President’s Message – February 2020

Timothy Johnson, MD, FACEP

“May you live in interesting times”—famous Chinese curse.

Minnesota emergency physicians are living in very interesting times. While I am excited and honored to serve over the next two years as the new president of our state chapter, there are more existential threats to our specialty and our patients than there have been for the past twenty years.  I know most of us don’t have any desire to be policy wonks, and we all long for a simpler past when we could just care for our patients and remain blissfully ignorant of the sausage-making that goes on in Washington, in St. Paul, and in the revenue cycle billing and coding back-of-the-house operations that we all depend on for our paychecks (unless elves bring sacks of gold to your door at night). Frankly, those days are not the interesting times we have before us right now. Whether you work for an independent group (like I do), an academic practice, a hospital-employed physician model, or even an independent contractor model, there are things happening right now that threaten to drop your pay by 30% or more, as well as slowing the throughput of your patients presenting with psychiatric emergencies even more than it is right now. 

“Surprise” billing legislation before the United States Congress right now has morphed from a well-intentioned grassroots effort to get our patients out of the middle of out-of-network bill balance bill disputes between doctors and insurance companies to a cudgel that insurers will use to ax your payments for patients that are already in-network as well as out-of-network. You read that right; three of the four bills before Congress right now are estimated by the Congressional Budget Office to provide 80% of the savings to government and private insurance from decreased payments from in-network patients where the provider and the insurer already successfully negotiated a contract in good faith. Minnesota is 50th out of 50 states for patients receiving out-of-network emergency medicine balance bills any higher than they would have received if they were in-network.  The truth is, a few bad actors, not from around here, have brought this problem we weren’t having to our door and now we are dealing with the crisis.

The solution? There is no perfect solution, but the best hope we have right now is a proposed bill just released from the House Ways and Means Committee; HR 5826 The Consumer Protections Against Surprise Medical Bills Act. ACEP supports this (imperfect) bill as the least-harmful scenario. Opposing all proposed bills will fail and will not be a good look for us, so we are hoping this is the bill that passes. As divided as government feels right now, there is a huge desire in both parties, both branches of Congress, and the president to pass a law by May 22 at the latest. For the wonks among you, this proposal includes baseball-style independent dispute resolution (IDR) loser pays, no allowed charge threshold, and allows batching of claims. It requires insurance companies to have only one deductible that gets satisfied by both in-and –out-of-network bills and it requires that the deductible amount be printed on the patient’s insurance card, helping to add some transparency to the subterfuge that the patient got a “surprise” bill because they had cheap phantom coverage.

If that’s not enough, bandwagoners in St. Paul have drafted a Minnesota bill to stamp out the emergency medicine surprise billing problem that we are not actually having, just in case the federal law is not draconian enough.  The only good part about this bill is that it also provides for arbitration and the arbitrator can consider usual and customary charges, unlike the federal bills which all forbid charges from being considered; only payments can be used. Stay tuned on this one too.

Finally, Fairview/M Health is hemorrhaging cash; $40 million per year by one account, which is obviously not sustainable.  Two of the sources of bleeding are the Bethesda rehab hospital and St. Joseph’s hospital in downtown St. Paul. With less than 6 weeks of warning, Fairview/M Health cut Bethesda’s beds from 89 to 50, which impacts the ability of ICUs across the metro to offload longer-term vented patients, which then potentially impacts your ability to get your critical patient an ICU bed in a timely fashion. If rumors about St. Joes closing are true, it would mean the loss of not just an emergency department, but also over 100 inpatient psychiatric beds. I do not need to spell out for you what that would mean for emergency psychiatric patients throughput and access to needed care throughout the Metro if not all of Minnesota.

So, I’ve presented three chief complaints and a history of present illness. What’s the plan?

  1. Join the 911 network which will get you weekly congressional updates and easy-to-use links to let your representatives in Washington hear you when it’s prime time to go on the offensive.
  2. Please join me and the Minnesota ACEP (MNACEP) board along with a few emergency medicine residents at the ACEP Leadership and Advocacy conference in Washington D.C. April 26-28. Hundreds of emergency physicians descend like locusts on Capitol Hill and visit every congressional office we can, spreading the gospel of emergency medicine. ER doctors from outstate Minnesota, I especially need YOU. Nothing gets the attention of an outstate congressperson or their healthcare legislative assistant like a constituent standing right in their office with a relatable problem and a bill that will fix it.
  3. Let your state legislators know that we need a minimum number of safety net of inpatient psychiatric beds in this state. We pay a provider tax, now we need them to use it for patients. In my opinion, because mental health services are so fragmented between cities and counties, it may require a state-brokered solution that shares the pain with all health systems in the state.
  4. I hate to say it, but money talks in politics, which sounds icky I know. What looks the least icky are lots of small individual donations, around $50 apiece. ACEP also has a political action committee (NEMPAC) that contributes to both Democrat and Republican candidates that can ally with emergency medicine. You can find the link to donate through the website. MNACEP also has a political action committee (MEPAC) that does the same thing at the state level. We are not fancy and don’t want any of your money going to a credit card link. We are working on getting Venmo, but it’s not ready yet. In the meantime, please snail mail us an old-timey paper check to: MEPAC, 6 Greenhaven Bay, Faribault, MN 55021. I give $500 to MEPAC every year and I promise you it makes a big difference.
  5. One last thing: save the date for our MNACEP Emergency Medicine Summit. It is October 5, 2020 at the Westin in Edina Galleria. A star-studded panoply of speakers will be there to edify you, and all your friends will be there. The networking is phenomenal. Seriously, it really is a great conference and AMA category one CEU credits are given on very timely clinical topics. More to come on this.

Before I sign off, I guess as your new president I should tell you a little about myself. I work clinically in St. Cloud and I finished residency at HCMC 17 years ago. I have a part-time administrative role in reimbursement; maybe you saw me speak at one of the MNACEP reimbursement conferences that we have had in the past until about 5 years ago. Let me know if you want to see those come back again. I grew up as the 7th of seven boys, kind of the runt of the litter. So I am short but a little aggressive. My favorite cause is advocating for emergency physicians. Drop me a line, especially if you want to advocate too.