- Email: [email protected]
Universal access: Its potential impact on emergency medicine
EDITORIALS
We must work with local, state, and federal legislators, emphasizing that the answer to gang violence is not just stronger punitive laws but getting them to allocate funds to alleviate the root causes. It should be clearly explained to lawmakers that gang violence is a preventable disease, worthy of their attention and funding. Along with others in the medical community, we as emergency physicians must address the issues of firearms and injuries and take a firm stance that handguns and assault rifles must be controlled. We should willingly support organizations that are working to pass laws to prevent children from sinking further into poverty because these are the children most at risk for gang involvement. Throughout America, children must be taught an a p p r o p r i a t e value system, encompassing a sense of personal pride, dignity, self-worth, accomplishment, and a healthy respect for all human life. Emergency physicians, community activists, family members, and others in the community can act as positive role models for our children. There must be a realization that whether we live in the inner city or in the suburbs, we are a nation of people who must show concern for the welfare of one another. Problems such as gang violence are touching us all directly and indirectly. For any solution to be effective, we must empower innercity communities to play a pivotal role in resolving these problems. It is essential that health care providers do not take maternalistic or paternalistic approaches when working toward solutions to these problems. The "benign neglect" of problems that exist in the inner city must come to an end. It is clearly much too costly, in terms of human life and health care dollars, to continue this approach. Only by implementing the above interventions can we hope to be safe from gang violence. HRangeHutson, MD DeirdreAnglin, MD William Marion, MD Departmentof EmergencyMedicine LosAngeles County/University of Southern Califomia Medical Center 1.Maxson CL, Gordon MA, Klein MW: Differences between gang and nongang homicides. Criminology1985;23:209-222. 2.Los Angeles Police Department, Gang Information Section: CrimeStatistics, 1991. 3.Los Angeles County Sheriff's Department, Operation Safe Streets: GangRelated CrimeStatistics,1991. 4. GatesIF, Jackson RK: Gang violence in LA. ThePoliceChiefNovember1990;20-22. 5.KidsCountDataBook:StateProfilesof ChildWeft-Being.Washington, DC, The Annie E Casey Foundation, Center for the Study of Social Policy, 1992. 6. Klein MW, Maxson CL, Cunningham LC: "Crack," street gangs, and violence. Criminology1991;29:701-727.
Day-Night Differences Are Not Always Due to Circadian Control See related a~tiele, p 1250. In the three decades since Halberg coined the word "circadian" (from the Latin circa, about, and dies, day), this neologism has largely replaced the terms diurnal, nychthemeral, and daily in referring to rhythmic 24-hour period variations.
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Unfortunately, its usage is less restricted than was probably intended in the original definition, possibly because of an ambiguity in the meaning of the word "about," whether it means "approximately a day" or "encompassing a day." A key observation responsible for the term was that daily rhythms of different types and in many species "free r u n " when the environmental daily cycle (eg, light/dark) is excluded. Under such constant conditions, the period or cycle length of a circadian system is commonly not exactly 24 h o u r s - perhaps 23 hours or, as for sleep-wake cycles of human beings in isolation, 25 hours, thus approximately one day. By contrast, some daily cycles are truly and exactly daily, commonly by virtue of some exogenous daily environmental variable that affects them directly-. Remove the environmental variable and the exogenously driven cycle disappears, whereas a truly endogenous circadian r h y t h m persists, albeit with a slightly different period. Endogenous circadian rhythms are entrained to the 24-hour day by environmental cycles, a fact that may sometimes confound the distinction between exogenous and endogenous rhythms. Extreme care must thus be exercised in the interpretation and classification of biological phenomena that exhibit daily rhythms, whether it be the occurrence of cardiac failures, platelet aggregability (which peaks in the early morning hours), photosynthesis in plants, or bioluminescence in dinoflagellates. We do not know, for example, whether the endogenous circadian timing system contributes to the welldescribed daily variations in h e a r t rate and blood pressure. Given this caveat, the careful description of these daily variations may have important implications for both those at risk and their providers. J WoodlandHastings, PhD Department of Cellular and DevelopmentalBiology The Biological Laboratories Harvard University Cambridge, Massachusetts CharlesA Czeisler, PhD, MD Department of Medicine Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts
Universal Access: Its Potential Impact on Emergency Medicine INTRODUCTION
A consensus has been reached among the major political forces in the health care field that reform must be enacted to provide basic physician and hospital benefits to more than 60 million Americans who are now without coverage some time during each year. 1 President Bush, many public officials, the American Medical Association, 2 the American Hospital Association, the Blue Cross/Blue Shield Association, and the Health Insurance Association of America all support the concept, although they are often far a p a r t on the details of providing universal access coverage. Those physicians who provide care in overcrowded emergency departments and treat many of those who are
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EDITORIALS
either uninsured or underinsured are particularly sensitive to the need for some health reform. Uncompensated care, in fact, has been a topic of p a r t i c u l a r interest to emergency physicians,3,4 as recently evidenced by a committee of the Society of Academic Emergency Medicine s indicating that "it appears inescapable that the solution must provide some form of universal access to comprehensive health care." Differences of opinion in these health reform discussions most often center a r o u n d the issue of whether to continue with the current procompetitive, pluralistic a p p r o a c h with its 1,500 t h i r d - p a r t y payers, 6 to emulate the German quasiprivate, quasipublic system, 7 or to implement a more regulated single-payer, Canadian-type design. 8 Those who are still supportive of the existing a p p r o a c h to delivering care argue that we have the finest scientific and technologic system in the world and that there should be grave concern about any further government intrusion into the practice of medicine.9,10 Those who are more supportive of replicating the German or the Canadian model in this country stress the significant savings that can be achieved by setting global targets for total health care expenditures, u by reducing administrative expenses ,12 and by the possibility of eliminating the unnecessary duplication of high-technology services. 13 Although it may be difficult to predict the steps, the specific benefits, and the timetable for the passage of a universal access plan in the United States or any specific state, it is now pertinent to speculate on some of the possible implications of such legislation on emergency medicine. If for no other reason than this, these social insurance programs could soon provide coverage to one fourth of the nation's population. F o r purposes of simplicity, this editorial is limited to these elements of a potential US universal access plan: the patient's benefits; the administration of the plan; its cost; and the reimbursement methodology and fiscal incentives for physician services to provide improved patient accessibility for care but also to contain total health care expenditures. PATIENTS'
BENEFITS
Because the uninsured have higher rates of illness and disability than the insured,la a major conceptual advantage of a universal access plan would be that the physician-patient relationship, for the now 37 million Americans without benefits each day, would no longer be constrained by the patient's inability to pay for services. This assumes that under the new plan there would be the availability of a b r o a d range of physician and hospital benefits including diagnostic, curative, and rehabilitative services without significant deductible or coinsurance features. Many of the currently proposed universal access plans provide emergency medicine and other basic benefits (eg, routine physician office visits, and as inpatients, maximum of 30 days' hospitalization) but exclude most t e r t i a r y services. This lack of b r o a d comprehensive coverage, which is related to fiscal affordability and not to compete with existing insurance contracts, is an issue for many medical and surgical subspecialists because the uninsured already have inadequate access to cardiology and cardiac surgery services,~.s high-risk newborn care, 16 high-cost and high-
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discretion procedures, 17 treatment for lung c a n c e r J 8 and other similar expensive and sophisticated services. It is difficult to foresee that mandating universal access benefits will result in a significant increase in the nation's total number of hospital ED visits. First, the past 15 years (1975-1990) have witnessed a growth from 69.2 to 86.8 million visits (an increase of 24.6%) but only an 8.3% increase in total visits when these data are adjusted for population growth. 19 Second, although there may be some reluctance to use alternatives to hospital EDs, the currently 37 million uninsured will have benefits to obtain p r i m a r y care services in a physician's office, thereby potentially reducing the number of routine visits to hospitals for all ambulatory care services. T h i r d , various providers will visualize that the previously uninsured are a new, fiscally viable " m a r k e t hitch," because they will now be entitled to t h i r d - p a r t y reimbursement. Therefore, we can expect the development of new ambulatorycare centers that focus on providing p r i m a r y care to the working poor and their dependents, many located in blue collar communities. F o r a number of cultural and fiscal reasons, these satellites will tend to be less profitable to these providers than those that have been developed in many s u b u r b a n locations, p a r t i c u l a r l y if they maintain highquality patient care standards. W h a t might be envisioned by most emergency physicians is a decline in the number of routine visits but an increased percentage of collections. These predictions are particularly relevant for urban-based emergency physicians who now serve a highly disproportionate share of the working poor and their dependents. ADMINISTRATION
OF P L A N
The prospect of introducing a single-payer Canadian-style national health insurance plan remains unlikely for the foreseeable future, even though such an a p p r o a c h would save between $6212 and $100 billion annually.20 This is in p a r t because many Americans are unwilling to allow the government to make health policy decisions that might affect the delivery of services to themselves or members of their family. In addition, the Heath Insurance Association of America and the Blue Cross/Blue Shield Association have retained powerful lobbyists who will advocate the use of existing third-party payers to achieve universal access, thereby ensuring their own future corporate viability. Because a m u h i p a y e r system is p r o b a b l y the only politically feasible a p p r o a c h to implementing a universal access plan, there has been considerable emphasis on the potential use of managed-care approaches to micromanage new benefits for the previously uninsured. When given a choice, some physicians would prefer to be hassled by such micromanagement methodologies as gate-keeping, precertifications, recertifications, second opinions, and concurrent review from various managed care plans than to be dictated to by one single p a y e r - - the government. But maybe the questio n should be, are managed care plans, which have experienced their major growth and can work well in a market-driven, procompetitive environment, conceptually consistent with the implementation of a highly regulated universal access plan?
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EDITORIALS
The success of most health maintenance organizations is dependent on their ability to select their enrollees, 21 reduce hospital inpatient u s e , 22 maintain long waiting times for nonemergency and most diagnostic visits without antagonizing the patient, 23 and other similar approaches to reduce either use or cost. 24,25 Managed care plans, excluding most large group or staff model health maintenance organizations, might well be alien to the regulatory environment where there is open enrollment for those now u n i n s u r e d ; where hospitals are reimbursed roughly the same amount for similar services regardless of the third-party payer; and where most physicians are paid on a fee-for-service rather than a salary or a capitated basis. The Health Insurance Association of America, the Blue Cross/Blue Shield Association, and other providers should be relatively successful in lobbying to foster u n d e r the universal access pla n the current muhipayer, micromanagement approach. But the conceptual inconsistency, the management difficulties in administering a plan for more than 60 million potential beneficiaries,26 and our predictable inability to contain the costs of a universal access plan might well encourage more public officials and others later on to restudy, as potential models here, the Canadian 8 or the German7 system.
COST The significant rise i n health care costs and the increasing number of persons without health insurance benefits in the 1980s cause doubts of the efficacy of the procompetitive model for the health field. Unless there is some agreement that this nation's percentage of its gross domestic product for health care should be increased as it implements universal access, there could be significant pressure to reduce either physician fees (ie, price) or use (ie, volume of services). There is increasing evidence based on experience in the United States, Canada, and ten European countries 27 that central fiscal control is the key factor to explain differences in health care spending across nations. National health insurance advocates 28 suggest that health care systems relying on some overall control of spending are generally more cost-effective than those counting on more decentralized mechanisms of control. It is doubtful, therefore, that costcontainment efforts for a universal access plan can be implemented by some cost-sharing approach (ie, deductibles and coinsurance) or the micromanaging of physician and hospital services by many managed care plans. R E I M B U R S E M E N T M E T H O D O L O G Y AND INCENTIVES The new resource-based relative value scale (RBRVS) Medicare fee schedule that is now being phased in over a five-year period was predicted to improve the imbalance in income between the primary-care and the procedure-oriented physicians. These regulations have been u n d e r attack by many medical and surgical subspecialists, as well as hospitalbased physicians, although at the outset it was suggested that they would only have a modest'impact on most of their incomes.
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In a n u m b e r of major metropolitan areas, there has already been some resistance by specialists to accept new Medicare patients. Because there is reasonable likelihood that the new universal access fee-for-service schedule will be tied to the Medicare reimbursement rates, emergency physicians in many s u b u r b a n communities could well find it as difficult as in the past to refer these newly insured patients for follow-up care. Conversely, many of these newly insured patients will be attractive to those who have served the traditional working poor and their dependents. This is because they will receive some reimbursement for previously uncompensated physicians' services. What should be of far greater concern to physicians in the long r u n is the expansion of the RBRVS approach to not only the currently u n i n s u r e d as part of the universal access plan, but the entire population, which many believe will eventually happen anyway. Because it is unlikely that most physicians u n d e r universal access and then a national health insurance plan will be paid on a salary or on a capitated basis, the Medicare RBRVS approach could become a critical, historic precedent. What could have an even greater impact on physician reimbursement than the relative value methodology are more studies that compare per capita expenditure for physician services in the United States with other western nations. A recent report 20 concluded that the cost of physician services is significantly greater (a ratio of 1.72) here than in Canada, and these differences were explained almost entirely by higher fees. Although fees in this country for procedures were more than three times as high as in Canada, physicians' net incomes here are only about one third higher. The recommendations contained in this study would be predictable by most physicians: There is a need to train more primary-care doctors (the top priority), to reduce billing costs, to eliminate some patient/employee amenities, to minimize overhead and administrative expenses, and in particular, to reduce those costs that relate to such expenditures as malpractice, marketing, and negotiating contractual relationships with third-party payers. Where physician reimbursement might be heading late in the 1990s is toward global target budgets in which physicians' fees and related services will be set on a national and then on a state-by-state basis. There eventually will be agreed-on, state-administered physician fee schedules. Large increases above projected volumes because of any consumer- or provider-induced demand will result in a reduction of the fees per unit of service the following year. An obvious concern is that these reimbursement methodologies would encourage quick and frequent visits, as has been the experience with the German quasiprivate, quasipublic approach. 29
SUMMARY The nation's current economic conditions, the first time in 60 years that a recession has adversely affected the middle class, might well be the actual trigger mechanism in the passage of a US universal access plan. When enacted, it would provide emergency medicine and other basic physician
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and hospital benefits to the currently uninsured patients now seen in hospital EDs, in doctors' offices, and as inpatients. It will, thereby, enhance current physician-patient relationships and enable many of the working poor and their dependents to receive medical care. Conventional wisdom suggests that such a social insurance plan could significantly reduce the number of routine visits to hospital EDs, assuming that additional, accessible, and high-quality alternative p r i m a r y care services are developed. In any case, a universal access plan should improve the percentage of billed charges collected by emergency physicians. The nation's 1,500 third-party payers, with their managed care strategy, will have difficulty (for the reasons outlined) in micromanaging such external pressures as ensuring highquality patient care, more benefits (including tertiary services), and less cost to the private and public sectors. As there is more micromanaging by t h i r d - p a r t y payers to reduce expenditures, it will be increasingly difficult for emergency physicians to find specialists willing to accept previously uninsured patients, except at public or teaching environments where the delivery of services to uncompensated patients has been the p a t t e r n for several decades. As a potential compromise between maintaining the existing pluralism and implementing a sin~e-payer Canadian a p p r o a c h , we could expect later on to proceed toward the German quasiprivate, quasipublic model in which there are national and state global budgets but no direct government intervention in the actual setting of physician fees. U n d e r these circumstances, emergency physicians would need to compete with all other practitioners for a finite amount of available dollars. Canadian physicians, on an overall basis, provide 24.5% more visits per capita p e r year 28 in a health care system that spends one third less of its gross domestic p r o d u c t for health than the United States. Interestingly, there is growing evidence that US procedure-oriented physicians might need to double their volumes to maintain their current revenue stream. 20 Whether emergency medicine and other hospitalbased physicians' workloads and incomes will fare well under these circumstances is too early to predict. Because Canadian hospitals use 3.3 full-time equivalent employees p e r occupied bed in comparison with 5.5 full-time equivalent employees per occupied bed in the United States ,3o it could be anticipated that hospital emergency and related ancillary departments could experience a reduction in staff, p a r t i c u l a r l y as there is a shift away from a nmrket-driven, competitive environment to a more proregulatory one. Less staffing, more delays in obtaining ancillary test or p r o c e d u r e results, and further overcrowding in some EDs u n d e r s t a n d a b l y would be intolerable to emergency physicians. This would result in accelerating professional b u r n o u t , which is a l r e a d y high in this new clinical discipline. This prediction in the reduction of total hospital staffing is made regardless of the fact that because of a n u m b e r of serious economic, political, social, cultural, and infrastructure issues facing our nation, p a r t i c u l a r l y in our major cities, the amount of t r a u m a , serious illness, and disability seen in hospital EDs and other departments can only be anticipated to increase in the decades ahead.
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Although a universal access plan may be ahen to our current values of pluralism and individual responsibility and our desire to solve local problems at the local level, I would vote for some type of evolutionary health reform now rather than waiting a few years until cost containment and the number of uninsured become increasing problems. Without some interim steps, 1 am fearful that in only a few years the political and economic pressures could bring far more radical changes in the organization and financing of emergency medicine and other related health care services. Thomas P Well, PhD Bedford Health Associates, Inc Management Consultants for Health and Hospital Services Asheville, North Carolina 1. Nelson C, Short K: Health Insurance, 1986-88.Washington, DC, Bureau of the Censu,, US Department of Commerce, current population reports, household economic studies series P-70, no. 17, March 1990. 2. Todd JS, Seekins SV, Krichbaum JA, et al: Health access America--Strengthening the US health care system. JAMA 1991;265:2503-2597. 3. American College of Emergency Physicians: Access to emergency medical care: Emergency physicians and uncompensated care. Ann EmergMed 1987;16:1302-1304. 4. Melnick 6A, Mann J, Golan I: Uncompensated emergency care in hospital markets in Los Angeles county. Am J Public Health 1989;79:514-516. 5. Lowe RA, Young 6P, Reinke 13,et ah Indigent health care in emergency medicine: An academic perspective. Ann Emerg Med 1991;29:790-794. 6. Blenclon RJ, Edwards JN: Caring for the uninsured: Choices for reform. JAMA 1991;265:2563-2565. 7. Iglehart JK: Germany's health care system. N Engl J Med 1991;324:503-508, 1750-1756. 8. Evans RG, Lomas J, Barer ML, et al: Controlling health expenditures--The Canadian reality. N Engl J Med 1989;320:571-577. 9. Bronow RS, Beltram RA, Cohan SC, et al: The physicians who care plan. JAMA 1991;265:2511-2515. 10. Cleveland WW: Redoing the health care quilt. Am J Dis Child 1991;45:499-504. 11. Hurst J: Reforming health care in seven European nations. HealthAff1991;10:7-21. 12, 6rumbach K, Bodenheimer T, Himmelstein DU, et al: Liberal benefits, conservative spending. JAMA 1991;265:2549-2554. 13. Rublee DA: Medical technology in Canada, Germany, and the United States. Health Aft 1989;8:178-181. 14. Davis K, Rowland 13:Uninsured and underserved: Inequalities in health care in the United States. Milbank Q 1983;61:149-176. 15. Wenneker MR, Weissman JS, Epstein AM: The association of payer with utilization of cardiac procedures in Massachusetts. JAMA 1990;264:1255-1260. 16. Braveman PA, Egerter S, Bennett T, et ah Differences in hospital resource allocation among sick newborns according to insurance coverage. JAMA 1991;266:3300-3398. 17. Hadley J, Steinberg EP, Feder J: Comparison of uninsured end privately insured hospital patients: Conditions on admission, resource use, and outcome. JAMA 1991;265:374-379. 18. Greenberg ER, Chute CG, Stukel T, et al: Social and economic factors in the choice of lung cancer treatment. N Engl J Med 1988;318:612-617. 19. American Hospital Association. Hospital Statistics, 1976 and 1991 editions. Chicago, AHA, 1976 and 1991. 29. Fuchs VR, Hahn JS: How does Canada do it? A comparison of expenditures for physicians' services in the United States and Canada. N Engl J Med 1999;323:884-890. 21. Luft HS, Miller RH: Patient selection in a competitive health care system. HealthAff 1988;7:97q 19. 22. Wagner E, 81edsoe T: The Rand health insurance experiment and HM13s. MedCare 1990;28:191-209. 23. Hillman AL: Financial incentives for physicians in HM0s: Is there a conflict of interest? N Engl J Med1987;317:1743-1748, 24. Langwell KM, Hadley JP: Insights from the Medicare HM13 demonstrations. Health
Aff1990;9:74-84. 25. Luft HS, Maerki SC, Trauner JB: The competitive effect of health maintenance organizations: Another look atthe evidence from Hawaii, Rochester, and Minneapolis/St Paul. J Health Polit Policy Law 1986;19:625-658. 26. Weil TP: A universal access plan: A step toward national health insurance? Hosp Health Serv Admin 1992;31:37-51.
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27.PfaffM: Differences in health care spending across countries: Statistical evidence. JHealthPolit Poficy Law 1990;15:1-68. 28.Schieber6J, Poullier J-P, Greenwald LM: Health care systems in twenty-four countries.HealthAff1991;19:29-31. 29,BrennerG, Schneider M: The 1987revision of physician fees in 6ermany. Health Aft I991;10:147-156. 3D.CanadaCenter for Health Information: Hospital statistics (preliminary annual report, 1989-1990).Ottawa, Canada, 1992.
Public Policy and the Emergency Department See related articles, p 1208, 1236, and 1266. INTRODUCTION
The current issue of Annals addresses several i m p o r t a n t aspects of the role of public policy relative to emergency medicine. Emergency medicine plays an integral and pivotal r01e in the definition, structure, and function of the health care system. In this regard, it is essential that emergency physicians and emergency medicine organizations play an active and formative role in the rapidly changing health care environment. I appreciate this opportunity to provide my views on some of the policy issues raised in the c u r r e n t articles by Cross, Mitchell and Remmel, and Weil. PRESSURE ON DEPARTMENT
THE
EMER6ENCY
Mr Cross provides a concise and informative review of the law relative to the evolving responsibility of the ED in providing care. The point is well made that despite Supreme Court decisions such as Youngberg v Romeo (457 US 307), which held that the State has no constitutional duty to p r o vide treatment, provisions of the Consolidated Omnibus Budget and Reconciliation Act (COBRA) of 1986, as amended, placed just such a responsibility to evaluate all patients 0n hospital EDs. I agree with the author that "the hospital ED should not become the default setting for general medical practice, simply because we lack the political will to act"; however, I do not concur with the expressed opinion that it would be wise policy to "remove all economic incentives and disincentives from the clinical decision making process so that physicians ...are absolutely free to make decisions based solely upon the medical evidence." Virtually all key policy issues relating to emergency medicine deal with the concept of quality. Politicians and health care administrators are interested in obtaining value for dollars spent, while providers are increasingly concerned that cost-containment activities are adversely affecting access and the subsequent ability to provide quality care. The debate over the a p p r o p r i a t e level of utilization and quality is based in the fundamental a p p r o a c h to medical care services. Physicians have traditionally assumed a "maximalist" a p p r o a c h to services whereby the patient is to receive any and all services that could possibly be of benefit.i P r i o r to diagnosis-related groups (DRGs) and the prospective payment system instituted in 1983, hospital services were reimbursed on a cost-plus basis, which provided an incentive for hospitals to encourage physicians to perform all relevant tests and procedures. Many health
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economists point to this system as one of the p r i m a r y factors in the enormous increases in health care spending over the past 25 years. U n d e r the DRG prospective payment system, hospitals have a strong incentive to minimize the length of stay and have focused on an "optimalist" a p p r o a c h to medical care. Optimalists believe strongly in the concept of diminishing marginal utility of medical care, and believe that at some point in the treatment process additional tests and procedures or time in the hospital are not worth the additional cost. Dr David Eddy, director of the Center for Health Policy at Duke University, has assisted the American College of Emergency Physicians in the development of clinical practice guidelines (ACEP's "clinical policies"). In 1986, Dr Eddy pointed out in a Health Affairs article that medicine is still an inexact art and that we lack the empirical research foundation of efficacy and effectiveness for many commonly accepted medical practices and procedures. 2 Without an adequate research foundation, the policy of encouraging physicians to do everything possible for their patients lacks credibility in an era of escalating cost containment. I believe there will be mounting pressure on all physicians, including those of us in emergency medicine, to provide the scientific justification for the treatments we prescribe. LEVELS
OF
UNCOMPENSATED
CARE
Drs Mitchell and Remmel provide a retrospective analysis of ED billing data in Florida. The authors found an overall collection rate of 59% and estimated that uninsured patients comprised about 20% of the sample. The descriptive statistics are interesting, although s t a n d a r d errors or confidence intervals were not reported. The study may lack national validity because F l o r i d a is not typical of many states, particularly with r e g a r d to the p r o p o r t i o n of Medicare recipients. The study provides evidence of a high degree of participation by emergency physicians in the Medicare and Medicaid programs. I agree with the policy conclusion of the authors that emergency physicians contribute significantly to the care of elderly and indigent patients. The authors estimated that 21% of patient visits were coded as either "extended" or "comprehensive" under the pro-1992 CPT emergency codes. The overall estimate of patients who were thought to be emergent or urgent "supporting the need for acute care in the emergency department" was 40%. The Inspector General of the Department of Health and Human Services estimated that more than one-half to two-thirds of Medicaid ED visits are for nonemergencies, 3 and some policy makers may conclude from the Mitchell and Remmell article that the Inspector General's estimate is accurate and that 60% of the patients in the study could have been treated in an alternative ambulatory care setting. UNIVERSAL
ACCESS
Dr Weil provides a very interesting and informative article dealing with the potential impact of universal insurance coverage on the ED. The author predicts the following m a j o r effects of universal coverage on the ED: • ED volumes will decline with p r o b a b l e consolidation of emergency services into fewer EDs; remaining EDs may experience cutbacks in staffing and support services.
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We must work with local, state, and federal legislators, emphasizing that the answer to gang violence is not just stronger punitive laws but getting them to allocate funds to alleviate the root causes. It should be clearly explained to lawmakers that gang violence is a preventable disease, worthy of their attention and funding. Along with others in the medical community, we as emergency physicians must address the issues of firearms and injuries and take a firm stance that handguns and assault rifles must be controlled. We should willingly support organizations that are working to pass laws to prevent children from sinking further into poverty because these are the children most at risk for gang involvement. Throughout America, children must be taught an a p p r o p r i a t e value system, encompassing a sense of personal pride, dignity, self-worth, accomplishment, and a healthy respect for all human life. Emergency physicians, community activists, family members, and others in the community can act as positive role models for our children. There must be a realization that whether we live in the inner city or in the suburbs, we are a nation of people who must show concern for the welfare of one another. Problems such as gang violence are touching us all directly and indirectly. For any solution to be effective, we must empower innercity communities to play a pivotal role in resolving these problems. It is essential that health care providers do not take maternalistic or paternalistic approaches when working toward solutions to these problems. The "benign neglect" of problems that exist in the inner city must come to an end. It is clearly much too costly, in terms of human life and health care dollars, to continue this approach. Only by implementing the above interventions can we hope to be safe from gang violence. HRangeHutson, MD DeirdreAnglin, MD William Marion, MD Departmentof EmergencyMedicine LosAngeles County/University of Southern Califomia Medical Center 1.Maxson CL, Gordon MA, Klein MW: Differences between gang and nongang homicides. Criminology1985;23:209-222. 2.Los Angeles Police Department, Gang Information Section: CrimeStatistics, 1991. 3.Los Angeles County Sheriff's Department, Operation Safe Streets: GangRelated CrimeStatistics,1991. 4. GatesIF, Jackson RK: Gang violence in LA. ThePoliceChiefNovember1990;20-22. 5.KidsCountDataBook:StateProfilesof ChildWeft-Being.Washington, DC, The Annie E Casey Foundation, Center for the Study of Social Policy, 1992. 6. Klein MW, Maxson CL, Cunningham LC: "Crack," street gangs, and violence. Criminology1991;29:701-727.
Day-Night Differences Are Not Always Due to Circadian Control See related a~tiele, p 1250. In the three decades since Halberg coined the word "circadian" (from the Latin circa, about, and dies, day), this neologism has largely replaced the terms diurnal, nychthemeral, and daily in referring to rhythmic 24-hour period variations.
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Unfortunately, its usage is less restricted than was probably intended in the original definition, possibly because of an ambiguity in the meaning of the word "about," whether it means "approximately a day" or "encompassing a day." A key observation responsible for the term was that daily rhythms of different types and in many species "free r u n " when the environmental daily cycle (eg, light/dark) is excluded. Under such constant conditions, the period or cycle length of a circadian system is commonly not exactly 24 h o u r s - perhaps 23 hours or, as for sleep-wake cycles of human beings in isolation, 25 hours, thus approximately one day. By contrast, some daily cycles are truly and exactly daily, commonly by virtue of some exogenous daily environmental variable that affects them directly-. Remove the environmental variable and the exogenously driven cycle disappears, whereas a truly endogenous circadian r h y t h m persists, albeit with a slightly different period. Endogenous circadian rhythms are entrained to the 24-hour day by environmental cycles, a fact that may sometimes confound the distinction between exogenous and endogenous rhythms. Extreme care must thus be exercised in the interpretation and classification of biological phenomena that exhibit daily rhythms, whether it be the occurrence of cardiac failures, platelet aggregability (which peaks in the early morning hours), photosynthesis in plants, or bioluminescence in dinoflagellates. We do not know, for example, whether the endogenous circadian timing system contributes to the welldescribed daily variations in h e a r t rate and blood pressure. Given this caveat, the careful description of these daily variations may have important implications for both those at risk and their providers. J WoodlandHastings, PhD Department of Cellular and DevelopmentalBiology The Biological Laboratories Harvard University Cambridge, Massachusetts CharlesA Czeisler, PhD, MD Department of Medicine Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts
Universal Access: Its Potential Impact on Emergency Medicine INTRODUCTION
A consensus has been reached among the major political forces in the health care field that reform must be enacted to provide basic physician and hospital benefits to more than 60 million Americans who are now without coverage some time during each year. 1 President Bush, many public officials, the American Medical Association, 2 the American Hospital Association, the Blue Cross/Blue Shield Association, and the Health Insurance Association of America all support the concept, although they are often far a p a r t on the details of providing universal access coverage. Those physicians who provide care in overcrowded emergency departments and treat many of those who are
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either uninsured or underinsured are particularly sensitive to the need for some health reform. Uncompensated care, in fact, has been a topic of p a r t i c u l a r interest to emergency physicians,3,4 as recently evidenced by a committee of the Society of Academic Emergency Medicine s indicating that "it appears inescapable that the solution must provide some form of universal access to comprehensive health care." Differences of opinion in these health reform discussions most often center a r o u n d the issue of whether to continue with the current procompetitive, pluralistic a p p r o a c h with its 1,500 t h i r d - p a r t y payers, 6 to emulate the German quasiprivate, quasipublic system, 7 or to implement a more regulated single-payer, Canadian-type design. 8 Those who are still supportive of the existing a p p r o a c h to delivering care argue that we have the finest scientific and technologic system in the world and that there should be grave concern about any further government intrusion into the practice of medicine.9,10 Those who are more supportive of replicating the German or the Canadian model in this country stress the significant savings that can be achieved by setting global targets for total health care expenditures, u by reducing administrative expenses ,12 and by the possibility of eliminating the unnecessary duplication of high-technology services. 13 Although it may be difficult to predict the steps, the specific benefits, and the timetable for the passage of a universal access plan in the United States or any specific state, it is now pertinent to speculate on some of the possible implications of such legislation on emergency medicine. If for no other reason than this, these social insurance programs could soon provide coverage to one fourth of the nation's population. F o r purposes of simplicity, this editorial is limited to these elements of a potential US universal access plan: the patient's benefits; the administration of the plan; its cost; and the reimbursement methodology and fiscal incentives for physician services to provide improved patient accessibility for care but also to contain total health care expenditures. PATIENTS'
BENEFITS
Because the uninsured have higher rates of illness and disability than the insured,la a major conceptual advantage of a universal access plan would be that the physician-patient relationship, for the now 37 million Americans without benefits each day, would no longer be constrained by the patient's inability to pay for services. This assumes that under the new plan there would be the availability of a b r o a d range of physician and hospital benefits including diagnostic, curative, and rehabilitative services without significant deductible or coinsurance features. Many of the currently proposed universal access plans provide emergency medicine and other basic benefits (eg, routine physician office visits, and as inpatients, maximum of 30 days' hospitalization) but exclude most t e r t i a r y services. This lack of b r o a d comprehensive coverage, which is related to fiscal affordability and not to compete with existing insurance contracts, is an issue for many medical and surgical subspecialists because the uninsured already have inadequate access to cardiology and cardiac surgery services,~.s high-risk newborn care, 16 high-cost and high-
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discretion procedures, 17 treatment for lung c a n c e r J 8 and other similar expensive and sophisticated services. It is difficult to foresee that mandating universal access benefits will result in a significant increase in the nation's total number of hospital ED visits. First, the past 15 years (1975-1990) have witnessed a growth from 69.2 to 86.8 million visits (an increase of 24.6%) but only an 8.3% increase in total visits when these data are adjusted for population growth. 19 Second, although there may be some reluctance to use alternatives to hospital EDs, the currently 37 million uninsured will have benefits to obtain p r i m a r y care services in a physician's office, thereby potentially reducing the number of routine visits to hospitals for all ambulatory care services. T h i r d , various providers will visualize that the previously uninsured are a new, fiscally viable " m a r k e t hitch," because they will now be entitled to t h i r d - p a r t y reimbursement. Therefore, we can expect the development of new ambulatorycare centers that focus on providing p r i m a r y care to the working poor and their dependents, many located in blue collar communities. F o r a number of cultural and fiscal reasons, these satellites will tend to be less profitable to these providers than those that have been developed in many s u b u r b a n locations, p a r t i c u l a r l y if they maintain highquality patient care standards. W h a t might be envisioned by most emergency physicians is a decline in the number of routine visits but an increased percentage of collections. These predictions are particularly relevant for urban-based emergency physicians who now serve a highly disproportionate share of the working poor and their dependents. ADMINISTRATION
OF P L A N
The prospect of introducing a single-payer Canadian-style national health insurance plan remains unlikely for the foreseeable future, even though such an a p p r o a c h would save between $6212 and $100 billion annually.20 This is in p a r t because many Americans are unwilling to allow the government to make health policy decisions that might affect the delivery of services to themselves or members of their family. In addition, the Heath Insurance Association of America and the Blue Cross/Blue Shield Association have retained powerful lobbyists who will advocate the use of existing third-party payers to achieve universal access, thereby ensuring their own future corporate viability. Because a m u h i p a y e r system is p r o b a b l y the only politically feasible a p p r o a c h to implementing a universal access plan, there has been considerable emphasis on the potential use of managed-care approaches to micromanage new benefits for the previously uninsured. When given a choice, some physicians would prefer to be hassled by such micromanagement methodologies as gate-keeping, precertifications, recertifications, second opinions, and concurrent review from various managed care plans than to be dictated to by one single p a y e r - - the government. But maybe the questio n should be, are managed care plans, which have experienced their major growth and can work well in a market-driven, procompetitive environment, conceptually consistent with the implementation of a highly regulated universal access plan?
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The success of most health maintenance organizations is dependent on their ability to select their enrollees, 21 reduce hospital inpatient u s e , 22 maintain long waiting times for nonemergency and most diagnostic visits without antagonizing the patient, 23 and other similar approaches to reduce either use or cost. 24,25 Managed care plans, excluding most large group or staff model health maintenance organizations, might well be alien to the regulatory environment where there is open enrollment for those now u n i n s u r e d ; where hospitals are reimbursed roughly the same amount for similar services regardless of the third-party payer; and where most physicians are paid on a fee-for-service rather than a salary or a capitated basis. The Health Insurance Association of America, the Blue Cross/Blue Shield Association, and other providers should be relatively successful in lobbying to foster u n d e r the universal access pla n the current muhipayer, micromanagement approach. But the conceptual inconsistency, the management difficulties in administering a plan for more than 60 million potential beneficiaries,26 and our predictable inability to contain the costs of a universal access plan might well encourage more public officials and others later on to restudy, as potential models here, the Canadian 8 or the German7 system.
COST The significant rise i n health care costs and the increasing number of persons without health insurance benefits in the 1980s cause doubts of the efficacy of the procompetitive model for the health field. Unless there is some agreement that this nation's percentage of its gross domestic product for health care should be increased as it implements universal access, there could be significant pressure to reduce either physician fees (ie, price) or use (ie, volume of services). There is increasing evidence based on experience in the United States, Canada, and ten European countries 27 that central fiscal control is the key factor to explain differences in health care spending across nations. National health insurance advocates 28 suggest that health care systems relying on some overall control of spending are generally more cost-effective than those counting on more decentralized mechanisms of control. It is doubtful, therefore, that costcontainment efforts for a universal access plan can be implemented by some cost-sharing approach (ie, deductibles and coinsurance) or the micromanaging of physician and hospital services by many managed care plans. R E I M B U R S E M E N T M E T H O D O L O G Y AND INCENTIVES The new resource-based relative value scale (RBRVS) Medicare fee schedule that is now being phased in over a five-year period was predicted to improve the imbalance in income between the primary-care and the procedure-oriented physicians. These regulations have been u n d e r attack by many medical and surgical subspecialists, as well as hospitalbased physicians, although at the outset it was suggested that they would only have a modest'impact on most of their incomes.
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In a n u m b e r of major metropolitan areas, there has already been some resistance by specialists to accept new Medicare patients. Because there is reasonable likelihood that the new universal access fee-for-service schedule will be tied to the Medicare reimbursement rates, emergency physicians in many s u b u r b a n communities could well find it as difficult as in the past to refer these newly insured patients for follow-up care. Conversely, many of these newly insured patients will be attractive to those who have served the traditional working poor and their dependents. This is because they will receive some reimbursement for previously uncompensated physicians' services. What should be of far greater concern to physicians in the long r u n is the expansion of the RBRVS approach to not only the currently u n i n s u r e d as part of the universal access plan, but the entire population, which many believe will eventually happen anyway. Because it is unlikely that most physicians u n d e r universal access and then a national health insurance plan will be paid on a salary or on a capitated basis, the Medicare RBRVS approach could become a critical, historic precedent. What could have an even greater impact on physician reimbursement than the relative value methodology are more studies that compare per capita expenditure for physician services in the United States with other western nations. A recent report 20 concluded that the cost of physician services is significantly greater (a ratio of 1.72) here than in Canada, and these differences were explained almost entirely by higher fees. Although fees in this country for procedures were more than three times as high as in Canada, physicians' net incomes here are only about one third higher. The recommendations contained in this study would be predictable by most physicians: There is a need to train more primary-care doctors (the top priority), to reduce billing costs, to eliminate some patient/employee amenities, to minimize overhead and administrative expenses, and in particular, to reduce those costs that relate to such expenditures as malpractice, marketing, and negotiating contractual relationships with third-party payers. Where physician reimbursement might be heading late in the 1990s is toward global target budgets in which physicians' fees and related services will be set on a national and then on a state-by-state basis. There eventually will be agreed-on, state-administered physician fee schedules. Large increases above projected volumes because of any consumer- or provider-induced demand will result in a reduction of the fees per unit of service the following year. An obvious concern is that these reimbursement methodologies would encourage quick and frequent visits, as has been the experience with the German quasiprivate, quasipublic approach. 29
SUMMARY The nation's current economic conditions, the first time in 60 years that a recession has adversely affected the middle class, might well be the actual trigger mechanism in the passage of a US universal access plan. When enacted, it would provide emergency medicine and other basic physician
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and hospital benefits to the currently uninsured patients now seen in hospital EDs, in doctors' offices, and as inpatients. It will, thereby, enhance current physician-patient relationships and enable many of the working poor and their dependents to receive medical care. Conventional wisdom suggests that such a social insurance plan could significantly reduce the number of routine visits to hospital EDs, assuming that additional, accessible, and high-quality alternative p r i m a r y care services are developed. In any case, a universal access plan should improve the percentage of billed charges collected by emergency physicians. The nation's 1,500 third-party payers, with their managed care strategy, will have difficulty (for the reasons outlined) in micromanaging such external pressures as ensuring highquality patient care, more benefits (including tertiary services), and less cost to the private and public sectors. As there is more micromanaging by t h i r d - p a r t y payers to reduce expenditures, it will be increasingly difficult for emergency physicians to find specialists willing to accept previously uninsured patients, except at public or teaching environments where the delivery of services to uncompensated patients has been the p a t t e r n for several decades. As a potential compromise between maintaining the existing pluralism and implementing a sin~e-payer Canadian a p p r o a c h , we could expect later on to proceed toward the German quasiprivate, quasipublic model in which there are national and state global budgets but no direct government intervention in the actual setting of physician fees. U n d e r these circumstances, emergency physicians would need to compete with all other practitioners for a finite amount of available dollars. Canadian physicians, on an overall basis, provide 24.5% more visits per capita p e r year 28 in a health care system that spends one third less of its gross domestic p r o d u c t for health than the United States. Interestingly, there is growing evidence that US procedure-oriented physicians might need to double their volumes to maintain their current revenue stream. 20 Whether emergency medicine and other hospitalbased physicians' workloads and incomes will fare well under these circumstances is too early to predict. Because Canadian hospitals use 3.3 full-time equivalent employees p e r occupied bed in comparison with 5.5 full-time equivalent employees per occupied bed in the United States ,3o it could be anticipated that hospital emergency and related ancillary departments could experience a reduction in staff, p a r t i c u l a r l y as there is a shift away from a nmrket-driven, competitive environment to a more proregulatory one. Less staffing, more delays in obtaining ancillary test or p r o c e d u r e results, and further overcrowding in some EDs u n d e r s t a n d a b l y would be intolerable to emergency physicians. This would result in accelerating professional b u r n o u t , which is a l r e a d y high in this new clinical discipline. This prediction in the reduction of total hospital staffing is made regardless of the fact that because of a n u m b e r of serious economic, political, social, cultural, and infrastructure issues facing our nation, p a r t i c u l a r l y in our major cities, the amount of t r a u m a , serious illness, and disability seen in hospital EDs and other departments can only be anticipated to increase in the decades ahead.
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Although a universal access plan may be ahen to our current values of pluralism and individual responsibility and our desire to solve local problems at the local level, I would vote for some type of evolutionary health reform now rather than waiting a few years until cost containment and the number of uninsured become increasing problems. Without some interim steps, 1 am fearful that in only a few years the political and economic pressures could bring far more radical changes in the organization and financing of emergency medicine and other related health care services. Thomas P Well, PhD Bedford Health Associates, Inc Management Consultants for Health and Hospital Services Asheville, North Carolina 1. Nelson C, Short K: Health Insurance, 1986-88.Washington, DC, Bureau of the Censu,, US Department of Commerce, current population reports, household economic studies series P-70, no. 17, March 1990. 2. Todd JS, Seekins SV, Krichbaum JA, et al: Health access America--Strengthening the US health care system. JAMA 1991;265:2503-2597. 3. American College of Emergency Physicians: Access to emergency medical care: Emergency physicians and uncompensated care. Ann EmergMed 1987;16:1302-1304. 4. Melnick 6A, Mann J, Golan I: Uncompensated emergency care in hospital markets in Los Angeles county. Am J Public Health 1989;79:514-516. 5. Lowe RA, Young 6P, Reinke 13,et ah Indigent health care in emergency medicine: An academic perspective. Ann Emerg Med 1991;29:790-794. 6. Blenclon RJ, Edwards JN: Caring for the uninsured: Choices for reform. JAMA 1991;265:2563-2565. 7. Iglehart JK: Germany's health care system. N Engl J Med 1991;324:503-508, 1750-1756. 8. Evans RG, Lomas J, Barer ML, et al: Controlling health expenditures--The Canadian reality. N Engl J Med 1989;320:571-577. 9. Bronow RS, Beltram RA, Cohan SC, et al: The physicians who care plan. JAMA 1991;265:2511-2515. 10. Cleveland WW: Redoing the health care quilt. Am J Dis Child 1991;45:499-504. 11. Hurst J: Reforming health care in seven European nations. HealthAff1991;10:7-21. 12, 6rumbach K, Bodenheimer T, Himmelstein DU, et al: Liberal benefits, conservative spending. JAMA 1991;265:2549-2554. 13. Rublee DA: Medical technology in Canada, Germany, and the United States. Health Aft 1989;8:178-181. 14. Davis K, Rowland 13:Uninsured and underserved: Inequalities in health care in the United States. Milbank Q 1983;61:149-176. 15. Wenneker MR, Weissman JS, Epstein AM: The association of payer with utilization of cardiac procedures in Massachusetts. JAMA 1990;264:1255-1260. 16. Braveman PA, Egerter S, Bennett T, et ah Differences in hospital resource allocation among sick newborns according to insurance coverage. JAMA 1991;266:3300-3398. 17. Hadley J, Steinberg EP, Feder J: Comparison of uninsured end privately insured hospital patients: Conditions on admission, resource use, and outcome. JAMA 1991;265:374-379. 18. Greenberg ER, Chute CG, Stukel T, et al: Social and economic factors in the choice of lung cancer treatment. N Engl J Med 1988;318:612-617. 19. American Hospital Association. Hospital Statistics, 1976 and 1991 editions. Chicago, AHA, 1976 and 1991. 29. Fuchs VR, Hahn JS: How does Canada do it? A comparison of expenditures for physicians' services in the United States and Canada. N Engl J Med 1999;323:884-890. 21. Luft HS, Miller RH: Patient selection in a competitive health care system. HealthAff 1988;7:97q 19. 22. Wagner E, 81edsoe T: The Rand health insurance experiment and HM13s. MedCare 1990;28:191-209. 23. Hillman AL: Financial incentives for physicians in HM0s: Is there a conflict of interest? N Engl J Med1987;317:1743-1748, 24. Langwell KM, Hadley JP: Insights from the Medicare HM13 demonstrations. Health
Aff1990;9:74-84. 25. Luft HS, Maerki SC, Trauner JB: The competitive effect of health maintenance organizations: Another look atthe evidence from Hawaii, Rochester, and Minneapolis/St Paul. J Health Polit Policy Law 1986;19:625-658. 26. Weil TP: A universal access plan: A step toward national health insurance? Hosp Health Serv Admin 1992;31:37-51.
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OCTOBER1992
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27.PfaffM: Differences in health care spending across countries: Statistical evidence. JHealthPolit Poficy Law 1990;15:1-68. 28.Schieber6J, Poullier J-P, Greenwald LM: Health care systems in twenty-four countries.HealthAff1991;19:29-31. 29,BrennerG, Schneider M: The 1987revision of physician fees in 6ermany. Health Aft I991;10:147-156. 3D.CanadaCenter for Health Information: Hospital statistics (preliminary annual report, 1989-1990).Ottawa, Canada, 1992.
Public Policy and the Emergency Department See related articles, p 1208, 1236, and 1266. INTRODUCTION
The current issue of Annals addresses several i m p o r t a n t aspects of the role of public policy relative to emergency medicine. Emergency medicine plays an integral and pivotal r01e in the definition, structure, and function of the health care system. In this regard, it is essential that emergency physicians and emergency medicine organizations play an active and formative role in the rapidly changing health care environment. I appreciate this opportunity to provide my views on some of the policy issues raised in the c u r r e n t articles by Cross, Mitchell and Remmel, and Weil. PRESSURE ON DEPARTMENT
THE
EMER6ENCY
Mr Cross provides a concise and informative review of the law relative to the evolving responsibility of the ED in providing care. The point is well made that despite Supreme Court decisions such as Youngberg v Romeo (457 US 307), which held that the State has no constitutional duty to p r o vide treatment, provisions of the Consolidated Omnibus Budget and Reconciliation Act (COBRA) of 1986, as amended, placed just such a responsibility to evaluate all patients 0n hospital EDs. I agree with the author that "the hospital ED should not become the default setting for general medical practice, simply because we lack the political will to act"; however, I do not concur with the expressed opinion that it would be wise policy to "remove all economic incentives and disincentives from the clinical decision making process so that physicians ...are absolutely free to make decisions based solely upon the medical evidence." Virtually all key policy issues relating to emergency medicine deal with the concept of quality. Politicians and health care administrators are interested in obtaining value for dollars spent, while providers are increasingly concerned that cost-containment activities are adversely affecting access and the subsequent ability to provide quality care. The debate over the a p p r o p r i a t e level of utilization and quality is based in the fundamental a p p r o a c h to medical care services. Physicians have traditionally assumed a "maximalist" a p p r o a c h to services whereby the patient is to receive any and all services that could possibly be of benefit.i P r i o r to diagnosis-related groups (DRGs) and the prospective payment system instituted in 1983, hospital services were reimbursed on a cost-plus basis, which provided an incentive for hospitals to encourage physicians to perform all relevant tests and procedures. Many health
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economists point to this system as one of the p r i m a r y factors in the enormous increases in health care spending over the past 25 years. U n d e r the DRG prospective payment system, hospitals have a strong incentive to minimize the length of stay and have focused on an "optimalist" a p p r o a c h to medical care. Optimalists believe strongly in the concept of diminishing marginal utility of medical care, and believe that at some point in the treatment process additional tests and procedures or time in the hospital are not worth the additional cost. Dr David Eddy, director of the Center for Health Policy at Duke University, has assisted the American College of Emergency Physicians in the development of clinical practice guidelines (ACEP's "clinical policies"). In 1986, Dr Eddy pointed out in a Health Affairs article that medicine is still an inexact art and that we lack the empirical research foundation of efficacy and effectiveness for many commonly accepted medical practices and procedures. 2 Without an adequate research foundation, the policy of encouraging physicians to do everything possible for their patients lacks credibility in an era of escalating cost containment. I believe there will be mounting pressure on all physicians, including those of us in emergency medicine, to provide the scientific justification for the treatments we prescribe. LEVELS
OF
UNCOMPENSATED
CARE
Drs Mitchell and Remmel provide a retrospective analysis of ED billing data in Florida. The authors found an overall collection rate of 59% and estimated that uninsured patients comprised about 20% of the sample. The descriptive statistics are interesting, although s t a n d a r d errors or confidence intervals were not reported. The study may lack national validity because F l o r i d a is not typical of many states, particularly with r e g a r d to the p r o p o r t i o n of Medicare recipients. The study provides evidence of a high degree of participation by emergency physicians in the Medicare and Medicaid programs. I agree with the policy conclusion of the authors that emergency physicians contribute significantly to the care of elderly and indigent patients. The authors estimated that 21% of patient visits were coded as either "extended" or "comprehensive" under the pro-1992 CPT emergency codes. The overall estimate of patients who were thought to be emergent or urgent "supporting the need for acute care in the emergency department" was 40%. The Inspector General of the Department of Health and Human Services estimated that more than one-half to two-thirds of Medicaid ED visits are for nonemergencies, 3 and some policy makers may conclude from the Mitchell and Remmell article that the Inspector General's estimate is accurate and that 60% of the patients in the study could have been treated in an alternative ambulatory care setting. UNIVERSAL
ACCESS
Dr Weil provides a very interesting and informative article dealing with the potential impact of universal insurance coverage on the ED. The author predicts the following m a j o r effects of universal coverage on the ED: • ED volumes will decline with p r o b a b l e consolidation of emergency services into fewer EDs; remaining EDs may experience cutbacks in staffing and support services.
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