Hope that is shared grows.
In that light, I am sharing with you my hope for healing of our emergency medicine physician community as we begin to emerge from the COVID pandemic. At each of our facilities, I hope that our patients feel safe to return to our departments to seek needed emergency care. At the North Carolina General Assembly, I hope that patient safety is paramount in guiding decisions regarding COVID and scope of practice legislation. In Washington DC, I hope that attention to families’ finances and the value of physician-led care guide rulemaking associated with the No Surprises Act.
Across our nation, emergency department visits declined over 40% during April 2020 and remained down nearly 25% throughout the close of 2020. However, across our state our patients appear to be returning to the emergency departments for emergency care with Charlotte and the Triangle emergency departments seeing June visit numbers equal to or above those in 2019. In contrast, our state’s more rural emergency departments continue to see volumes that remain 10-20% below their 2019 levels.
It’s a big year for healthcare at the North Carolina General Assembly Regular Session, with six of the top ten most viewed and most monitored bills dealing with healthcare issues! Not surprisingly, those that have received the most publicity deal with COVID and scope of practice issues, including SB 191 “No Patient Left Alone” recently approved by the Senate requiring licensed hospitals to permit patients to receive visitors to the fullest extent permitted under CMS, CDC, or other federal guidelines and HB 558 “Prohibit Mandatory CV19 Vaccinations” which seeks to prohibit state agencies or public health from mandating COVID vaccination and prohibit differentiation of individuals by vaccination status by employers, schools, insurance companies, and health care providers. Within the scope of practice realm, North Carolina Medical Society backed SB 345 “PA – Team-Based Practice” requires a physician assistant to execute and maintain a supervisory agreement with a physician, unless the PA practices in team-based settings and has more than 4,000 hours of practice experience as a licensed PA and more than 1,000 hours of practice within the specific medical specialty of practice with a physician in that specialty; this strengthens current patient protections. Alternatively, HB 277 “The SAVE Act” seeks to eliminate the requirement for physician supervision requirement for APRNs, essentially creating a lower standard of practice and an obvious safety risk for patients. Graduating medical students (without 3-7 years of residency training) have five times the educational requirements and ten times clinical training/hands-on experience of fully licensed NPs, while fully licensed physicians have an average of 16,000 hours of clinical training in comparison to an NPs 600 hours. Further bills with potential positive effects on the licensing and daily practice realm for emergency physicians include HB 868 Telehealth Licensure Reciprocity, SB 380 Interstate Medical Licensure Compact, HB 751 Abolish Employment At-Will, and SB 598 Require 20-Minute Paid Work Breaks. Finally, HB 93 Requirement for Opioid Antagonist Education with Opioid Scripts and HB 525 Allow ERPOs to Prevent Suicides and Save Lives have the potential to increase patient safety though at present may require revision to address concerns for unintended consequences. If you’re interested in reading the text or tracking any of the above active North Carolina bills, visit https://legiscan.com/NC. For a summary of all active North Carolina bills of interest to emergency care, visit the NCCEP website’s Legislative Updates page here.
In Washington DC, the Departments of Labor, Health and Human Services, and the Treasury are now engaged in the implementation phase of the No Surprises Act, which was enacted by Congress and signed by the President in the closing days of 2020 after nearly two years of Congressional debate regarding solutions for Balance Billing (the difference between the undiscounted fee charged by the out-of-network provider and the amount reimbursed by the private health plan). The No Surprises Act requires private health plans to cover surprise medical bills for emergency services, including air ambulance services and prohibits out-of-network emergency care providers from balance billing patients beyond the applicable in-network cost sharing amounts. After removing the patient/family from the equation, the Act provides for baseball style independent dispute resolution following a 30-day period during which the plan and provider try to negotiate a payment amount. If negotiations are unsuccessful, the provider and payer make a final payment offer and the arbitrator must choose one of those two payment amounts. The arbitrator may consider a number factors, including the plan’s median in-network rate for the service, but it may not consider the undiscounted provider charge or the amount public payers would pay for the service. IDR decision is binding and the loser pays the cost of the arbitration. By July 1, federal rules regarding determination of the in-network cost sharing amount (likely to be based on the health plan’s median in-network rate for a given service in 2019, known as the qualifying payment amount, and indexed for future years) and information that private payers must share with out-of-network providers and facilities are scheduled to be implemented. The second implementation phase will focus on rule making governing the arbitration process and must be finalized by the law January 1, 2022 when the No Surprises Act becomes law. The College is working hard to allow the Federal law to take effect in North Carolina instead of North Carolina Senate Bill 415, filed again this year by Senator Hise, which seeks to end balance billing by setting a rate for out-of-network provider payment at or below the Medicare rate, thus further endangering North Carolina patients’ access to healthcare.
Share my hope for healing of the emergency medicine physician community and for protection of the physical and financial health of patients seeking our care. Please share your hope and any questions you may have with me.
Jennifer Casaletto, MD, FACEP