suicide through text polling, and often there’s as many as one third of the students who have considered suicide, which is eye opening and heart breaking. Through the program, they provide resources and let the students know what to do in these tricky situations. Lives have already been saved, and more will be in the future. Already, there are six events scheduled for the spring. If you are interested in helping, donating, or for more information please go to rachaelsfirstweek.com.

Numerous opportunities are coming up to volunteer with RWF February through May 2018.

By Ashley Satorius-Rutz, MD Emergency Medicine 2nd year resident

Summer 2017 Legislation Update – What Matters in the Emergency Department

This post represents an individual resident’s reflection on current events and does not primarily represent the views of IUSM EM nor does it intend to provide expert level resources or facts on the matter, though a fair assessment of readily available information was attempted in writing this post. 

Just past midnight on July 28th, 2017 an unexpected twist took place in the Senate chamber as Senator John McCain broke from Republican party lines and voted no for a “skinny repeal” on Obamacare, joining the other Republican senators Susan Collins of Maine and Lisa Murkowski of Alaska (and many Democrats) who steadfastly opposed healthcare reform in this manner. This effectively terminated the bill which would have dismantled parts of Obamacare and according to the U.S. Congressional Budget Office would have led to 16 million additional Americans becoming uninsured in 10 years and health insurance companies estimating rate increases for coverage. This was the stripped down version of a larger repeal and replace bill BRCA proposed by senators but also that met opposition and failed to pass voting earlier this month.

John McCain made it clear that he was not protecting Obamacare but that he wanted real health care reform that would not have happened in the form of the skinny bill in the following statement,

“While the amendment would have repealed some of Obamacare’s most burdensome regulations, it offered no replacement to actually reform our health care system and deliver affordable, quality health care to our citizens,” he said. “The Speaker’s statement that the House would be ‘willing’ to go to conference does not ease my concern that this shell of a bill could be taken up and passed at any time.”

“I’ve stated time and time again that one of the major failures of Obamacare was that it was rammed through Congress by Democrats on a strict-party line basis without a single Republican vote. We should not make the mistakes of the past that has led to Obamacare’s collapse, including in my home state of Arizona where premiums are skyrocketing and health care providers are fleeing the marketplace. We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of aisle, heed the recommendations of nation’s governors, and produce a bill that finally delivers affordable health care for the American people. We must do the hard work our citizens expect of us and deserve.”

(https://www.mccain.senate.gov/public/index.cfm/2017/7/statement-by-senator-john-mccain-on-voting-no-on-skinny-repeal)

The question is – – what next? And what does it matter to Emergency doctors?

Far from the stone edifices of Washington D.C. we are taking care of patients day in and day out in the Emergency departments of Indianapolis. Hundreds of thousands of visits by Hoosiers (and sometimes neighboring states since we are “the Crossroads of America) take place here every year. Do our patients care about this reform? Recent polls suggest two thirds of U.S. citizens have cooled to the idea of immediate reform and want Congress to get to other tasks. (https://www.reuters.com/article/us-usa-healthcare-poll-idUSKBN1AE0RY)

I am an Emergency doctor with a mind for trying to play my role in the medical team of the system at large; since I cannot address and change the course of every ailment our patients come to the Emergency Department for. Aside from ruling out any bad emergencies, I take time to think about what I can do to help them in the meantime, what they need to know, and what they should try next for solutions. It matters to me that I play this role and that my patients understand that when our visit ends today, we may just be scratching the surface and not be done yet. It also matters that they discover other places to get this appropriate care and planning aside from the Emergency Department.

There is a particular part of me that despairs when I see someone without health insurance, who will surely not be able to better their health on their own, and will have a much steeper if not impossible time of getting appointments with my colleagues in the outpatient and surgery world. They came to me because they had a problem, I showed that it was not an emergent problem that required hospitalization, surgery, or intervention at that second, however, their problem will likely persist and frustrate them, feeling like “no one helped.” Without access to the medical system most typically through insurance, things are not going to be looking better for them.

We see lots of patients. We have the honor of serving patients regardless of their ability to pay or their insurance status and I appreciate the equality of that. I chose to train at IUEM program for the number of patients and the variety of people I can help. Unfortunately, business can also mean ED overcrowding and physician burnout, and it seems that numbers of ED visits climb every year. That is the trend in many Emergency Departments, and providing insurance does not do what we might have expected, which is give people a better option to outpatient doctors to get their conditions under control so they can avoid coming to the ED. Instead we are seeing a growing number of ED visits since implementation of the ACA and more people gained access to health care. (http://www.annemergmed.com/article/S0196-0644(17)30319-0/fulltext)

What gives?

When the board of incoming patients never clears, when the patient’s concerns and requests of you seem unreasonable, you quickly drop the Lady Liberty act, “Give me your tired, your poor, Your huddled masses yearning to breathe free…” yadda yadda. As an intern up until July 2017, I spent the last year seeing a large percentage of my patients in the lower acuity area of our emergency departments. This did not mean patients did not need help or medical attention, but that they did not need to be in shock rooms where they might get an emergent airway, trauma survey, or invasive medical procedures performed under minute to minute monitoring. The use of an Emergency department for some of the complaints seemed a bit dubious, even to me as an idealistic intern.

On the flipside, I know how the system works and I am being trained specifically to tell an emergency from non-emergency. How many years of study did it take for me to get to this position? The burden of placing the patient in determination of what an emergency is cannot be expected for the reason I mentioned before. U.S. citizens have on average a 7th or 8th grade reading level. Good luck interpreting medical literature with that reading level and while you are trying to decide if you are experiencing an emergency.

Before ACA implementation we knew as a nation we had a shortage of doctors, especially primary care doctors, surgeons, psychiatrists, which are the specialties I most acutely need the assistance of when taking care of patients in the Emergency department. (https://www.aamc.org/data/workforce/reports/439206/physicianshortageandprojections.html). We generally do not have an optimum number of providers to patients in all fields including emergency medicine. That takes more policy change and training shifts than what the ACA can provide. However, repeal also does not even begin to tackle this problem and instead offers to take away Medicaid and what small payments outpatient offices can get for seeing these patients.

Indiana’s Insurance Program HIP 2.0

I am relieved for the near future that this round of health care reform will not proceed without more deliberation and hopefully bipartisan and policy expert input. Lots of questions must be resolved. I understand that part of the opposition to leaving the ACA intact involves the increasing insurance premiums and decreased choice available on state exchanges. Indiana, which has a Medicaid waiver to run its own Medicaid expansion program called HIP 2.0 was discussed as a possible example of nationwide Medicaid reform at the 2017 ACEP Leadership and Advocacy conference in D.C.  Despite being touted as a success, this program is not without its issues, outside policy researchers found that the monthly payments or “skin in the game” notion that patients must contribute to stay active in the program confused and often locked them out of care for a time period.

“One-third of eligible individuals who apply are not enrolled because they haven’t made a premium payment… Around 30,000 people… had been found eligible in the past 60 days but hadn’t enrolled at all. HIP 2.0’s premiums are deterring significant numbers of eligible low-income people from enrolling… For many people, the cost wasn’t the biggest obstacle. Rather, 84 percent of people who were bumped from HIP Plus to HIP Basic for nonpayment said they had been confused about the payment process and the program in general.” (https://www.theatlantic.com/business/archive/2016/12/medicaid-and-mike-pence/511262/?utm_source=atlgp)

Another obstacle facing our own state, and many others, is that costs of insurance premiums are increasing and less insurance companies are participating in the exchange which negates competitive pricing options. In 2018 in Indiana only two insurers will continue to participate in Obamacare exchanges, whether this changes now that legislation to gut Obamacare has failed thus far, we will see. (https://www.ibj.com/articles/64327-only-two-insurers-to-offer-obamacare-plans-in-indiana-next-year?v=preview) Insurance markets and incentives go way beyond my level of understanding and I hope that as a state we have the right people at the table to turn back this trend for Hoosiers and propose ways to improve this moving forward.

Future for EM and American Health Care

I stand in favor of providing access and working to make the system more preventative than reactionary when providing Americans with health care. I welcome debate, education, and well-thought out ideas about how to make this system better as an Emergency resident and physician providing medical care to my fellow people. In summary and in agreement with the following, I include the most recent statement about health care reform from President of American College of Emergency Physicians, Becky Parker, MD, FACEP:

“We have expressed concerns throughout this process regarding the devastating impact some of the repeal proposals under consideration could have had.  Looking ahead, we now urge lawmakers on both sides of the aisle to work together to address the serious problems that still exist involving the health insurance market. These solutions must include appropriate protections for the tens of millions of emergency medical patients that go to emergency departments each year.

Guaranteed coverage for emergency medical care must continue to be protected by federal law. Patients should be able to seek and receive emergency care when and where it is needed, without fear that their insurance company will not cover it.  In addition, when patients have insurance plans with unreasonably high deductibles, they often delay medical care until the problem becomes a life-threatening emergency.

Policymakers, lawmakers, business leaders, physicians and health care experts must work together to help improve a health care system that benefits every American.” (http://newsroom.acep.org/2017-07-28-ACEP-Statement-on-Future-Health-Care-Legislation)

 

Reflection by Jennica Siddle, MD MPH, 2nd year Emergency Medicine Resident