YEAR-END REPORT - 2020 Published 21-Dec-2020 HPTS Issue Brief 12-21-20.6 Health Policy Tracking Service - Issue Briefs Healthcare Providers & Facilities Emergency Care The Issue Brief was written by David J. Steiner, J.D., a contributing writer and member of the Ohio bar. 12/21/2020 I. Introduction A recently published study using data from emergency department visits found that the psychosocial consequences related to coronavirus disease 2019 (COVID-19) may place individuals at a heightened likelihood of opioid overdose or relapse. Health care system Ascension Wisconsin has announced that it is opening three new urgent care centers in southeast Wisconsin in partnership with Physicians Immediate Care. Physicians Immediate Care operates over 40 locations in Illinois and Indiana. The Massachusetts State Senate recently passed legislation intended to ensure safe patient access to emergency care. The University of Wisconsin School of Medicine and Public Health (SMPH) recently announced that is one of four sites awarded a total of $7.5 million from the National Institutes of Health (NIH) to conduct research that could potentially lead to improved care in emergency departments for people with dementia. The American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) have expressed support for a decision from the U.S. Court of Appeals for the 11th Circuit that will revive a lawsuit the organizations filed to force Anthem's Blue Cross Blue Shield of Georgia to rescind a policy that allows it to deny claims for emergency care on a retroactive basis. The American College of Emergency Physicians (ACEP) is supporting the bipartisan, “Holding Providers Harmless from Medicare Cuts During COVID-19 Act of 2020.” This bill attempts to address cuts to physician reimbursement that are planned to take effect in January 2021, including a six percent Medicare reduction for emergency physicians. II. General Emergency Care news Small and independent physician practices weigh in on federal surprise billing legislation debate Nearly 900 smaller and independent physician practices across medical specialties recently sent a letter to Congress outlining the potential unintended consequences that they claim some legislative proposals to solve surprise bills could have on physicians' ability to care for patients. The letter emphasizes strong concerns that rate setting or benchmarking will further “tip the scales” in favor of insurance companies and eliminate the few incentives that remain for insurers to negotiate “fairly.” This system would also, according to the physicians, increase system costs and the likelihood of consolidation, as well as potentially drive these physicians out of network, or out of the market entirely. The letter states in part that, “ ... at best [many insurance companies] offer us only drastically undervalued ‘take-it-or- leave-it’ contracts that will not even cover the costs of our overhead--while others ignore altogether our inquiries to be part of health plan networks. The wrong approach to addressing surprise bills will only further empower insurers to weaken our practices.” The signatory physicians strongly support an independent dispute resolution (IDR) process as the best approach to take patients out of the middle, while also providing a “fair and efficient way to resolve disputes between providers and insurers.” In New York, IDR has successfully saved consumers $400 million and reduced out-of-network billing 34 percent, according to the New York State Department of Financial Services. The letter further states that, “Based on successful state models, it is clear such an approach when used federally can eliminate surprise bills, reduce health care costs, and ensure fair and equitable contracting dynamics between insurers and physicians without adding undue burdens or costs to taxpayers.” © 2021 Thomson Reuters. No claim to original U.S. Government Works. -1- The letter also opposes the idea of restricting IDR claims to a qualifying dollar amount, a request allegedly supported by informal estimates from the Congressional Budget Office that show little to no impact on scoring should a threshold be reduced or eliminated. Smaller and independent physician practices are urging Congress to be thoughtful about the best solution to address surprise bills while ensuring patients' access to care. The physicians wrote that, “We firmly believe, therefore, that an appropriate policy must be crafted that keeps costs contained, preserves access to care for patients, and will not disrupt contracting dynamics between physicians and insurers who attempt to negotiate in good faith.” The letter also noted that, “Again, we strongly urge you to consider how these federal policies currently under consideration may disproportionally impact small physician groups and the care we provide to your constituents. We are deeply concerned that the wrong approach will ultimately drive many of us out of the market entirely, which will drive up health care costs as more smaller practices will be purchased by hospital systems and others, leading to increased consolidation. Studies have shown that if this consolidation [FN2] happens, health care costs could increase by as much as 30 percent.” Washington state surprise medical bill law goes into effect While lawmakers in Washington D.C. debate federal legislation addressing surprise health care bills, Washington state has taken matters into its own hands. Effective Jan. 1, 2020, certain medical providers are prohibited from sending surprise bills to consumers in Washington state under a new law that Insurance Commissioner Mike Kreidler supported. Patients in Washington who receive emergency services or certain services at an in-network hospital or surgical facility cannot be surprise or ‘balance’ billed from an out-of-network provider. According to Commissioner Kreidler, “For more than a decade, we've heard from many people hit with a balance or surprise medical bill. They shared their stories (www.columbian.com) of receiving a bill on top of what they expected to pay, despite going to their health plan's hospital or facility. Just within the last year we learned of two consumers who received surprise bills of over $100,000 and who both faced losing their homes and medical bankruptcy.” Washington is one of 13 states to approve comprehensive protections against surprise bills. Its law is considered among the strongest in the nation. Kreidler further noted that, “I think the breadth of these stories - and that no one was immune - finally provided the motivation needed for the parties to come together and work out a solution. I'm grateful to the many consumers who told their personal stories.' The new law also allows self-insured employers to opt in to the protections for their employees. Over 150 such employers have already opted in to the new law. Key protections include of the law include: • A consumer who receives emergency care in an out-of-network emergency room or who receives a non-emergency medical procedure in an in-network hospital or facility cannot be balanced billed; • An insurer cannot balance bill a patient if they seek emergency care at an out-of-network facility in a state that borders Washington; • Insurers must pay the out-of-network provider or facility directly for care their enrollee receives; • If the insurer and provider or facility do not agree on a commercially reasonable payment for out-of-network services within 30 days, their dispute goes to binding arbitration; • Consumers will be given a notice describing when they can and cannot receive a balance bill; • Insurers, providers, and facilities must include up-to-date network information on their websites; and • Any provider who continues to illegally balance bill may be referred to the state Department of Health for enforcement. Commissioner Kreidler also stated that, “There is much more that we need to do to address the challenges facing our health care system. But to finally put this issue to rest lifts a weight for many and should give thousands of consumers more piece of mind. For now, [FN3] we'll settle for that victory.” Washington hospital settles with state attorney general for at least $250,000 to patients and $1.2 million to state over alleged failure to follow state charity care laws; emergency department collection practices implicated Washington Attorney General Bob Ferguson recently announced that Capital Medical Center in Olympia must provide full restitution to patients as part of a settlement of his lawsuit against the hospital for its alleged failure to follow state charity care laws. Under the terms of the settlement, Capital Medical Center must provide at least $250,000 in refunds to patients to whom Capital allegedly unlawfully denied access to charity care. The exact amount of the settlement will depend on the number of eligible patients who file claims. Capital is also required to provide over $131,000 in debt relief to all patients who still owe Capital for treatment from 2012 to 2016, regardless of their income. The company must also pay $1.2 million to the Attorney General's Office to cover the costs of the investigation and enforcement of charity care laws. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -2- According to Attorney General Ferguson, “Patients entitled to charity care were forced to incur debt or cancel important procedures because of Capital's greed. That's unfair and illegal. Today's resolution holds Capital accountable and ensures the hospital will provide relief to the low-income patients they harmed.” Under state law, hospitals are required to provide charity care to patients near the federal poverty level. Ferguson filed a lawsuit against Capital in 2017, alleging that management at the for-profit hospital created a culture that “elevated aggressive collection over meeting its legal obligation to provide access to charity care.” As a result of these practices, thousands of charity care-qualified patients were forced to pay for their treatment upfront, incur medical debt or defer important medical care. According to the lawsuit, Capital's focus on aggressive collection originated from its management. One of Capital's former executives called collection and registration staff members the emergency department's “money makers.” He said in a 2012 meeting that the hospital needed to “get something out of” every patient and told staff to not let uninsured patients “leave without paying anything.” Capital also allegedly provided cash bonuses and other incentives to staff who met collection targets. In an email to a team of emergency room registrars, Capital's Patient Access Director emphasized collecting payment from “every patient, every time.” In 2014, Capital had the lowest charity care rate in both the Southwest Washington region and in the state as a whole. The hospital provided 0.37 percent of its adjusted revenue in charity care that year, a total of about $926,500. If it had provided charity care at the Southwest Washington average of about six percent, it would have given more than $15.2 million. The terms of the settlement include: • Every Capital patient who qualified for charity care from 2012 to 2016 will have the opportunity to receive refunds, whether or not they had health insurance. All patients who made a payment to Capital between 2012 and 2016, a total of 34,533 patients, will receive a letter and a form in the mail with information about restitution. The Attorney General's Office estimates today's resolution has the potential to benefit thousands of patients; • Capital must write off all outstanding balances patients still owe for treatment between 2012 and 2016, whether or not they were eligible for charity care at the time of their treatment. This amounts to $131,377 in debt relief for 34 patients. These patients will receive notice of the write-off and the settlement; • Capital must provide charity care to patients with an income of up to 400 percent of the federal poverty level -- well beyond the legal requirement of 200 percent -- for the next five years. This has the potential to benefit thousands of low-and-middle income Washingtonians in Southwest Washington; • Capital will conduct outreach to patients about their charity care rights. This includes five public meetings conducted by a qualified organization at local community centers such as food banks, libraries and social service organizations. Capital must provide copies of its charity care application in English, Spanish and Vietnamese to these organizations; and • Capital will pay the Attorney General's Office $1.2 million to cover the costs of investigating and bringing the charity care lawsuit. Patients whose income was at or below 200 percent of the federal poverty level at the time of their treatment will need to complete a form they receive in the mail. No other income documentation is required. Eligible patients will receive a refund of their medical bills. Patients must fill out the form in order to receive a refund. Capital is required to provide full restitution to all patients who were unlawfully denied access to charity care. Capital must send forms to every patient who made a payment to Capital during that period to ensure everyone has the opportunity to receive relief. Because Capital's records to do not reliably show which patients were charity care eligible at the time of treatment, the exact amount of restitution is unclear. It could amount to millions of dollars. The hospital is required to pay at least $250,000 in restitution. If it does not receive enough forms to distribute that amount, it must donate the remainder to a local community organization that provides free and reduced-cost care to low income patients. Capital must also contact credit bureaus in order to rehabilitate the credit of all patients who receive debt relief or refunds. The hospital will report all accounts written off or refunded as closed to credit reporting bureaus. Washington state law requires all hospitals (both for-profit and non-profit, public, and private) to provide charity care to individuals who are near the federal poverty level. Hospitals are required to provide notice of the availability of charity care both verbally and in writing; screen patients for charity care eligibility before attempting to collect payment, and; and only require patients to provide one income- related document to prove charity care eligibility. The lawsuit asserted that Capital violated all of these requirements by training its staff to aggressively demand payment from patients without screening them for charity care eligibility or informing them of their charity care rights. Capital also allegedly required patients to [FN4] produce multiple forms of income documentation to apply for charity care. ER Anywhere app in Rensselaer County, New York boasts impressive results in first three months of operation; intended for use by Medicaid recipients Capital District Physicians' Health Plan (CDPHP) is a physician-founded, member-focused and community-based not-for-profit health plan that offers health insurance plans to members in 26 counties throughout New York. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -3- CDPHP recently announced plans to expand access to ER Anywhere, a virtual health care app. The app is powered by United Concierge Medicine (UCM), and is intended to reduce health care costs and improve patient care by providing CDPHP Medicaid members with an innovative alternative to the emergency room. First introduced in Rensselaer County, New York as an initiative of County Executive Steve McLaughlin, ER boasts the following results in its first three months: 80+ consults, 99% patient satisfaction, and 97% ER avoidance. Based on the program's initial success, county leaders from across New York have expressed interest in offering the service to their Medicaid population. Speaking at the New York State Association of Counties (NYSAC) Legislative Conference in Albany, CDPHP announced plans to expand the service to its full Medicaid membership, which includes 85,000 patients in 16 counties across the state. ER Anywhere allows patients to consult with a UCM emergency provider for treatment or triage of any acute medical issue, ranging from minor concerns to those requiring an ambulance transport. According to CDPHP president and CEO, Dr. John D. Bennett “Today's consumers want instant access to goods and service, health care is no exception. CDPHP is excited to now offer ER Anywhere to more counties to meets those demands. Access to ER Anywhere will allow us to actively reduce health care costs by cutting down on unnecessary trips to the emergency room while still providing the highest quality health care for our members.” CDPHP contends that ER Anywhere is a new and unique alternative to the ER, “providing real-time access to emergency medical providers in minutes, rather than hours.” The organization hopes the app's proliferation will lead to an increase in quality and speed of care, as well as a reduction of stress and cost to the system. Rensselaer County Executive Steve McLaughlin noted that, ‘New York State is currently struggling with a huge Medicaid deficit and challenges in ensuring needed medical attention is available for those in need. Rensselaer County launched ER Anywhere to create avenues of potential savings for our taxpayers, ensure valuable medical resources are available in real emergencies, and to provide Medicaid recipients with a convenient, private, and useful tool to access medical attention and advice for routine medical situations.’ NYSAC Executive Director Stephen J. Acquario also commented on the app, stating that, “The ER Anywhere service in Rensselaer County was the first of its kind innovative solution that connects health care and county 9-1-1 responses through telemedicine. ER Anywhere is a win-win program. It expands access, improves the quality of health care and lowers costs at the same time.” To access the ER Anywhere provider team, members must download the ER Anywhere app on a smartphone, tablet, or desktop and be instantly connected with an emergency medical provider. Patients also have the option of speaking to a doctor by calling 1-866-ER- ANYWHERE. In its initial launch in Rensselaer County, this program also provides access to ER Anywhere through both 911 and in EMS vehicles for instant onsite triage of patients. This feature often prevents unnecessary trips to the ER. Keith Algozzine, PA-C, CEO of United Concierge Medicine also commented on ER Anywhere, noted that, “ER Anywhere represents an innovative solution to an enormous public health challenge.” Algozzine also stated that, “By working together with 911, EMS agencies, County leaders, and CDPHP, Medicaid members will now have emergency medical treatment and triage in the palm of their hands. That means the power of our Virtual Emergency Room will [FN5] help this population get the right care, in the right place, at the right time.” Emergency physicians group opposes Supreme Court ruling upholding Trump administration's “public charge” rule; claims rule will deter some from seeking necessary treatment The American College of Emergency Physicians (ACEP) recently issued a statement strongly opposing the recent Supreme Court decision upholding the Trump Administration's “public charge” rule, which denies certain immigrants their legal status if they rely on public benefits. William Jaquis, MD, FACEP, president of ACEP, stated that, “Efforts to deny access to federal safety-net programs, such as Medicaid, could deter people who are in our country lawfully from seeking medically-necessary treatment out of fear it could jeopardize their immigration status. This in turn puts every American's health at greater risk, particularly as we're seeing how untreated and highly- contagious infectious diseases can spread rapidly and globally.” ACEP contends that depriving people of essential federal benefits may also lead to additional strain on the country's already overcrowded emergency departments and resources. Dr. Jaquis further noted that, “Emergency physicians will continue to treat anyone who walks through our doors, but we are concerned that people who need care will delay or skip appointments until their local emergency department becomes the best, or perhaps the [FN6] only, option.” Study finds increasing repeat ER visits for opioid-related emergencies; analysis included 9,295 patients in four Indiana hospital systems A recently released study found that the emergency department is being increasingly used as a patient's best or only treatment option for opioid use disorder (OUD). New analysis in Annals of Emergency Medicine shows that the prevalence of patients who visited © 2021 Thomson Reuters. No claim to original U.S. Government Works. -4- emergency departments at four Indiana hospital systems for repeat opioid-related emergencies increased from 8.8 percent of all opioid- related visits in 2012 to 34.1 percent in 2017. These figures represent a four-fold increase in five years. According to Casey P. Balio, PhD candidate at IU Richard M. Fairbanks School of Public Health at IUPUI and lead study author, “Emergency departments are vital partners in treatment for opioid disorders. Less frequently discussed is the value of emergency department data that can be applied to predict and prevent emergencies among at-risk patients.” Balio further commented that, “Because the ED is such an important site for care, we need to identify opportunities for treatment and support that help increase efficiency across systems of care and benefit patients.” The analysis found that patients more likely to have a future emergency department encounter for opioid-related emergencies were those with greater numbers of previous opioid-related ED visits, previous unique number hospital systems for which they've had an ED encounter, heroin use being documented at the encounter, and those insured by Medicaid or uninsured relative to privately insured. The analysis of 9,295 patients in four Indiana hospital systems was conducted with data from a statewide regional Health Information Exchange system that examined prescription history, visit detail, and community characteristics. Ms. Balio also stated that, “Consolidating patient information from multiple emergency departments can improve risk assessment and help identify more opportunities to provide patients with treatment, particularly those who have multiple ED visits for opioid-related [FN7] health emergencies. More effective use of health information can enable more efficient care for these individuals.” Florida federal judge dismisses lawsuit against HCA hospitals over alleged surprise ER bills A Florida federal judge recently ruled against claims in a 2019 lawsuit alleging that HCA Florida hospitals were billing patients surprise facility fees for emergency room visits. U.S. District Judge Roy K. Altman noted in an order that the hospitals did charge facility fees, but these fees were disclosed on the internet on lists known as chargemasters, which list the costs of various goods and services. The proposed class action lawsuit was filed on behalf of anyone financially responsible for patients who were charged surprise extra fees at all HCA-affiliated emergency rooms in Florida in the last four years. The suit did not name HCA affiliates in Miami-Dade County. Judge Altman took issue with each of the three plaintiffs' claims of receiving emergency room fees. One plaintiff claimed he received a bill with an undisclosed facility fee of $1,642, but what he really received was an “itemization of hospital services” that did not reflect the amount he actually owed. Furthermore, according to the judge, “Palms West wrote off this patient's account on May 8, 2019 -- one week before the complaint was filed.” Another plaintiff claimed that he was asked to pay an undisclosed fee of nearly $4,000 on a $23,865 bill at Poinciana Medical Center in Kissimmee. The judge observed that the hospital was only seeking approximately $3,000, although that included “some percentage (however small)” of the facility fee. This plaintiff's claims still failed, according to the judge, because no hospital had tried to collect payment from him since November 2017. The hospitals also claimed that this person's account was written off years ago, and that they would not be trying to collect the money or selling his account to a third party for collection. A third plaintiff claimed that his dependent child received emergency care at Fort Walton Beach Medical Center and was billed approximately $6,600 with a facility fee of an unstated amount. That was not true, the judge said, but this plaintiff actually did receive a bill for $820. Judge Altman, however, noted that he was not persuaded by the HCA hospitals' argument that their disclosure of the facility fee via a chargemaster could never be pursued as an unfair trade practice under Florida law. A federal court in Orlando dismissed similar claims, the hospitals said in a statement. The HCA Hospital's statement also noted that, “We appreciate the work of both courts and continue to believe we have appropriately disclosed our charges and complied with the law.” The lawsuit, filed in 2019, stated in part that, “The failure to disclose the surcharge is particularly egregious in light of the fact that defendants represent themselves as providing care and help to patients in the community.” The proposed class action claimed that HCA Florida uses a formula to determine the level of surcharge fee on a scale of one to five, “with the level of the charge being based on an internally developed, undisclosed formula known exclusively to the defendants.” The lawsuit also stated that, “The high cost of medical services is a matter of great public concern, and emergency care patients have a [FN8] right to be informed of a surcharge before it is incurred.” Hyde-Smith addresses rural health care needs, including emergency care, during HHS budget review U.S. Senator Cindy Hyde-Smith (R-Miss.) recently “reaffirmed” her commitment to work with the U.S. Department of Health and Human Services (HHS) to improve rural health care and support financially-troubled rural hospitals, including in the area of emergency care. Hyde-Smith, a member of the Senate Telehealth Working Group, sought details from HHS Secretary Alex Azar on how the HHS budget request for fiscal year 2021 will advance rural health care. She also praised the Trump administration for including aspects © 2021 Thomson Reuters. No claim to original U.S. Government Works. -5- of the CONNECT for Health Act in its budget plan. Azar testified at a Senate Labor, Health and Human Services, and Education Appropriations Subcommittee hearing Tuesday. According to Senator Hyde-Smith, “I am pleased the administration's budget request includes legislative provisions from the CONNECT for Health Act to help expand telehealth at community health centers, rural health clinics and Indian Health Services facilities.” The Mississippi Senator further noted that, “Those provisions can help improve access to care in rural areas throughout in Mississippi and across the nation. The most recent data just released from 2019 shows that nearly 50 percent of rural hospitals are still operating in the red. I'm ready to help with advancing ideas to help address the crisis in access in rural America.” Azar, who formed a HHS Rural Health Task Force to focus attention on workable solutions, testified that, “On the rural task force, we've now matured into the point that rural healthcare is a centerpiece of the president's healthcare agenda and a centerpiece on the budget proposals.” Azar further stated that, “We have many proposals in the budget. One of them, which I'm very excited about, it would help with rural hospital closure, would allow critical access hospitals to convert to emergency facilities with an emergency room and outpatient and not have to bear the burden of continuing inpatient bed facilities, and also get payment supplements on that. So I think that that could be a real lifeline to our rural communities if we can get that approved.” Secretary Azar also commented on the CONNECT for Health Act, suggesting that the budget recommends expanding access to telehealth and compensation for facilities in rural America and Indian country. He also pointed to an effort to modernize the payment system for rural health clinics “because our community health centers in rural health areas, in rural areas, can be an important backbone of our system also.” At the hearing, Hyde-Smith also addressed changes to liver transplant policies that could affect the successful transplant program at the University of Mississippi Medical Center, in addition to lowering prescription drug costs. The Labor, Health and Human Services, and Education Appropriations Subcommittee is expected to conduct a series of hearings in the [FN9] coming weeks to review the budget requests for departments and agencies under its jurisdiction. HHS Health Resources and Services Administration announces grants for rural tele-emergency services The Department of Health and Human Services Health Resources and Services Administration has recently announced an opportunity to apply for funding under the Telehealth Network Grant Program (TNGP). The funding opportunity is intended to promote rural Tele-emergency services with an emphasis on tele-stroke, tele-behavioral health, and Tele-Emergency Medical Services (Tele-EMS). This goal will be achieved by enhancing telehealth networks to deliver 24-hour Emergency Department (ED) consultation services via telehealth to rural providers without emergency care specialists. Eligible applicants include rural or urban nonprofit entities that will provide direct clinical services through a telehealth network. Each entity participating in the networks may be a nonprofit or for-profit entity. Faith-based, community-based organizations and tribal organizations are eligible to apply. Services must be provided to rural areas, although the applicant may be located in an urban area. Tele-emergency is defined as “an electronic, two-way, audio/visual communication service between a central emergency healthcare center (Tele-emergency hub) and a distant hospital emergency department (ED) (remote ED) designed to provide real-time emergency care consultation.” These services may include assessment of patients upon admission to the ED, interpretation of patient symptoms and clinical tests or data, supervision of providers administering treatment or pharmaceuticals, or coordination of patient transfer from the local ED. The overall goals for the Telehealth Network Grant Program are to: • Expand access to, coordinate, and improve the quality of health care services; • Improve and expand the training of health care providers; and • Expand and improve the quality of health information available to health care providers, and patients and their families, for decision- making. TNGP recipients will also support a range of Tele-emergency service programs that will allow for the analysis of a significant volume of patient encounters. The goal is for each TNGP recipient, under this NOFO, to analyze the provision of Tele-emergency services under common metrics and protocols that will allow for a multi-site analysis of the effectiveness of those services. Each of the recipients will participate in a broad-scale analysis and evaluation of the program coordinated by the Federal Office of Rural Health Policy (FORHP) [FN10] as well as individual award recipient analysis and evaluation. Detroit area hospital closes ER and curbside COVID-19 testing on March 26 to focus on treating COVID-19 patients Beaumont Health is Michigan's largest health care system (based on inpatient admissions and net patient revenue). It operates eight hospitals, has 145 outpatient locations, nearly 5,000 physicians, and over 38,000 employees. Beaumont has a 185-bed facility in Wayne, Michigan. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -6- As of 4:00 p.m., March 26, 2020, Beaumont Health hospitals was experiencing high volumes of COVID-19 patients. At that time, it was caring for 650 patients who have tested positive for COVID-19 and over 200 patients with tests pending. The health system had already been transferring some COVID-19 patients between sites as part of the system's overall ongoing disaster plan. Beaumont Health CEO John Fox announced that the hospital system was closing its Beaumont Wayne emergency room and its COVID-19 curbside screening at that location. Mr. Fox noted that, “The number of patients coming to our Emergency Rooms continues to grow rapidly. We have decided to create dedicated surge capacity to care for more COVID-19 patients at locations such as Beaumont Hospital, Wayne. Also, on a limited basis, we are partnering with other Michigan health systems with capacity for COVID-19 to move patients outside Beaumont for care.” Beaumont Health Chief Operating Officer Carolyn Wilson added, “The Beaumont, Wayne team has the expertise and ability to respond quickly to meet the needs of our COVID-19 patients. When patients come to a Beaumont hospital to seek care for COVID-19, our physicians will assess them. If the hospital does not have the capacity to care for the patient, we will transfer more COVID-19 patients to Beaumont Hospital, Wayne.” Ms. Wilson further commented that, “We continue to monitor the shifting volumes and needs of our patients and teams across Beaumont to make the best decisions. I am confident the team at our Wayne hospital is ready to serve the needs of COVID-19 patients. We are sending additional staff, supplies and equipment to help support our phenomenal team at Wayne.” A notice from the hospital stated, “To allow more COVID-19 patients to be cared for, the Emergency Center at Beaumont Wayne and obstetrical services will be temporarily closed as soon as possible. Patients who need emergency care, even for COVID-19, should seek medical attention at the nearby Beaumont Canton Emergency Center or another hospital. Curbside Screening for COVID-19 at Beaumont, Wayne will also close.” Obstetrical services at that location were also suspended, and those patients will receive care at Beaumont Hospital, Dearborn. CEO Fox further noted that, “This approach provides strong and focused care for our COVID-19 patients at Beaumont, Wayne, and [FN11] reduces the pressure on our other seven hospitals.” Emergency physician groups sends letter to HHS Secretary Azar about COVID-19 and CARES act On March 27, 2020, William P. Jaquis, MD, MSHQS, FACEP, President of the American College of Emergency Physicians (ACEP), submitted a letter to Alex Azar, Secretary of the U.S. Department of Health and Human Services (HHS), relating to the novel coronavirus (COVID-19). Dr. Jaquis noted that the “Coronavirus Aid, Relief, and Economic Security (CARES) Act” provides $100 billion to the Public Health and Social Services Emergency Fund to “prevent, prepare for, and respond to coronavirus, domestically or internationally, for necessary expenses to reimburse, through grants or other mechanisms, eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus.” HHS will be responsible for allocating the $100 billion appropriation to providers and suppliers that apply for funds. Jaquis commented that, “We strongly request that HHS prioritizes funding for frontline health care workers, especially emergency physicians, who are risking their lives combatting the virus and are at the highest risk of being exposed and missing work.” Dr. Jaquis further noted that, “On behalf of our 38,000 members, the American College of Emergency Physicians (ACEP) thanks you for your continued efforts to respond to the novel coronavirus (COVID-19). As you know, it is critical to ensure that our nation's emergency physicians and health care system have the resources they need to treat patients in response to this global pandemic.” The letter also addressed the fact that many emergency physicians are not directly employed by hospitals, but rather contract with hospitals to provide emergency department (ED) coverage. When one of these physicians is exposed to COVID-19, their group must both cover that physician's sick leave and maintain full coverage of the ED, often requiring hiring temporary help to fill that gap. As such, noted Jaquis, “We need specific financial support for emergency physicians who are either already treating COVID-19 patients or are in the process of preparing for a surge of those patients that we anticipate will need emergency services in the coming weeks.” The letter concluded by making the following recommendations to HHS: • Prioritizing applications for funding from emergency physician groups; • Reserving at least fifty percent of the funding for physician groups who are on the frontlines dealing with the crisis rather than other Medicare providers or suppliers who are not directly treating COVID-19 patients; • Streamlining the application process, ensuring that it is not burdensome for emergency physician groups to apply for the funding; and • Ensuring that applications are processed in a timely manner and that funds are rapidly distributed to those practices in critical need of [FN12] additional resources. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -7- Texas Emergency Care Center CEO asks governor to lobby Trump administration for CMS recognition of freestanding ERs during COVID-19 outbreak In late March, Texas Emergency Care Center CEO Rhonda Sandel requested via letter that Texas Governor Greg Abbott immediately communicate to President Donald Trump the need for freestanding emergency centers to be recognized by the Centers for Medicare & Medicaid (CMS) to better serve the community during the COVID-19 and coronavirus pandemic. Ms. Sandel is a founder and past president of the Texas Association of Freestanding Emergency Centers (TAFEC) and the National Association of Freestanding Emergency Centers (NAFEC). She has been working since 2006 to obtain this recognition for freestanding ER facilities. Because they are licensed emergency facilities, the State of Texas requires freestanding emergency centers to evaluate and treat all patients that seek care regardless of insurance status or the patient's ability to pay. However, because freestanding ERs are not recognized by CMS, they do not receive reimbursement for treating Medicare, Medicaid, and Tricare patients. According to Sandel, “We love caring for all of our patients and gladly serve the community but would like to be recognized by CMS like other licensed medical facilities so that all individuals have the ability to choose where they seek care. We are not asking for anything novel or unconventional. CMS has routinely recognized other innovative, licensed models such as ambulatory surgery centers. They have also recognized telemedicine and urgent cares, which are unlicensed models in Texas.” Ms. Sandel further noted that, “In a world where emergency rooms are overcrowded and have up to 10-hour wait times, freestanding emergency centers provide increased access to quality care by licensed, trained and experienced emergency medicine physicians. We have lobbied the federal government for this change since Texas began licensing freestanding emergency rooms in 2010 and with a looming disaster, now is the time for the federal government to act. Freestanding ERs across Texas work hand-in-hand with hospital ERs on a daily basis and in this situation these centers can provide much needed relief to our healthcare system.” There are over 200 Freestanding ER centers with 1,550 beds across Texas. The Texas Emergency Care Center contends that freestanding ERs can increase the capacity of the healthcare system to test for coronavirus and treat the outbreak. This added capacity includes beds, pharmacies, supplies, personal protective equipment (PPE), ventilators, and trained and experienced emergency medicine physicians and staff capable of treating all urgent and emergent medical conditions. Ms. Sandel added in her letter that, “Medicare patients are some of the most vulnerable in our community. We treat your mom and your dad, grandma and grandpa in facilities that generally have shorter wait times and are less crowded than other facilities. It's the right thing to do to ensure that these individuals are covered and that freestanding ERs across the country are recognized for the care, treatment, and services they provide. This change would also allow us to fully support hospital ERs and the local communities like we did during Hurricane Harvey.” Texas Emergency Care Centers opened in 2006 with the mission to “provide the highest level of emergency medical care to each patient we treat.” The physicians at Texas Emergency Care Center are residency-trained and board certified or board eligible in Emergency Medicine. The company's 24/7 emergency rooms are located in the Greater Houston areas and are Joint Commission [FN13] Accredited. Emergency physician group expresses concern over reduction of services at some ERs during COVID-19 pandemic The American College of Emergency Physicians (ACEP) issued a statement addressing emergency physicians and care teams who are experiencing a reduction in their incomes as a result of the COVID-19 pandemic. The statement specifically discusses the handling of personnel issues in rural and underserved emergency departments during this period. It notes that: While most people are doing their part by staying home, emergency physicians and care teams are risking their lives each day as they combat the greatest public health challenge of our lifetime. Our profession is not known for hyperbole, so believe us when we say the situation is dire. Our friends and colleagues are dying alongside the thousands of patients we have taken an oath to protect. *** Many emergency departments in rural or underserved communities are seeing a decline in patient volume--likely a positive outcome from official recommendations to stay home. But this is one of several economic realities that puts emergency departments that already operate on razor thin margins in a precarious position and forces difficult decisions to remain operational. Cutting benefits or reducing shifts in today's environment is akin to signing a ‘Do Not Resuscitate’ order for many emergency departments and the physicians that care for the patients, especially those in rural or underserved areas. Turning off the lights at these vital emergency departments eliminates the best, and sometimes the only, option for care for these communities. Emergency physicians are the sentinels of America's emergency care safety net. Now more than ever we need to rally behind our health care heroes, and that means ensuring they have the resources and support they need as they fight this protracted battle. This pandemic will end at some point and this country may look and feel very different when we emerge. It is often said that crisis reveals character. Those on the frontline are risking their lives to do their jobs. In these challenging times, we must not take emergency [FN14] physicians for granted.” © 2021 Thomson Reuters. No claim to original U.S. Government Works. -8- ER usage across country declines during COVID-19 outbreak; doctors urge people to seek treatment for medical emergencies Throughout the COVID-19 outbreak, emergency physicians continue to encourage Americans to seek non-COVID emergency care when necessary. According to William Jaquis, MD, FACEP, president of The American College of Emergency Physicians (ACEP), “Despite concerns about the coronavirus, there is no reason to delay or avoid treatment if you think you're having a medical emergency. Waiting too long to seek medical attention could make the difference between life and death.” Emergency departments across the country are reporting a reduction in patient volume of over 30 percent. In some rural or underserved communities, emergency physicians are seeing fewer patients and report that those who do seek treatment are more seriously ill or injured, which may be a sign that they are delaying necessary care. Dr. Jaquis further noted that, “People continue to have accidents, heart attacks, and strokes, and the emergency department remains the best--and often only--source of lifesaving care, even during a pandemic. Emergency physicians are expertly trained to protect our patients during a pandemic, and we have protocols in place to prevent the spread of the virus.” A press release from ACEP states that, “Emergency physicians and other frontline health care workers remain committed to providing care to those in their communities, 24 hours a day--regardless of the current public health crisis. Do not hesitate to contact your doctor [FN15] or call 911 if you need medical attention. It is also important to know when to go to the emergency department.” Cleveland based University Hospitals temporary closing several freestanding ERs due to decreased demand during COVID-19 pandemic; claims Ohio hospitals are losing $42 million per day Cleveland-based University Hospitals (UH) recently announced that it is temporarily suspending operations for freestanding emergency departments in several cities in the Cleveland metropolitan area. A press release from the hospital system stated that, “The COVID-19 pandemic is requiring University Hospitals to carefully evaluate and align system-wide programs and services to meet evolving patient care needs.” It further indicated that, “An unforeseen consequence of the pandemic has been a sharp decline in the number of patients visiting UH emergency departments system-wide. Current patient volumes are down 50 percent at UH hospital-based emergency departments and more than 70 percent at UH freestanding emergency departments. Patients are seeking care in different ways that include phone or online virtual care and urgent care.” Cities where freestanding emergency departments are being closed include Avon, Amherst, Broadview Hts., Kent, and Twinsburg, effective 7 a.m. Sunday, April 26. Other UH ambulatory services at these UH health center locations will continue to be open and available to patients. Emergency departments remain open at all UH hospitals. UH urgent care facilities in Broadview Heights, Kent, and Twinsburg will continue to operate. On Monday, April 27, UH will open urgent cares in Amherst and Avon. UH states that Urgent cares offer patients a “lower-cost access point for many services than emergency departments, and these facilities can transition patients to UH hospitals when more acute care is needed.” The hospital system has partnered with first responders from 182 medical commands across the region to assure that patients are transported to locations providing the appropriate level of care. UH is notifying and discussing the temporary suspension of services at these free-standing emergency departments with local, regional, state, and federal government officials and agencies. According to UH Chief Operating Officer Eric Beck, DO, MPH, “University Hospitals is committed to providing the safest, highest-quality care for our patients in these communities during the COVID-19 pandemic and for all of our patients' needs now and in the future.” Caregivers at these temporarily closed facilities will have options to move into positions at newly opened urgent cares and at other locations within the UH health system. Beck further noted that, “We appreciate the flexibility and dedication of our caregivers in response to the COVID-19 pandemic, which has created unique demands for our health care services.” UH had previously suspended operations at freestanding emergency departments in Andover and North Ridgeville. Health systems across the country have been impacted financially by the high costs associated with preparedness for a surge in COVID-19 patients and a reduction in revenues from the suspension of non-essential surgeries and procedures. Additionally, some patients have been reluctant during the pandemic to access medical care in traditional ways In Ohio, it is estimated that hospitals are experiencing financial losses of $42 million per day, while. at the same time, spending an additional $5 million per day on increased costs of supplies. UH states that it will continually evaluate patient volumes and preferences as a guide for the return of these emergency department [FN16] services. Poll finds over one-fourth of respondents have delayed or avoided seeking medical care due to COVID-19 concerns © 2021 Thomson Reuters. No claim to original U.S. Government Works. -9- A recently released poll from Morning Consult and the American College of Emergency Physicians (ACEP) found that approximately 29 percent of respondents said that they have delayed or avoided seeking medical care because they are concerned about contracting COVID-19. ACEP is a national medical society representing emergency medicine. William Jaquis, MD, FACEP, president of ACEP, noted that, “Waiting to see a doctor if you think you're having a medical emergency could be life threatening. While it's important to stay home and follow social distancing guidelines, it's critical to always know when to go to the emergency department.” Nearly three-quarters of respondents (73 percent) stated that they are concerned about overstressing the health care system, and over half (59 percent) stated that they are worried they will not be able to receive treatment by a physician if they need care. Lower-income adults were among the groups who expressed the most concern about access to medical care. The poll was conducted during the period of April 18 to April 20, 2020 among a national sample of 2201 adults. Results from the full survey have a margin of error of plus or minus two percent. Dr. Jaquis further noted that, “Despite all the uncertainty around us, the emergency department remains the best place for you to get medical care any time you need it. Emergency physicians are expertly trained for these situations and have protocols in place to keep their patients protected even in the midst of a pandemic.” The poll results also showed a desire for more federal intervention to protect and support emergency departments, as well as to protect frontline health workers. Nearly all respondents (97 percent) said that the federal government needs to support efforts to increase access to protective equipment for emergency physicians. Furthermore, 90 percent of respondents stated that they believe emergency physicians should receive hazard pay as they risk their lives to protect patients. According to ACEP's Dr. Jaquis, “Emergency physicians are risking their lives on the frontlines to protect our communities. We must do more to make sure that these brave heroes are supported and have the protective equipment that they need today and, in the weeks and months ahead. This pandemic gives our leaders and legislators an opportunity to address immediate needs and strengthen our health care safety net. We have to make sure that patients remain confident in our health system at a time when everyone needs us [FN17] most.” Philadelphia area urgent care chain offering both COVID-19 diagnostic and serological tests Philadelphia-based vybe urgent care has announced that it is offering COVID-19 serological antibody testing to help patients determine if they have already been exposed to the coronavirus. The COVID-19 serum antibody test is used to detect the presence of antibodies, not to diagnose an active infection. A positive result indicates that the individual has had exposure to COVID-19. Some people infected with COVID-19 will never exhibit symptoms but will have detectable antibodies. Vybe now offers patients two options for coronavirus testing: • PCR diagnostic test (nasal swab): A viral diagnostic test that tells sick or exposed patients they have an active COVID-19 infection. Since those currently infected can spread the virus, knowing their status helps patients to take proper health precautions for themselves and the community. • Coronavirus antibody test (blood test): An antibody test tells patients who have no current symptoms whether they've been previously infected with the coronavirus. Although vybe can perform this test at any time, it can take 1-3 weeks for antibodies to be fully detectable after an infection. According to the company, the serology antibody testing it offers differs from “finger prick” blood tests because a laboratory analyzes the blood sample for different types of antibodies that result after exposure to COVID-19. This test has been authorized by the FDA under an Emergency Use Authorization (EUA). Peter Hotz, vybe urgent care's president and CEO, stated that, “We've completed thousands of PCR tests for suspected COVID-19 patients. Knowing the high rate of asymptomatic individuals, we're pleased to now offer this highly accurate antibody test to patients who believe they may have been infected.” Mr. Hotz further noted that, “We recognize how important these results are for patient's peace of mind and for understanding community health as we gradually return to work and other activities in the greater Philadelphia region. We've been actively talking with employers about safe return-to-work and business continuity programs and the proper role of testing in these initiatives.” All COVID-19 testing at vybe testing begins with a telemedicine visit, where a clinician recommends the test that best meets a patient's needs based on the patients current or former symptoms (or lack thereof). Dr. Geoff Winkley, vybe's medical director, also commented on the serological tests, stating that, “With most viruses, the presence of antibodies would suggest some degree of immunity. We do not yet know if having antibodies to the coronavirus can protect someone from reinfection or how long that protection might last. Still, knowing their status may help patients make better-informed decisions as [FN18] we learn more about COVID-19.” Vermont National Guard assists ER at University of Vermont Medical Center in response to COVID-19 pandemic © 2021 Thomson Reuters. No claim to original U.S. Government Works. -10- Twenty-nine members of the Vermont National Guard served on a task force with the Emergency Department (ED) at the University of Vermont Medical Center. Members of the Vermont National Guard spent several weeks in late March working in a modified ED layout as the State of Vermont activated the National Guard as part of its response to the COVID-19 pandemic. The task force, composed of C Company (Medical), 186th Brigade Support Battalion, and support personnel from across the 86th Infantry Brigade Combat Team, Vermont National Guard, set up a treatment area to help the ED in anticipation of a surge of COVID-19 patients. It took them less than 72 hours to set up the treatment area. According to U.S. Army Major Joseph Phelan, Charlie Company commander. “It was really amazing to see it all come together, especially considering that we had half the task force not C-MED organic, so it's folks we've never seen before and never worked with before. They're from the CAV (Cavalry), from the BEB (Brigade Engineer Battalion), for them to jump right in, they did a phenomenal job.” The University of Vermont Medical Center's emergency entrance was transformed with temporary traffic cone patterns and three large Army tents. All staff wore face masks, suits, and gloves. Patients would drive up and speak with a triage nurse and provider to determine the proper course of treatment. Some patients were treated within their vehicles. For example, staff applied bandages for smaller cuts or scrapes, while other patients moved into the ED or to the treatment tent for care. C Med Soldiers helped treat over 140 patients. Treatment teams included three medics and a provider, with an equivalent team on standby. Other personnel assisted with drive- through triage services and checking in patients and transporting them in the hospital. One to three medics eventually rotated through the emergency department providing patient care and shadowing nurses and providers. U.S. Army Staff Sergeant Andralee Strassner, a combat medic with Charlie Med, commented on the project, stating that: “It was a great opportunity to grow in their skills as a medic, to be able to do rotations in the ER, and learn from providers and nurses there and give care to patients and just be able to use their skills in a setting other than training.” Many National Guard members traveled from out of state to support the mission, including from New Hampshire, New Jersey, and New York. Several of these traveling members were out of work in their civilian positions. Staff Sergeant Andralee Strassner further noted that, “I work in health care myself, but not in a hospital setting considered essential. Being able to come somewhere where I am considered essential and being able to make a difference in a community that I know they really appreciated the help that we were able to provide for them and take a little stress off of their ER staff, it just means a lot to be able to do that.” Major Phelan called the mission an “amazing opportunity to work side-by-side with our civilian partners' to help them fill gaps or needs ... We were treating and serving our neighbors ... Vermonters - they did it, they lowered the curve and should be proud of that.” Twenty four of the 29 participating soldiers volunteered to remain on after the ED surge operations, expecting new missions to support [FN19] the state. North Carolina hospital system issues press release urging patients to use the ER when necessary during COVID-19 pandemic Mooresville, North Carolina's Lake Norman Regional Medical Center recently urged its local community to seek emergency care when needed, without delay. In a recent press release, the hospital system stated that, “If you experience a medical emergency such as stroke symptoms or chest pain that may be a heart attack, a timely response will support the best possible outcome.” According to the press release, the hospital has implemented precautions to protect patients and staff, despite “limited” cases of COVID-19 in the community. These precautions include screening all patients for symptoms and risk factors, and placing any individuals with suspected or confirmed COVID-19 in a separate area. The hospital also emphasizes cleaning and disinfection in caregiving areas and throughout the facility. Dr. Adam Crilly, Emergency Medical Director and hospital Chief of Staff, noted that, “Easy access to emergency medical care is one of the things that separates healthcare delivery in America compared to many other places in the world. During these trying times, it can be confusing or even scary to decide on your own what is an emergency medical condition. Our emergency department at Lake Norman regional Medical Center is open and able to care for any and all types of acute medical conditions. We don't want people to deny or ignore symptoms that If left untreated can worsen or do them real harm. People need to know that our department is a safe place. We have enacted guidelines and protocols which keep both our staff AND patients safe during this pandemic.” Dr. Crilly further stated that, “In fact, we have not had one staff member test positive for COVID-19. What I like to tell patients is: If it seems like an emergency to you, come let us help you check it out. We don't expect patients to be experts in deciding what is an emergency, if they have concern over their health or well-being, that's enough sometimes to seek attention or medical care. I've been helping take care of our community in Mooresville for almost 10 years, and I know my Department is ready, willing and able to take care of all your emergencies, no matter how big or small.” © 2021 Thomson Reuters. No claim to original U.S. Government Works. -11- Lake Norman Regional Medical Center is also supporting the latest campaign by the American Heart Association (AHA): BE CERTAIN IN UNCERTAIN TIMES. The AHA is working to remind all Americans that heart attacks, strokes, and cardiac arrests do not stop for [FN20] COVID-19. Study finds significantly fewer 911 calls in U.S. from March through May, likely due to COVID-19 concerns; calls that did occur were for more serious emergencies A recently released study led by a University at Buffalo researcher found that, since early March (and the start of the COVID-19 pandemic), 911 calls for emergency medical services (EMS) have fallen by 26.1% in the U.S. compared to the same period in the prior two years. The researchers also found that EMS-attended deaths doubled during this period, likely indicating that EMS calls that were made during this period in 2020 were, on average, for more serious emergencies than usual. According to E. Brooke Lerner, PhD, first author on the paper and professor and vice chair for research in the Department of Emergency Medicine in the Jacobs School of Medicine and Biomedical Sciences at UB, “The public health implications of these findings are alarming.” Dr. Lerner further noted that, “When people are making fewer 911 calls but those calls are about far more severe emergencies, it means that people with urgent conditions are likely not getting the emergency care they need in a timely way. The result is increased morbidity and mortality resulting from conditions not directly related to exposure to SARS-CoV2.” The time period covered by the study was the six weeks that began on March 2, 2020 and lasted until the end of May. Dr. Lerner suggested two possible reasons for the decrease in 911 calls: fear of contracting COVID-19 at health care facilities and the desire to not burden health care facilities with issues unrelated to COVID-19. Dr. Lerner further stated that, “The doubling of deaths and cardiac arrests during this relatively short period of time, from March through May, demonstrates that people who need emergency health care may be delaying care such that their lives are actually in jeopardy.” She also observed that, “This may mean that future consideration needs to be given to how we message the risks associated with seeking medical care during a pandemic. At the same time that we are stressing how to stay safe from COVID-19, it may also be necessary to stress how important it is to continue to seek care for serious conditions unrelated to the novel coronavirus.” The study involved a comparative, retrospective analysis of standardized patient care records that are submitted by more than 10,000 EMS agencies across 47 states and territories nearly in real-time. Those data are submitted to the National Emergency Medical Services Information System (NEMSIS) database, which stores EMS data nationwide. The study was published online June 17 in Academic Emergency Medicine. Co-authors are Craig D. Newgard, MD, of Oregon Health and Science University, and N. Clay Mann, MD, of the University of Utah School of Medicine. The work was supported by the National Highway Traffic Safety Administration, Office of Emergency Medical Services, and the Health Resources and Services Administration of the U.S. Department of Health and Human Services. Dr. Lerner also added that the findings are consistent with those in other countries, such as Italy, where there was an increase in heart attack fatalities during the height of the pandemic there. Another finding of the study was that the number of 911 calls related to injuries decreased during times when regions were shutdown, likely because there were fewer opportunities for driving and recreation-related injuries. Dr. Lerner also commented on the lasting effects of this trend, noting that, “The fact that this trend persists even as the pandemic in some areas has started to lessen in severity shows that the fear of accessing health care has continued.” The study also revealed issues relating to the financial viability of EMS in crisis situations. Dr. Lerner stated that, “The financial strain on EMS agencies will have long-term ramifications for maintaining this important safety net for our communities, especially those agencies [FN21] whose revenue is based solely on patient transports.” CDC report suggests sharp decrease in ER visits during COVID-19 pandemic, especially in Northeast The CDC recently released a report showing that, during the period of late March through late April 2020, emergency department (ED) visits decreased by 42% from the same period in 2019, from a mean of 2.1 million per week (March 31-April 27, 2019) to 1.2 million (March 29-April 25, 2020). The most significant decreases in emergency department usage was among those 14 years old and younger, females, and those living in the Northeast. During this same period, the proportion of infectious disease-related visits was four times higher nationwide. The CDC then suggested that, “Health care systems should continue to address public concern about exposure to SARS-CoV-2 in the ED through adherence to CDC infection control recommendations, such as immediately screening every person for fever and symptoms of COVID-19, and maintaining separate, well-ventilated triage areas for patients with and without signs and symptoms of COVID-19.” The report also stated, “Wider access is needed to health messages that reinforce the importance of immediately seeking care for serious conditions for which ED visits cannot be avoided, such as symptoms of myocardial infarction. Expanded access to triage © 2021 Thomson Reuters. No claim to original U.S. Government Works. -12- telephone lines that help persons rapidly decide whether they need to go to an ED for symptoms of possible COVID-19 infection and other urgent conditions is also needed. For conditions that do not require immediate care or in-person treatment, health care systems [FN22] should continue to expand the use of virtual visits during the pandemic.” Study finds growth in total number of ER doctors but potential shortages in rural areas A recently released workforce analysis published in Annals of Emergency Medicine found that large areas of rural America are experiencing shortages of emergency physicians. This trend is occurring at the same time that the country's usage of emergency rooms has been increasing. According to the authors of the “National Study of the Emergency Physician Workforce, 2020,” the nation's rural emergency physician shortage is expected to worsen in the future. For example, of the 48,835 clinically active emergency physicians in the United States, 92 percent (44,908) practice in urban areas and eight percent (3,927) practice in rural communities. In 2008, the percentage of emergency doctors practicing in rural communities was ten percent. Christopher Bennett, MD, MA, assistant professor of emergency medicine at Stanford University School of Medicine and lead study author, commented on the findings. Dr. Bennett noted that, “The number of emergency physicians is increasing but there is a clear unmet need for emergency physicians in rural areas. Policymakers and health leaders should prioritize opportunities to make sure that emergency departments across the country are led by appropriately trained and certified emergency physicians.” The analysis also found that the rural emergency physician workforce is aging. Nearly all (96 percent) of the emergency medicine residency or fellowship graduates within the last four years practice in more urban areas. At the same time, emergency physicians in rural communities were often closer to retirement age, with over 70 percent having completed their medical training more than 20 years ago. Moreover, the median age for an urban emergency physician is 50 years old, while the median age in large rural communities is 58 years old and 62 years old in smaller rural communities. The emergency care specialty, however, is growing, and the nation's residency programs continue to expand. There were 4,565 residents in 145 programs in 2008. Today there are 7,940 residents in 247 programs. Almost one-third (28 percent) of practicing emergency physicians today are women, which represents an increase from 22 percent in 2008. One in five Americans lives in a rural area, and the American College of Emergency Physicians (ACEP) notes that it “recognizes that action is needed to address emergency physician shortages and other challenges facing rural emergency care.” According to ACEP, “This research underscores ACEP's concerns and complements a developing analysis from its Emergency Medicine Workforce Task Force that will help identify best practices, site supervision requirements, and funding mechanisms to support research, cost savings, and promotion of residency training programs with more focus on rural emergency care.” Dr. Bennett further noted that, “Demand for emergency care in rural areas will remain high while emergency physician shortages in these communities continues to pose significant challenges for health systems and patients. There are reasons to be optimistic about the pipeline of residents and trainees, however; we need to encourage a larger percentage of these individuals to work in rural [FN23] America.” Study finds steady increase in mental health ER visits from 2007 to 2016 despite ACA implementation during this period A recent study found that mental health emergency room visits in the United States increased every year from the years 2007 to 2016, despite the expansion of health insurance coverage over that same period. Researchers involved in the study, including T. Greg Rhee of the UConn School of Medicine, suggested that communities and states need to do more to make mental health resources available to those who need them. The paper was published in the Journal of Clinical Psychiatry. Emergency departments in the United States reported that 7 of every 100 people who visited emergency rooms in 2007 were there for mental health and substance abuse-related needs. By 2016, that number had risen to 11 of every 100, according to data from the Centers for Disease Control and Prevention (CDC). The Affordable Care Act (ACA), which expanded access to health insurance, was implemented in 2014. The existence of the ACA and insurance expansion would suggest fewer emergency room visits for mental health issues. However, the opioid epidemic could also account for the steady rise in such numbers over the relevant period. Rhee, assistant professor of medicine and public health at UConn Health, noted that, “The health care delivery system needs to be better aligned for people with mental health needs,” and that “Health insurance is not the only factor” in obtaining the care they need. For example, patients also need to be able to make appointments with a mental healthcare provider, and these specialists are in high demand in many areas of the country. Furthermore, some of these providers (especially psychiatrists) may not accept health insurance at all. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -13- During the nine years covered by the study, emergency room visits for substance abuse-related issues doubled from 2% to 4%, while visits for psychiatric disturbances increased from less than one percent to approximately 2%. The number of visits of people with both substance and psychiatric diagnoses in the emergency room also increased over that same time period. Rhee further noted that, “The problem isn't gone, just because we are focusing on COVID-19. Anxiety, depressive disorders, alcohol and substance use will all increase” due to the psycho-social stresses caused by the pandemic. These stresses include unemployment [FN24] and social isolation. Emergency care group joins other medical specialties in denouncing Trump administration rule addressing foreign students; also denounces rollback of discrimination protections of patients based on gender identity Several of the country's medical associations, including the American College of Emergency Physicians (ACEP) and the American Medical Association, recently cautioned the Trump Administration that its decision to restrict visas for qualified foreign workers could have a dangerous impact on access to care for our nation's patients. A July 6, 2020 announcement from the Trump administration noted that it will require international students taking online courses to transfer to in-person instruction. This decision will force some foreign students to leave the country or face removal. According to a press release from ACEP, “these restrictions will hit the medical and research sectors particularly hard and could cause longer-term damage to our health care workforce.” The organizations sent a letter to this effect to the departments of State and Homeland Security. They emphasized the fact that the entry of H-1B physicians and their dependent family members is in the national interest of the country. The letter also noted how America relies on international medical graduates (IMGs) to maintain a “robust” health care workforce that is capable of addressing the health needs of everyone in the U.S. According to ACEP, “This principle is especially important to emergency physicians who by law and by oath must treat anyone who seeks care at the emergency department.” Prior to the COVID-19 pandemic, the United States was already facing a shortage of physicians due to the growth and aging of the nation's population and the impending retirement of many physicians. IMGs represent more than 25 percent of the physician workforce in our country, and nearly 21 million people live in areas of the U.S. where foreign-trained physicians account for at least half of all physicians. The ACEP press release also stated that, “The world's brightest minds have long sought opportunities at leading institutions throughout the United States. Policies of this nature ignore the collaborative global nature of today's workforce and will drive talented individuals away from the United States while limiting opportunities for our country's leadership and innovation. The entry of every qualified medical student is in America's best interest especially during the pandemic, when physicians are needed in every specialty now.” The letter to the agencies stated that, “we urge you to clarify that all health care professionals, such as medical residents and fellows, biomedical researchers, and those working in non-clinical settings--not only those who are involved in COVID-19 research and practice--are critical to our national interest, and therefore exempt from the proclamation.” Signatories to the letter to the United States government included the following professional groups: American Medical Association American Academy of Allergy, Asthma & Immunology, American Academy of Hospice and Palliative Medicine, American Academy of Neurology, American Academy of Ophthalmology, American Academy of Pediatrics, American Academy of Physical Medicine and Rehabilitation, American College of Allergy, Asthma and Immunology, American College of Emergency Physicians, American College of Gastroenterology, American College of Obstetricians and Gynecologists, American College of Physicians, American College of Radiology, American College of Rheumatology, American Gastroenterological Association, American Psychiatric Association, American Society for Clinical Pathology, American Society for Dermatologic Surgery Association, American Society for Gastrointestinal Endoscopy, American Society for Radiation Oncology, American Society of Anesthesiologists, American Society of Hematology, American Society of Nuclear Cardiology, American Society of Retina Specialists, Association for Clinical Oncology, Association of American Medical Colleges, College of American Pathologists, Endocrine Society, Heart Rhythm Society Medical Group Management Association, Renal Physicians Association, Society for Cardiovascular Angiography and Interventions, Society of Hospital Medicine [FN25] Society of Interventional Radiology, and The Society of Thoracic Surgeons. In response to the Trump administration's announcement that it would rescind regulations that prohibit health care discrimination against patients based on gender identity, William Jaquis, MD, FACEP, president of ACEP released the following statement: Any form of discrimination in health care should be prohibited. Emergency physicians object to this final rule and believe it violates the Emergency Medical Treatment and Labor Act (EMTALA), which requires clinicians treat every patient who comes to the emergency department. Every patient--regardless of race, religion, sexual orientation, gender identity, ethnic background, social status, type of illness, or ability to pay--has the right to expect the best possible care and to receive the most appropriate treatment and information about their condition. By not addressing the rights and needs of all patients undergoing an emergency and the legal obligations of emergency physicians, this rule will undermine the critical role that emergency departments play in our communities. In 2019, ACEP's past president Vidor E. Friedman, MD, FACEP wrote a letter to the Secretary of the Department of Health and Human Services, in which he opposed allowing such discrimination. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -14- The letter, dated August 13, 2019, stated in part: Patients with life-threatening injuries or illnesses may not have time to wait to be referred to another physician or other healthcare professional to treat them if the present provider has a moral or religious objection. Likewise, EDs operate on tight budgets and do not have the staffing capacity to be able to have additional personnel on hand 24 hours a day, seven days a week to respond to different types of emergencies that might arise involving patients with different backgrounds including sexual orientations and gender identities. The proposed rule seems to demand that, to meet EMTALA requirements, an ED must anticipate treating transgender patients, survey its employees to ascertain who might object treating such a patient, and staff accordingly. This is an impossible task that jeopardizes the ability to provide care, both for standard emergency department readiness and for emergency preparedness. EDs serve as the safety net in many communities, providing a place where those who are most vulnerable and those in need of the most immediate attention can receive care. By not addressing the rights and needs of all patients undergoing an emergency, the legal obligations of emergency physicians, and the budget and staffing constraints that EDs face, this rule will undermine the critical role that EDs play [FN26] across the country. Survey finds high rates of hesitancy to use ER for Black and Hispanic heart attack and stroke victims because of COVID-19 Recently released data from a survey conducted online by The Harris Poll on behalf of the American Heart Association found that Hispanics and Black Americans are most likely to stay home if experiencing medical emergencies such as a heart attack or a stroke to avoid the risk of contracting COVID-19 at the hospital. Data from the survey found that more than half of Hispanics (55%) would be scared to go to the hospital if they thought they were having a heart attack or stroke because they might get infected with COVID-19, and 41% of respondents would actually stay home if they thought they were experiencing a heart attack or stroke rather than risk becoming infected at the hospital. The survey also found that nearly half of Black Americans who responded (45%) said they would be scared to go to the hospital if they thought they were having a heart attack or stroke because they might become infected with COVID-19. A third (33%) stated that they would stay home if they thought they were experiencing a heart attack or stroke rather than risk infection at the hospital. Fewer than half of the white respondents (40%) stated that they would be scared to go to the hospital if they thought they were having a heart attack or stroke because they might become infected with COVID-19, and less than a quarter (24%) of white respondents would rather stay home than risk infection at the hospital. To address the fears of potential heart attack and stroke victims, the American Heart Association has created a public education and awareness campaign in English and in Spanish called “Don't Die of Doubt.” This campaign tells Americans, especially in Hispanic and Black communities, that the hospital is the safest place to be if you are experiencing symptoms of a heart attack or a stroke. Rafael Ortiz, MD, American Heart Association volunteer medical expert and Chief of Neuro-Endovascular Surgery at Lenox Hill Hospital, Northwell Health, commented on the findings, noting that, “This finding is yet another challenge for Black and Hispanic communities, who are more likely to have underlying health conditions such as cardiovascular disease and diabetes and dying of COVID-19 at disproportionately high rates.” According to Dr. Ortiz, “I am proud of the work the American Heart Association is doing to address this critical issue with the Don't Die of Doubt campaign. Health care professionals know what to do even when things seem chaotic, and emergency departments have made plans behind the scenes to keep patients and healthcare workers safe even during a pandemic.” These traditionally excluded communities are dying of COVID-19 at disproportionately high rates, and they are more likely to have underlying health conditions such as cardiovascular disease and diabetes. [FN27] Cardiovascular disease remains the leading cause of death in the United States. Emergency physicians group urges nation's patients to not delay care based on COVID-19 fears Although patient volumes in many of America's emergency departments have begun to return to traditional levels as communities continue to reopen, capacity in emergency rooms has not returned to full visit levels. Health care professionals remain concerned that people who need treatment are still afraid to go to the emergency room. According to a poll from the American College of Emergency Physicians (ACEP) and Morning Consult, 80 percent of Americans say they are concerned about contracting the virus from visiting a medical facility, and nearly one-third reported delaying seeking medical care as a result. Furthermore, recent data from the Centers for Disease Control and Prevention (CDC) shows that, in the 10 weeks following the onset of the pandemic, the number of emergency visits for heart attack patients was down 23 percent. These numbers were also down 20 percent for those suffering from a stroke. According to William Jaquis, MD, FACEP, president of ACEP, “Emergency physicians are highly trained to handle pandemics and prevent the spread of infectious diseases. Don't hesitate to call 911 if you're experiencing symptoms of a medical emergency. The emergency department is the safest place to be.” Mike Hastings, MSN, RN, CEN, president of the Emergency Nurses Association (ENA), stated that, “Emergency nurses are among the first to meet and triage patients in the ED, and we understand the importance of safely and accurately assessing those seeking COVID © 2021 Thomson Reuters. No claim to original U.S. Government Works. -15- and non-COVID treatment. Our commitment to care drives us to provide you with the best environment possible treat your emergency needs.” Emergency departments across the country are now screening all patients upon arrival for COVID-19 symptoms. Some hospitals have created external waiting rooms for patients with known symptoms, and others have separate wings for those who are presumed to have the disease. Emergency care teams are also using telehealth technology to conduct remote consultations with patients and to connect them with friends or family members while they are admitted. Emergency departments have also greatly intensified their cleaning and disinfecting efforts, and some are using enhanced treatments (such as negative pressure rooms and UV-filtration) to decontaminate the air and prevent the spread of the virus. American Nurses Association President Ernest J. Grant, PhD, RN, FAAN noted that, “Even in the midst of a global pandemic, the tireless work of nurses, physicians, and health care teams is what makes emergency departments safe places to receive care. However, it is critical that patients visiting emergency departments wear cloth masks and maintain physical distancing, to protect themselves and those providing treatment. I encourage patients and families to contact their local emergency department before visiting [FN28] to understand updated instructions in order to ensure a positive and safe experience.” Several medical societies send Congress letter about surprise billing in proposed COVID-19 relief bills In late July, several state and national medical societies, including the American Medical Association, co-signed a letter to leaders in the U.S. House and Senate relating to the issue of surprise medical billing in any new COVID-19 relief package. The letter noted in part that, “Unfortunately, despite the fragility of physician practices, some see an opportunity to include surprise medical billing provisions in the next COVID-19 relief package. America's physicians strongly agree that it is critical to protect patients from surprise medical bills, and we firmly believe that a thoughtful, measured federal solution is possible to achieve. However, now is not the time to adopt divisive surprise billing legislation.” It also stated that, “It is important to note that physicians who have received emergency funding cannot balance-bill coronavirus patients, thus helping ensure that patients do not receive a surprise medical bill during the pandemic. Furthermore, the medical community remains committed to working with Congress to seek a broader solution that protects patients from unanticipated medical bills when their insurer fails to provide them with an adequate network of physicians. At the same time, it is imperative that any solution should facilitate a process to quickly, efficiently, and fairly resolve physician and health plan billing disputes.” The letter included a list of essential provisions relating to surprise medical billing, such as: • Patients must be protected and should only be responsible for their in-network cost-sharing amounts, including deductibles, when receiving unanticipated medical care. • To keep patients out-of-the-middle of any payment disputes between health plans and providers, provide physicians with direct payment/assignment of benefits from the insurer. • Following the delivery of out-of-network medical care, a reasonable payment should be paid to providers. A benchmark payment rate set at median or mean in-network contract rates or some percentage of Medicare is insufficient because it fails to recognize nuances in individual patient care, will increase health care costs by accelerating consolidation in the health care market, jeopardizes the emergency care safety net and restricts patient access to in-network physicians. • To prevent surprise medical bills from occurring in the first place, health plans should be held accountable for provider networks that are appropriate to meet patients' medical needs - including ensuring access to specialists and subspecialists on a timely basis, including in a facility. Health plans must also ensure that that provider directories are up-to-date and accurate. However, patients must be allowed to access elective out-of-network care when they so choose. • If the provider determines that the insurer's payment is not reasonable, there must be a fair, accessible and equitable independent dispute resolution (IDR) process to resolve payment disputes. An accessible IDR process must not be restricted to claims above a specific dollar amount/threshold. Providers should also not be limited to accessing the IDR process only after a “cooling off” period. To maximize administrative efficiency, providers should be allowed to “batch” claims for the same or similar service under the same insurance provider. The letter also addressed the proposed “baseball-style” dispute resolution process, and included a set of necessary dispute resolution guidelines that would lead to fair decisions: • Rates for comparable services in the same geographic region considered reasonable based on commercial insurance rates from an independent and transparent database of all commercial payer claims data; • Any previous contracting history; • Demonstration of good-faith efforts (or lack thereof) made by either party (i.e. the out-of-network provider or the health plan) to enter into network contracts; • Market share held by the out-of-network health care provider or the health plan; © 2021 Thomson Reuters. No claim to original U.S. Government Works. -16- • Level of training, education, experience, outcomes, and quality metrics of the physician providing the service; • Complexity of the services rendered; • Individual patient characteristics; and • Any additional relevant factors contributed by either party. The letter ended by urging Congress to address the complicated issue of surprise billing in legislation separate from a COVID-19 relief bill. It stated, “Like you, we strongly agree that patients must be protected from surprise medical bills, and we reaffirm our commitment to devise a balanced approach. However, the complexity and multifaceted nature of the issues pertaining to surprise medical bills warrants due consideration from Congress. Any final proposal to address unanticipated medical bills should be addressed separately [FN29] from any forthcoming COVID-19 relief legislation.” Wake Forest Baptist Health receives $1.2 Million from HHS to improve rural health care in Wilkes County Wake Forest Baptist Health, based out of Winston-Salem, NC, recently announced that it has received a $1.2 million grant from the U.S. Health Resources and Services Administration (HRSA) to help improve rural cardiovascular care in Wilkes County. The HRSA is part of the U.S. Department of Health and Human Services and is the primary federal agency for improving health care to people who are geographically isolated or economically or medically vulnerable. The funding will be used to expand the hospital system's telehealth services by connecting its emergency care and cardiovascular experts virtually and in real-time with staff at Wilkes EMS, Wilkes County Health Department's Public Health Community Clinic (PHCC), and Wake Forest Baptist Health - Wilkes Medical Center's emergency department. By using telehealth capabilities, Wake Forest Baptist's expert clinicians will help Wilkes EMS paramedics quickly classify patients based on EKG readings, vital signs, and risk scores. They will also assist with treatment and transportation decisions. Wake Forest Baptist will also provide guidance to Wilkes Medical Center's emergency department providers in evaluating, managing, and transferring patients. Wake Forest Baptist will also provide PHCC staff with consultative advice for patients who are seen in their clinic after they are treated by EMS or in the emergency department for cardiovascular symptoms. According to Simon Mahler, M.D., M.S., professor of emergency medicine at Wake Forest Baptist, “The goal of this project is to improve rural health equity and outcomes for patients by using telehealth to bring new, leading-edge cardiovascular care to communities throughout Wilkes County.” Dr. Mahler also noted that, “Our health system already operates a wide-reaching tele-stroke network for emergency departments across rural North Carolina - including Wilkes Medical Center - so expanding our telehealth program to improve rural cardiovascular care is a natural extension of that work.” As part of the project, Mahler and his team will measure whether the implementation of cardiovascular telehealth helps reduce unnecessary emergency department visits, transfers, and re-admissions. They will also attempt to determine if the program contributes to a decrease in heart attacks, invasive coronary procedures, and cardiovascular mortality in Wilkes County. This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human [FN30] Services (HHS) as part of a financial assistance award totaling $1,198,513 with 100 percentage funded by HRSA/HHS. Research paper shows increase in opioid overdose ER cases during pandemic at Virginia hospital A recently published study using data from emergency department visits found that the psychosocial consequences related to coronavirus disease 2019 (COVID-19) may place individuals at a heightened likelihood of opioid overdose or relapse. Researchers analyzed data from an emergency department in Virginia, and found a greater number of visits for opioid overdoses in the first four months of the COVID-19 pandemic. They also found that Black patients made up a relatively larger proportion of opioid overdose visits compared with the previous year. These findings may also demonstrate additional evidence of racial and ethnic disparities in health that have worsened during the COVID-19 pandemic and during the recent protests in May and June 2020. The researchers concluded that the reasons for the increase in nonfatal opioid overdoses presenting to the emergency department warrant further investigation. In one previous study, emergency medical services responses to opioid overdoses in Kentucky increased in the early weeks following the COVID-19 state emergency declaration compared with the 52 previous days. This newer study compared numbers of nonfatal and unintentional opioid-related overdoses presenting to an urban emergency department during the early months of the pandemic relative to the prior year. In conducting this study, patients with opioid overdoses from March 1 to June 30, 2019, and from March 1 to June 30, 2020, were identified from electronic medical records from the Virginia Commonwealth University based on the following chief concern terms: overdose, opioid, heroin, fentanyl, and altered mental status. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -17- Data on opioid overdose fatalities during the second quarter of 2020 were not yet available for analyses at the time the study was conducted. Intentional opioid overdoses (suicide attempts) and nonopioid-related opioid overdoses (patients who did not receive naloxone or were not reported as suspected opioid overdoses) were also excluded. The number of acute myocardial infarction diagnoses, and the number of total emergency department visits were examined as comparisons during the same time periods. Two research teams reviewed records to obtain demographic and visit characteristics of each patient. Demographic characteristics included age, sex, race/ethnicity, and insurance status. Visit characteristics included the percentage of patients who received a naloxone prescription to fill at their community pharmacy, received a list of contact information for local treatment resources and/or a referral at discharge, received an addiction medicine consult if admitted, and accessed opioid agonist or antagonist treatment at the institution's outpatient clinic. The researchers found that the total number of non-fatal opioid overdose visits increased from 102 between March and June 2019 to 227 between March and June 2020. Also, compared with 2019, the total number of acute myocardial infarction diagnoses decreased from 41 to 31 and the number of all emergency department visits decreased from 36,565 to 26,061 in March through June 2020. Among patients who presented with a nonfatal opioid overdose in March through June 2019 and March through June 2020, the mean ages were 42.2 years and 44.0 years, 71 (70%) and 165 (73%) were male, 64 (63%) and 181 (80%) were Black, and 45 (44%) and 91 (40%) were uninsured, respectively (Table). Addressing visit characteristics, in March through June 2019 and March through June 2020, 55 (54%) and 127 (56%) patients received a naloxone prescription and 45 (44%) and 154 (68%) received treatment resources and/or a referral at discharge, respectively. Four (4%) and 14 (6%) of the 17 (17%) and 46 (20%) admitted patients received an addiction medicine consult, and 3 (3%) and 23 (10%) accessed treatment at the outpatient clinic after overdosing, respectively. The study has several potential limitations. First, these findings were from one city's emergency department in a small sample of patients and may not be generalizable to other locations. The number of opioid overdoses was also underestimated because official reporting of fatal opioid overdoses is delayed and because patients who did not present to the emergency department were not included. According to the study's authors, “This increased risk of opioid overdose may be particularly concerning among Black patients, who have been overrepresented in COVID-19-related infections, hospitalizations, and deaths, as well as associated socioeconomic [FN31] consequences.” Wisconsin hospital system to partner with urgent care company to open three new urgent care centers Health care system Ascension Wisconsin has announced that it is opening three new urgent care centers in southeast Wisconsin in partnership with Physicians Immediate Care. Physicians Immediate Care operates over 40 locations in Illinois and Indiana. According to Bernie Sherry, Senior Vice President, Ascension and Ministry Market Executive, “These new urgent care centers complement our existing urgent care and occupational health sites and provide additional care options to the communities we're privileged to serve. These additional sites of care will allow us to continue to deliver on the promise to provide care in ways that are affordable, accessible and convenient for our communities.” The urgent care centers will be located in South Milwaukee, Brookfield, and Mount Pleasant. Stan Blaylock, CEO of Physicians Immediate Care, noted in a statement that, “We are excited to partner with Ascension to bring accessible and affordable care to its patients. Ascension Wisconsin's leadership and strong commitment to that goal aligns perfectly [FN32] with our purpose of providing ‘remarkable care you can count on, when and where you need it.”’ Massachusetts Senate passes bill to increase physical access to ERs; named after woman who died within feet of steps of emergency room The Massachusetts State Senate recently passed legislation intended to ensure safe patient access to emergency care. The bill, also known as “Laura's Law,” was named in memory of Somerville, MA resident Laura Beth Levis, who died in 2016 from an asthma attack just outside the emergency room. Levis, 34, was a Harvard University editor who walked to the emergency room of CHA Somerville Hospital before dawn one morning but was unable to enter. Her attack worsened, and she collapsed before help could arrive. According to Senate President Karen Spilka, there were several safety failures at the hospital (inadequate ER signage, lighting, and an abandoned hospital security desk) that contributed to her death. Spilka noted that, “Laura Levis' death was preventable, and this bill takes common sense steps to protect others in similar situations. Peter DeMarco's efforts to share his wife's story speak to his remarkable resolve and commitment to helping others. I am grateful to him, as well as Senators Pat Jehlen, Michael Rodrigues, and Jo Comerford for proactively leading the way to make sure that Laura's story is not repeated.” Under Laura's Law, the Department of Public Health would be required to create state standards for all hospital in Massachusetts to ensure safe, timely, and accessible access to emergency departments. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -18- The bill, which would not go into effect until after the governor's Covid-19 state of emergency has been lifted, now moves to the House of Representatives for consideration. Senator Patricia Jehlen (D-Somerville), lead sponsor of the bill, commented that, “When people are in need of emergency services, every minute counts and the dim lights and unclear signage took minutes from Laura that cost her life. We simply do not want this to happen to anyone again, and we believe this legislation is one step toward saving lives with clear signage, lighting, wayfinding and better security monitoring of emergency department entrances.” Senator Michael J. Rodrigues (D-Westport), Chair of the Senate Committee on Ways and Means, also commented on the proposed legislation, noting that, “This is a commonsense bill that will save lives. Access to emergency care starts with making sure emergency rooms are clearly identifiable and reachable for patients in crisis. I applaud Senator Jehlen for her hard work on this important bill and my colleagues in the Committee for advancing it to the Senate for consideration.” Senator Jo Comerford, co-chair of the Joint Committee on Public Health (D-Northampton), stated that, “Needless tragedies like what happened to Laura Levis must never happen again. Thanks to the leadership of Senator Jehlen, the Senate President, and our Senate Ways and Means Chair, the Senate took action today to make sure that our emergency rooms are well-lit, well-marked, and accessible [FN33] day and night. I hope this bill quickly advances to the Governor and becomes law.” Wisconsin School of Medicine and Public Health one of four sites to receive award from NIH for dementia ER research The University of Wisconsin School of Medicine and Public Health (SMPH) recently announced that is one of four sites awarded a total of $7.5 million from the National Institutes of Health (NIH) to conduct research that could potentially lead to improved care in emergency departments for people with dementia. According to Manish Shah, MD, MPH, professor of emergency medicine and co-principal investigator, the effort will try to leverage expertise in emergency medicine, geriatrics and Alzheimer's disease and related dementias to identify gaps in emergency care for people with dementia and address those gaps. For example, many commonly used medications are difficult for people with dementia. Better understanding of which medications are safest for this vulnerable population would help clinicians better care for them, he said. Dr. Shah further noted that, “The emergency department is not an ideal care setting for people with dementia. What we want to do is find better ways to care for one of our most vulnerable populations, namely older adults with cognitive impairment.” The funds will support Geriatric Emergency Care Applied Research Network 2.0 - Advancing Dementia Care (GEAR 2.0 ADC). This project is a collaboration between SMPH, Yale School of Medicine, Feinberg School of Medicine at Northwestern University, and Washington University School of Medicine in St. Louis. All four institutions are home to an NIH-National Institute on Aging-designated Alzheimer's Disease Research Center. Ula Hwang, MD, MPH, at Yale, is serving as co-principal investigator. The study has two phases. In phase one, the co-principal investigators will convene a panel of experts to review current research related to dementia patient care in emergency departments, identify areas where more research is needed, and create an infrastructure in which care researchers across the country can conduct this research. In phase two, the research will begin. With joint support from numerous partners, GEAR 2.0-ADC will award more than $1.1 million to fund nine pilot study awards. Phase two will also see the deployment of resources and mentoring support to help researchers successfully execute their research projects. The network's executive committee, task force, and advisory committee members are from more than 35 academic medical centers across the United States. GEAR 2.0 community partners include American Geriatrics Society, American Federation on Aging Research/ Clin-STAR, Alzheimer's Association, Emergency Medicine Foundation, Family Caregiver Alliance, Geriatric Emergency Department Collaborative, IMPACT Collaboratory, NIA Research Coordination Center Network, Patient Family Center Care, and West Health [FN34] Institute. Emergency physician groups applaud appeals court decision reinstating lawsuit over surprise ER bills The American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) have expressed support for a decision from the U.S. Court of Appeals for the 11th Circuit that will revive a lawsuit the organizations filed to force Anthem's Blue Cross Blue Shield of Georgia to rescind a policy that allows it to deny claims for emergency care on a retroactive basis. In its opinion, the Eleventh Circuit held that: • Providers who receive a patient's assignment of benefits have the right to seek equitable relief under ERISA. • Anthem/Blue Cross Blue Shield's emergency room claims review process is being conducted on a systemic versus individual basis - noting the company uses a pre-determined list of undisclosed diagnoses to make its decisions. • The Anthem/Blue Cross Blue Shield policy could subject ACEP and MAG physicians to past and ongoing harm. The court also noted that, “The [emergency department] review is also conducted by a physician, not a layperson. The prudent layperson standards ask what someone with ‘average knowledge of health and medicine’ would think is an emergency based on the © 2021 Thomson Reuters. No claim to original U.S. Government Works. -19- severity of ‘acute symptoms' ... A physician's professional assessment of symptoms is irrelevant. The regulations do not call upon a medical doctor to put aside her years of training to evaluate what someone without such training would view as a medical emergency.” ACEP and MAG have consistently argued that the prudent layperson standard both safeguards patients by requiring health insurers to base claims payments on a patient's symptoms rather than their final diagnosis. The two organizations have also argued that insurers should be prohibited from requiring patients to seek prior authorization before they seek emergency care. MAG President Lisa Perry-Gilkes, MD, FACS commented on the decision, stating that, “This is a great development for patients and physicians. The average patient simply isn't knowledgeable enough to make judgments about what qualifies as a medical emergency, and they shouldn't have to worry about getting a large bill when they're in the middle of a medical emergency.” ACEP president Mark Rosenberg, DO, MBA, FACEP, noted that, “ACEP is pleased that the 11th Circuit Court has recognized the validity of our cause to hold Anthem accountable to follow the law. We are emboldened by this ruling to continue our fight to ensure the millions of patients our members treat each year are not deterred from seeking emergency care when they need it.” According to ACEP, Anthem has implemented the policy in Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. Under this policy, patients who seek emergency care in these states are responsible for paying their entire bills if Anthem later determines that their diagnoses were not true emergencies after a retrospective review. ACEP and MAG originally filed the lawsuit in federal court in 2018. The District Court for the Northern District of Georgia dismissed the suit in March 2020 at Anthem's request. ACEP and MAG then appealed the case to the Eleventh Circuit Court of Appeals. The American College of Emergency Physicians (ACEP) is a national medical society representing approximately 40,000 emergency [FN35] physician members. Physicians group supports bill halting scheduled Medicare cuts to doctors (including ER doctors) The American College of Emergency Physicians (ACEP) is supporting the bipartisan, “Holding Providers Harmless from Medicare Cuts During COVID-19 Act of 2020,” introduced by Rep. Ami Bera (D-CA) and Rep. Larry Bucshon (R-IN). This bill attempts to address cuts to physician reimbursement that are planned to take effect in January 2021, including a six percent Medicare reduction for emergency physicians. According to Mark Rosenberg, DO, MBA, FACEP, president of ACEP, “Without congressional intervention, these planned cuts will come at a time when many emergency physicians are under unprecedented financial strain as they risk their lives to protect people from this public health crisis. This bill would provide some much-needed stability for those on the frontlines while the fight against COVID-19 continues.” H.R. 8702 would hold these physicians harmless from any reductions that would be less than what they were reimbursed in 2020. It would also maintain the scheduled pay increases for primary care. For physicians who do receive a cut, the bill authorizes a temporary additional payment for 2021 and 2022 equal to the amount lost. This bill follows a letter penned by Representatives Bera and Bucshon and co-signed by 229 Representatives in support of efforts to avoid Medicare pay cuts. Dr. Rosenberg further noted that, “After nearly a year of fighting this pandemic, many emergency physicians are struggling with financial hardships and professional uncertainty. Cases are increasing across the country, and we cannot abandon our support for our health care heroes during this critical time.” ACEP is currently working with legislators, regulators, and other physician and non-physician groups affected by the budget neutrality rule to encourage a solution that holds physicians harmless. In comments to the Centers for Medicare & Medicaid Services, ACEP [FN36] summarizes how a public health emergency would worsen the effects of a reduction and recommends steps to lessen these cuts. © Copyright Thomson/West - NETSCAN's Health Policy Tracking Service [FN2] . “Smaller, Independent Physician Practices Urge Congress to Solve Surprise Billing the Right Way,” December 5, 2019, available at: https://www.emergencyphysicians.org/press-releases/2019/12-5-19-smaller-independent-physician-practices-urge-congress-to-solve- surprise-billing-the-right-way. [FN3] . “New law now protects patients from surprise medical bills in Washington,” January 2, 2019, available at: https://www.insurance.wa.gov/news/new-law-now-protects-patients-surprise-medical-bills-washington? utm_content=&utm_medium=email&utm_name=&utm_source=govdelivery&utm_term=. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -20- [FN4] . “As a Result of AG Charity Care Lawsuit, Capital Medical Center to Provide Full Restitution, Debt Relief to Patients Who Were Unlawfully Denied Access to Charity Care,” January 16, 2020, available at: https://www.atg.wa.gov/news/news-releases/result-ag- charity-care-lawsuit-capital-medical-center-provide-full-restitution. [FN5] . “ER Anywhere Pilot Produces Impressive Results: 97% ER avoidance, 99% patient satisfaction,” January 27, 2020, available at: https://www.cdphp.com/newsroom/2020/01/01-27-er-anywhere-impressive-results. [FN6] . “Emergency Physicians Oppose Supreme Court Decision to Allow “Public Charge” Rule,” January 29, 2020, available at: https:// www.emergencyphysicians.org/press-releases/2020/1-29-20-emergency-physicians-oppose-supreme-court-decision-to-allow-public- charge-rule. [FN7] . “New Data Shows Rising Repeat ER Visits for Opioid-Related Emergencies,” February 12, 2020, https:// www.emergencyphysicians.org/press-releases/2020/new-data-shows-rising-repeat-er-visits-for-opioid-related-emergencies. [FN8] . Ben Conarck, “South Florida judge tosses surprise emergency room fees lawsuit against HCA hospitals,” February 6, 2020, available at: htps:// www.miamiherald.com/news/health-care/article240038958.html. [FN9] . “Hyde-Smith Addresses Rural Health Care Needs During HHS Budget Review,” February 26, 2020, available at: https:// www.hydesmith.senate.gov/hyde-smith-addresses-rural-health-care-needs-during-hhs-budget-review. [FN10] . “HRSA-20-036, Telehealth Network Grant Program, Department of Health and Human Services Health Resources and Services Administration,” February 11, 2020, available at: https://www.grants.gov/web/ grants/view-opportunity.html?oppId=315882&utm_source=Master+List&utm_campaign=48fd0e6d85- EMAIL_CAMPAIGN_2020_02_18_09_41&utm_medium=email&utm_term=0_094d53132c-48fd0e6d85-157015625. [FN11] . “Beaumont Health caring for 650 confirmed COVID-19 patients, expanding surge plan to potentially care for more patients infected with the virus,” March 26, 2020, available at: https://www.beaumont.org/health-wellness/press-releases/beaumont-health-caring- for-650-confirmed-covid-19-patients-expanding-surge-plan-to-potentially-care-for-more-patients-infected-with-the-virus. [FN12] . March 27, 2020, available at: https://www.acep.org/globalassets/new-pdfs/advocacy/acep-letter-to-secretary-azar-on-cares-act- funding.pdf. [FN13] . “Texas Emergency Care Center CEO Asks Governor Abbott to Request the Federal Administration to Have CMS Certify, Grant Freestanding ERs Medicare, Medicaid, Tricare Recognition,” March 25, 2020, available at: https://www.businesswire.com/news/ home/20200325005768/en/. [FN14] . “Now is Not the Time to Reduce Support for Health Care Heroes,” April 7, 2020, available at: https://www.emergencyphysicians.org/ press-releases/2020/4-7-20-now-is-not-the-time-to-reduce-support-for-health-care-heroes. [FN15] . “Amidst COVID-19 Concerns, Emergency Physicians Urge Public Not to Delay Necessary Medical Care,” April 15, 2020, available at: https://www.emergencyphysicians.org/press-releases/2020/4-15-20-amidst-covid-19-concerns-emergency-physicians-urge-public-not- to-delay-necessary-medical-care. [FN16] © 2021 Thomson Reuters. No claim to original U.S. Government Works. -21- . “UH Suspends Operations at Freestanding Emergency Departments to aid COVID-19 Response and Recovery Efforts,” April 22, 2020, available at: https://news.uhhospitals.org/news-releases/harrington-heart-vascular-institute/uh-suspends-operations-at- freestanding-emergency-departments-to-aid-covid-19-response-and-recovery-efforts.htm. [FN17] . “New Poll: Nearly a Third are Delaying or Avoiding Medical Care Due to COVID-19 Concerns,” April 28, 2020, available at: https:// www.emergencyphysicians.org/press-releases/2020/4-28-20-new-poll-nearly-a-third-are-delaying-or-avoiding-medical-care-due-to- covid-19-concerns. [FN18] . “vybe urgent care Now Offering COVID-19 Serum Antibody Testing,” May 8, 2020, available at: https://www.vybe.care/blog/vybe- urgent-care-now-offering-covid-19-serum-antibody-testing/. [FN19] . 1st Lt. Chelsea Clark, “Vermont National Guard helps hospital with emergency care,” May 19, 2020, available at: https:// www.army.mil/article/235737/vermont_national_guard_helps_hospital_with_emergency_care. [FN20] . “Do Not Delay Emergency Care,” April 30, 2020, available at: https://www.lnrmc.com/news-room/do-not-delay-emergency-care-15518. [FN21] . Ellen Goldbaum, “Nationwide EMS calls have dropped 26% since the start of the pandemic,” June 25, 2020, available at: http:// www.buffalo.edu/news/releases/2020/06/035.html. [FN22] . Kathleen P. Hartnett, PhD, et al., “Impact of the COVID-19 Pandemic on Emergency Department Visits -- United States, January 1, 2019-May 30, 2020,” June 12, 2020, available at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6923e1.htm? s_cid=mm6923e1_w#suggestedcitation. [FN23] . “New Analysis Reveals Worsening Shortage of Emergency Physicians in Rural Areas,” August 12, 2020, available at: https:// www.emergencyphysicians.org/press-releases/2020/8-12-20-new-analysis-reveals-worsening-shortage-of-emergency-physicians-in- rural-areas. [FN24] . Kim Krieger - UConn Communications, “Psychiatric Visits to the Emergency Room Rise Despite the ACA,” July 28, 2020, available at: https://today.uconn.edu/2020/07/psychiatric-visits-emergency-room-rise-despite-aca/#. [FN25] . “Emergency Physicians & Residents Discouraged by U.S. Restrictions on International Health Workforce,” July 9, 2020, available at: https://www.emergencyphysicians.org/press-releases/2020/7-9-20-emergency-physicians--residents-discouraged-by-u.s.-restrictions- on-international-health-workforce. [FN26] . “Emergency Physicians Object to Roll Back of Protections against Health Care Discrimination,” June 16, 2020, available at: https:// www.emergencyphysicians.org/press-releases/2020/6-16-20-emergency-physicians-object-to-roll-back-of-protections-against-health- care-discrimination. [FN27] . “Fueled by COVID-19 fears, approximately half of Hispanics and Black Americans would fear going to the hospital if experiencing symptoms of a heart attack or stroke.” July 23, 2020, available at: https://newsroom.heart.org/news/fueled-by-covid-19-fears- approximately-half-of-hispanics-and-black-americans-would-fear-going-to-the-hospital-if-experiencing-symptoms-of-a-heart-attack-or- stroke. [FN28] . “Emergency Physicians and Nurses Remind Patients the ER is Safest Place in a Medical Emergency,” July 22, 2020, available at: https://www.emergencyphysicians.org/press-releases/2020/7-22-20-emergency-physicians-and-nurses-remind-patients-the-er-is- safest-place-in-a-medical-emergency. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -22- [FN29] . “Joint Letter to Congress regarding Surprise Medical Billing in COVID-19 Relief Package,” July 29, 2020, available at: https:// www.aaem.org/UserFiles/file/SMBFederationSign-onLetter.pdf. [FN30] . “Wake Forest Baptist Health Receives $1.2 Million to Help Improve Rural Health Care in Wilkes County,” September 22, 2020, available at: https://newsroom.wakehealth.edu/News-Releases/2020/09/Grant-Received-to-Help-Improve-Rural-Health-Care-in-Wilkes- County. [FN31] . Taylor A. Ochalek, PhD, “Nonfatal Opioid Overdoses at an Urban Emergency Department During the COVID-19 Pandemic,” JAMA, September 18, 2020, available at: https://jamanetwork.com/journals/jama/fullarticle/2770986?guestAccessKey=c2779f56-b659-43a0- a1ef-881696d7d6da&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=091820. [FN32] . “Ascension Wisconsin to open three new urgent care locations,” GM Today, October 8, 2020, available at: https://www.gmtoday.com/ business/ascension-wisconsin-to-open-three-new-urgent-care-locations/article_5cdf3f56-0960-11eb-822a-4715af814db5.html. [FN33] . “Senate Passes Legislation Ensuring Safe Patient Access to Emergency Care,” October 22, 2020, available at: https:// karenspilka.com/updates/2020/10/22/senate-passes-legislation-ensuring-safe-patient-access-to-emergency-care. [FN34] . “UW School of Medicine and Public Health: Research funding awarded to identify ways to improve emergency department visits for people with dementia” (press release), available at: https://www.wisbusiness.com/2020/uw-school-of-medicine-and-public-health- research-funding-awarded-to-identify-ways-to-improve-emergency-department-visits-for-people-with-dementia/. [FN35] . “ACEP & MAG Applaud Court's Decision to Revive Lawsuit Forcing Anthem/Blue Cross Blue Shield of Georgia to Rescind Its ER Claims Policy,” October 29, 2020, available at: https://www.emergencyphysicians.org/press-releases/2020/10-29-20-acep--mag- applaud-courts-decision-to-revive-lawsuit-forcing-anthemblue-cross-blue-shield-of-georgia-to-rescind-its-er-claims-policy. [FN36] . “ACEP Applauds Introduction of Bill to Prevent Physician Cuts During Pandemic,” November 4, 2020, available at: https:// www.emergencyphysicians.org/press-releases/2020/11-4-20-acep-applauds-introduction-of-bill-to-prevent-physician-cuts-during- pandemic. Produced by Thomson Reuters Accelus Regulatory Intelligence 14-Mar-2021 © 2021 Thomson Reuters. No claim to original U.S. Government Works. -23-