Neal Flomenbaum, MD

New rules by the Centers for Medicare and Medicaid Services (CMS) defining inpatient hospital care for Medicare recipients could increase patients’ expenses, decrease hospital reimbursements, and add to ED overcrowding and ED lengths of stay.

The story so far: to better differentiate between hospitalized Medicare recipients who are considered inpatients (Medicare Part A) from those hospitalized for “observation services” (Medicare Part B), CMS issued new rules on August 2, 2013 defining appropriate inpatient admissions as those requiring hospital stays over at least two midnights. The rules further require that the physician accepting the hospitalized patient record upon admission whether or not the patient is expected to remain for two midnights. CMS recently added that the time frame for ED admissions starts when patients begin to receive care there, excluding prior waiting room time or triage.

The new rules went into effect on October 1, 2013 with a 6-month period for CMS administrative contractors to review claims and educate hospital administrators and physician providers. On January 31, 2014, CMS extended these “probe and educate” audits for an additional 6 months, but emphasized that the rules apply throughout this period.

Though many hospitals with available beds have already been formally providing “observation services,” overcrowded urban teaching hospitals lacking observation-unit beds and/or sufficient inpatient capacity have not, even after CMS began reimbursing all hospitals at the outpatient services rate for many 1- or 2-day admissions.

What difference does it make if a hospitalization is considered an inpatient stay or observation services? Medicare reimbursement to hospitals for observation services is less than the inpatient rate, while observation patients frequently have more and higher co-pays and fewer posthospitalization benefits, especially after multiple tests and procedures during a hospital stay of more than 2 days.

Many hospitals, physicians, and patient advocacy groups have expressed unhappiness over the new rules, which may also create additional problems for overcrowded EDs struggling to bring down long lengths of stay as the number of ED patients requiring hospitalization continues to rise. According to the 2013 Rand report on the evolving role of EDs, nearly all of the increases in inpatient admissions between 2003 and 2009 were the result of a 17% increase in unscheduled admissions from EDs (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf).

To prevent admitted patients from getting stuck in EDs for extended periods, most hospitals long ago gave EPs the ultimate authority to admit patients to the most appropriate inpatient service. Until now though, the admitting physician—the physician who will be caring for the patient upon admission—was not required to determine if the patient would need a two-midnight stay, or possibly be evaluated afterward on the accuracy rate of those predictions. If an admitting physician (or resident, PA or NP working with an attending physician) is not convinced that a patient needs admission or care on that particular service, further delays may now ensue.

Avoiding such prolonged discussions and disagreements was precisely the reason EPs were given the authority to make the final decision to “admit.” To prevent any additional delays under the new rules, perhaps EPs should instead be given the authority to “transfer further care of ED patients to the appropriate inpatient service,” even as the nature and location of that hospital care is being determined. EPs who may mourn the loss of authority to “admit” a patient to any service should recall that, from an ED perspective, “a rose by any other name.…”

To be continued. 

New rules by the Centers for Medicare and Medicaid Services (CMS) defining inpatient hospital care for Medicare recipients could increase patients’ expenses, decrease hospital reimbursements, and add to ED overcrowding and ED lengths of stay.

The story so far: to better differentiate between hospitalized Medicare recipients who are considered inpatients (Medicare Part A) from those hospitalized for “observation services” (Medicare Part B), CMS issued new rules on August 2, 2013 defining appropriate inpatient admissions as those requiring hospital stays over at least two midnights. The rules further require that the physician accepting the hospitalized patient record upon admission whether or not the patient is expected to remain for two midnights. CMS recently added that the time frame for ED admissions starts when patients begin to receive care there, excluding prior waiting room time or triage.

The new rules went into effect on October 1, 2013 with a 6-month period for CMS administrative contractors to review claims and educate hospital administrators and physician providers. On January 31, 2014, CMS extended these “probe and educate” audits for an additional 6 months, but emphasized that the rules apply throughout this period.

Though many hospitals with available beds have already been formally providing “observation services,” overcrowded urban teaching hospitals lacking observation-unit beds and/or sufficient inpatient capacity have not, even after CMS began reimbursing all hospitals at the outpatient services rate for many 1- or 2-day admissions.

What difference does it make if a hospitalization is considered an inpatient stay or observation services? Medicare reimbursement to hospitals for observation services is less than the inpatient rate, while observation patients frequently have more and higher co-pays and fewer posthospitalization benefits, especially after multiple tests and procedures during a hospital stay of more than 2 days.

Many hospitals, physicians, and patient advocacy groups have expressed unhappiness over the new rules, which may also create additional problems for overcrowded EDs struggling to bring down long lengths of stay as the number of ED patients requiring hospitalization continues to rise. According to the 2013 Rand report on the evolving role of EDs, nearly all of the increases in inpatient admissions between 2003 and 2009 were the result of a 17% increase in unscheduled admissions from EDs (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf).

To prevent admitted patients from getting stuck in EDs for extended periods, most hospitals long ago gave EPs the ultimate authority to admit patients to the most appropriate inpatient service. Until now though, the admitting physician—the physician who will be caring for the patient upon admission—was not required to determine if the patient would need a two-midnight stay, or possibly be evaluated afterward on the accuracy rate of those predictions. If an admitting physician (or resident, PA or NP working with an attending physician) is not convinced that a patient needs admission or care on that particular service, further delays may now ensue.

Avoiding such prolonged discussions and disagreements was precisely the reason EPs were given the authority to make the final decision to “admit.” To prevent any additional delays under the new rules, perhaps EPs should instead be given the authority to “transfer further care of ED patients to the appropriate inpatient service,” even as the nature and location of that hospital care is being determined. EPs who may mourn the loss of authority to “admit” a patient to any service should recall that, from an ED perspective, “a rose by any other name.…”

To be continued. 

New rules by the Centers for Medicare and Medicaid Services (CMS) defining inpatient hospital care for Medicare recipients could increase patients’ expenses, decrease hospital reimbursements, and add to ED overcrowding and ED lengths of stay.

The story so far: to better differentiate between hospitalized Medicare recipients who are considered inpatients (Medicare Part A) from those hospitalized for “observation services” (Medicare Part B), CMS issued new rules on August 2, 2013 defining appropriate inpatient admissions as those requiring hospital stays over at least two midnights. The rules further require that the physician accepting the hospitalized patient record upon admission whether or not the patient is expected to remain for two midnights. CMS recently added that the time frame for ED admissions starts when patients begin to receive care there, excluding prior waiting room time or triage.

The new rules went into effect on October 1, 2013 with a 6-month period for CMS administrative contractors to review claims and educate hospital administrators and physician providers. On January 31, 2014, CMS extended these “probe and educate” audits for an additional 6 months, but emphasized that the rules apply throughout this period.

Though many hospitals with available beds have already been formally providing “observation services,” overcrowded urban teaching hospitals lacking observation-unit beds and/or sufficient inpatient capacity have not, even after CMS began reimbursing all hospitals at the outpatient services rate for many 1- or 2-day admissions.

What difference does it make if a hospitalization is considered an inpatient stay or observation services? Medicare reimbursement to hospitals for observation services is less than the inpatient rate, while observation patients frequently have more and higher co-pays and fewer posthospitalization benefits, especially after multiple tests and procedures during a hospital stay of more than 2 days.

Many hospitals, physicians, and patient advocacy groups have expressed unhappiness over the new rules, which may also create additional problems for overcrowded EDs struggling to bring down long lengths of stay as the number of ED patients requiring hospitalization continues to rise. According to the 2013 Rand report on the evolving role of EDs, nearly all of the increases in inpatient admissions between 2003 and 2009 were the result of a 17% increase in unscheduled admissions from EDs (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf).

To prevent admitted patients from getting stuck in EDs for extended periods, most hospitals long ago gave EPs the ultimate authority to admit patients to the most appropriate inpatient service. Until now though, the admitting physician—the physician who will be caring for the patient upon admission—was not required to determine if the patient would need a two-midnight stay, or possibly be evaluated afterward on the accuracy rate of those predictions. If an admitting physician (or resident, PA or NP working with an attending physician) is not convinced that a patient needs admission or care on that particular service, further delays may now ensue.

Avoiding such prolonged discussions and disagreements was precisely the reason EPs were given the authority to make the final decision to “admit.” To prevent any additional delays under the new rules, perhaps EPs should instead be given the authority to “transfer further care of ED patients to the appropriate inpatient service,” even as the nature and location of that hospital care is being determined. EPs who may mourn the loss of authority to “admit” a patient to any service should recall that, from an ED perspective, “a rose by any other name.…”

To be continued. 

In the midst of a seemingly endless number of docudramas, “reality” series, and “infotainment” programs about emergency medicine, two new remarkable full-length documentaries present a much more accurate and compelling picture of our specialty and work place.

"...side[s] of emergency medicine that EPs have long wanted the public to see..."

The Waiting Room, a 2012 film that aired nationwide on PBS last month (http://www.pbs.org/independentlens/waiting-room/), graphically demonstrates what it is like to spend 24 hours in an overcrowded ED waiting room of a large public hospital in northern California. No alternative care is available to the many patients who must wait hour-after-hour for treatment of their acute conditions and chronic illnesses. None of the patients are particularly odd, flamboyant, or embarrassingly funny, and though the film devotes little time to the dramatic life-threatening trauma and illness that characterize most “ER shows,” its strength lies in how adeptly it captures the oppressive, tedious, and anxiety-producing atmosphere of an overburdened health system—making it easy to understand why even the sickest patients sometimes leave without being seen. Eventually, those who do remain are called inside where most are helped and provided with some form of follow-up care. The Waiting Room presents a side of emergency medicine that EPs have long wanted the public to see—not to scare them away from coming to EDs, but in the hope that our country will find a way to provide the resources needed to end epidemic ED overcrowding and ensure adequate emergency care for all.

At its premier screening at the Los Angeles Film Festival last June, Code Black (2013) (http://codeblackmovie.com/) won the jury award for best full-length documentary and went on to win similar awards at the next two film festivals. It is the compelling story of a group of idealistic emergency medicine residents struggling to learn their craft while saving lives in the overcrowded setting of Los Angeles County General Hospital. The overwhelming numbers of ill patients waiting to be seen, a condition the residents refer to as “code black,” and the cramped surroundings of the old County Hospital ED with its legendary “C-Booth” resuscitation area, present daunting challenges to the residents’ goal of helping all who need care. But these challenges turn out to be nothing compared to the residents’ need, midway through their training, to adapt to a new earthquake-resistant LA County General Hospital. Suddenly their familiar ED and its beloved C-Booth are gone. Pristine and functional, the new hospital replaces visibility with privacy, easy access with confidentiality, and patient contact time with endless paperwork.

Can the residents’ idealism survive 21st-century rules and requirements, inaccessibility of care, and a financially strapped municipality that freezes vacant nursing positions, forcing their brand new ED to close almost half the ED beds? In the words of Ryan McGarry, MD, *director of Code Black and a featured EM resident in the film, “When we started this it seemed so simple. We were going to be doctors. We were going to help people. But what if those ideals can die? What if this hope can fade into the failure of the system?” This movie is not just about emergency medicine; it is also about the timeless struggle between young idealists and the worn out, unsuccessful systems they inherit and must adapt to in order to change them and achieve their goals. It is no wonder that Code Black is resonating so strongly with audiences, and why there is reason to believe that our patients and our specialty will be in very good hands for years to come. 

*Ryan McGarry, MD, is currently an EM faculty member at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. During his interview for a position with us last April, he mentioned that he had just completed a documentary about his residency. We hired him anyway.

In the midst of a seemingly endless number of docudramas, “reality” series, and “infotainment” programs about emergency medicine, two new remarkable full-length documentaries present a much more accurate and compelling picture of our specialty and work place.

"...side[s] of emergency medicine that EPs have long wanted the public to see..."

The Waiting Room, a 2012 film that aired nationwide on PBS last month (http://www.pbs.org/independentlens/waiting-room/), graphically demonstrates what it is like to spend 24 hours in an overcrowded ED waiting room of a large public hospital in northern California. No alternative care is available to the many patients who must wait hour-after-hour for treatment of their acute conditions and chronic illnesses. None of the patients are particularly odd, flamboyant, or embarrassingly funny, and though the film devotes little time to the dramatic life-threatening trauma and illness that characterize most “ER shows,” its strength lies in how adeptly it captures the oppressive, tedious, and anxiety-producing atmosphere of an overburdened health system—making it easy to understand why even the sickest patients sometimes leave without being seen. Eventually, those who do remain are called inside where most are helped and provided with some form of follow-up care. The Waiting Room presents a side of emergency medicine that EPs have long wanted the public to see—not to scare them away from coming to EDs, but in the hope that our country will find a way to provide the resources needed to end epidemic ED overcrowding and ensure adequate emergency care for all.

At its premier screening at the Los Angeles Film Festival last June, Code Black (2013) (http://codeblackmovie.com/) won the jury award for best full-length documentary and went on to win similar awards at the next two film festivals. It is the compelling story of a group of idealistic emergency medicine residents struggling to learn their craft while saving lives in the overcrowded setting of Los Angeles County General Hospital. The overwhelming numbers of ill patients waiting to be seen, a condition the residents refer to as “code black,” and the cramped surroundings of the old County Hospital ED with its legendary “C-Booth” resuscitation area, present daunting challenges to the residents’ goal of helping all who need care. But these challenges turn out to be nothing compared to the residents’ need, midway through their training, to adapt to a new earthquake-resistant LA County General Hospital. Suddenly their familiar ED and its beloved C-Booth are gone. Pristine and functional, the new hospital replaces visibility with privacy, easy access with confidentiality, and patient contact time with endless paperwork.

Can the residents’ idealism survive 21st-century rules and requirements, inaccessibility of care, and a financially strapped municipality that freezes vacant nursing positions, forcing their brand new ED to close almost half the ED beds? In the words of Ryan McGarry, MD, *director of Code Black and a featured EM resident in the film, “When we started this it seemed so simple. We were going to be doctors. We were going to help people. But what if those ideals can die? What if this hope can fade into the failure of the system?” This movie is not just about emergency medicine; it is also about the timeless struggle between young idealists and the worn out, unsuccessful systems they inherit and must adapt to in order to change them and achieve their goals. It is no wonder that Code Black is resonating so strongly with audiences, and why there is reason to believe that our patients and our specialty will be in very good hands for years to come. 

*Ryan McGarry, MD, is currently an EM faculty member at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. During his interview for a position with us last April, he mentioned that he had just completed a documentary about his residency. We hired him anyway.

In the midst of a seemingly endless number of docudramas, “reality” series, and “infotainment” programs about emergency medicine, two new remarkable full-length documentaries present a much more accurate and compelling picture of our specialty and work place.

"...side[s] of emergency medicine that EPs have long wanted the public to see..."

The Waiting Room, a 2012 film that aired nationwide on PBS last month (http://www.pbs.org/independentlens/waiting-room/), graphically demonstrates what it is like to spend 24 hours in an overcrowded ED waiting room of a large public hospital in northern California. No alternative care is available to the many patients who must wait hour-after-hour for treatment of their acute conditions and chronic illnesses. None of the patients are particularly odd, flamboyant, or embarrassingly funny, and though the film devotes little time to the dramatic life-threatening trauma and illness that characterize most “ER shows,” its strength lies in how adeptly it captures the oppressive, tedious, and anxiety-producing atmosphere of an overburdened health system—making it easy to understand why even the sickest patients sometimes leave without being seen. Eventually, those who do remain are called inside where most are helped and provided with some form of follow-up care. The Waiting Room presents a side of emergency medicine that EPs have long wanted the public to see—not to scare them away from coming to EDs, but in the hope that our country will find a way to provide the resources needed to end epidemic ED overcrowding and ensure adequate emergency care for all.

At its premier screening at the Los Angeles Film Festival last June, Code Black (2013) (http://codeblackmovie.com/) won the jury award for best full-length documentary and went on to win similar awards at the next two film festivals. It is the compelling story of a group of idealistic emergency medicine residents struggling to learn their craft while saving lives in the overcrowded setting of Los Angeles County General Hospital. The overwhelming numbers of ill patients waiting to be seen, a condition the residents refer to as “code black,” and the cramped surroundings of the old County Hospital ED with its legendary “C-Booth” resuscitation area, present daunting challenges to the residents’ goal of helping all who need care. But these challenges turn out to be nothing compared to the residents’ need, midway through their training, to adapt to a new earthquake-resistant LA County General Hospital. Suddenly their familiar ED and its beloved C-Booth are gone. Pristine and functional, the new hospital replaces visibility with privacy, easy access with confidentiality, and patient contact time with endless paperwork.

Can the residents’ idealism survive 21st-century rules and requirements, inaccessibility of care, and a financially strapped municipality that freezes vacant nursing positions, forcing their brand new ED to close almost half the ED beds? In the words of Ryan McGarry, MD, *director of Code Black and a featured EM resident in the film, “When we started this it seemed so simple. We were going to be doctors. We were going to help people. But what if those ideals can die? What if this hope can fade into the failure of the system?” This movie is not just about emergency medicine; it is also about the timeless struggle between young idealists and the worn out, unsuccessful systems they inherit and must adapt to in order to change them and achieve their goals. It is no wonder that Code Black is resonating so strongly with audiences, and why there is reason to believe that our patients and our specialty will be in very good hands for years to come. 

*Ryan McGarry, MD, is currently an EM faculty member at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. During his interview for a position with us last April, he mentioned that he had just completed a documentary about his residency. We hired him anyway.

With this issue, Emergency Medicine expands upon its original mission of providing readable, essential, practical clinical advice, and inaugurates some of the most innovative changes in our 40-year history—changes designed to best meet the 21st century needs of all who practice our ever-changing specialty.

Each new issue of EM will once again offer in-depth feature articles on important clinical topics, along with all of our highly valued regular features that include Emergency Imaging, Case Studies in Toxicology, Derm Dilemmas, Challenges in Sports Medicine and Orthopedics, and Diagnosis at a Glance. Malpractice Counsel and Emergency Ultrasound will also re-appear in the near future, and new features will include “First EDition” which contains news and summaries of important meeting presentations and recent journal articles of particular interest to emergency physicians.

Emergency Medicine will also soon have an updated website at emed-journal.com, which will continue to offer easy access to articles from our print edition, while also presenting news, podcasts, quizzes, videos, and new multimedia and interactive features—all tailored to emergency physicians’ interests and CME needs. Best of all, the site will be optimized to enable easy reading on smart phones, iPads, and tablets. Readers will be able to leave a comment, share an article with colleagues, and incorporate items from the website into their personal media files. Also in the works is an on-line article submission site that will streamline our entire process of peer review and approval.

For this issue of EM, Keith D. Hentel, MD, Chief of Emergency and Musculoskeletal Imaging at NewYork Presbyterian/Weill Cornell Medical Center, has assembled a group of colleagues knowledgeable in the imaging needs of emergency physicians, to present a broad, but detailed, survey of those imaging modalities currently used in practice and those that will be available in the near future. In months to come, a feature article entitled “How Inhibited Are You?” will consider direct thrombin inhibitors (DTIs). Another article will focus on the recognition and management of carbon monoxide poisoning in the elderly and how to “winterize” them from the devastating effects of such seasonal illnesses as influenza, pneumonia, and frostbite. A third article will deal with life-threatening emergencies caused by “hardware for the heart”.

We look forward to hearing your comments on articles by e-mail at [email protected], or on our new website and, as always, please feel free to suggest topics for future clinical reviews and please let us know what you think of the “new” Emergency Medicine, and especially how the journal can better meet your needs and interests in the future.

With this issue, Emergency Medicine expands upon its original mission of providing readable, essential, practical clinical advice, and inaugurates some of the most innovative changes in our 40-year history—changes designed to best meet the 21st century needs of all who practice our ever-changing specialty.

Each new issue of EM will once again offer in-depth feature articles on important clinical topics, along with all of our highly valued regular features that include Emergency Imaging, Case Studies in Toxicology, Derm Dilemmas, Challenges in Sports Medicine and Orthopedics, and Diagnosis at a Glance. Malpractice Counsel and Emergency Ultrasound will also re-appear in the near future, and new features will include “First EDition” which contains news and summaries of important meeting presentations and recent journal articles of particular interest to emergency physicians.

Emergency Medicine will also soon have an updated website at emed-journal.com, which will continue to offer easy access to articles from our print edition, while also presenting news, podcasts, quizzes, videos, and new multimedia and interactive features—all tailored to emergency physicians’ interests and CME needs. Best of all, the site will be optimized to enable easy reading on smart phones, iPads, and tablets. Readers will be able to leave a comment, share an article with colleagues, and incorporate items from the website into their personal media files. Also in the works is an on-line article submission site that will streamline our entire process of peer review and approval.

For this issue of EM, Keith D. Hentel, MD, Chief of Emergency and Musculoskeletal Imaging at NewYork Presbyterian/Weill Cornell Medical Center, has assembled a group of colleagues knowledgeable in the imaging needs of emergency physicians, to present a broad, but detailed, survey of those imaging modalities currently used in practice and those that will be available in the near future. In months to come, a feature article entitled “How Inhibited Are You?” will consider direct thrombin inhibitors (DTIs). Another article will focus on the recognition and management of carbon monoxide poisoning in the elderly and how to “winterize” them from the devastating effects of such seasonal illnesses as influenza, pneumonia, and frostbite. A third article will deal with life-threatening emergencies caused by “hardware for the heart”.

We look forward to hearing your comments on articles by e-mail at [email protected], or on our new website and, as always, please feel free to suggest topics for future clinical reviews and please let us know what you think of the “new” Emergency Medicine, and especially how the journal can better meet your needs and interests in the future.

With this issue, Emergency Medicine expands upon its original mission of providing readable, essential, practical clinical advice, and inaugurates some of the most innovative changes in our 40-year history—changes designed to best meet the 21st century needs of all who practice our ever-changing specialty.

Each new issue of EM will once again offer in-depth feature articles on important clinical topics, along with all of our highly valued regular features that include Emergency Imaging, Case Studies in Toxicology, Derm Dilemmas, Challenges in Sports Medicine and Orthopedics, and Diagnosis at a Glance. Malpractice Counsel and Emergency Ultrasound will also re-appear in the near future, and new features will include “First EDition” which contains news and summaries of important meeting presentations and recent journal articles of particular interest to emergency physicians.

Emergency Medicine will also soon have an updated website at emed-journal.com, which will continue to offer easy access to articles from our print edition, while also presenting news, podcasts, quizzes, videos, and new multimedia and interactive features—all tailored to emergency physicians’ interests and CME needs. Best of all, the site will be optimized to enable easy reading on smart phones, iPads, and tablets. Readers will be able to leave a comment, share an article with colleagues, and incorporate items from the website into their personal media files. Also in the works is an on-line article submission site that will streamline our entire process of peer review and approval.

For this issue of EM, Keith D. Hentel, MD, Chief of Emergency and Musculoskeletal Imaging at NewYork Presbyterian/Weill Cornell Medical Center, has assembled a group of colleagues knowledgeable in the imaging needs of emergency physicians, to present a broad, but detailed, survey of those imaging modalities currently used in practice and those that will be available in the near future. In months to come, a feature article entitled “How Inhibited Are You?” will consider direct thrombin inhibitors (DTIs). Another article will focus on the recognition and management of carbon monoxide poisoning in the elderly and how to “winterize” them from the devastating effects of such seasonal illnesses as influenza, pneumonia, and frostbite. A third article will deal with life-threatening emergencies caused by “hardware for the heart”.

We look forward to hearing your comments on articles by e-mail at [email protected], or on our new website and, as always, please feel free to suggest topics for future clinical reviews and please let us know what you think of the “new” Emergency Medicine, and especially how the journal can better meet your needs and interests in the future.