Before the Assembly Standing Committee on Health Chairman, Assembly Richard N. Gottfried

Assembly Standing Committee On Insurance
Chairman, Assemblyman Alexander B. Grannis

February 16, 2005
Roosevelt Hearing Room C,
Legislative Office Bldg., Albany, NY

The New York Chapter of the American College of Emergency Physicians (New York ACEP) greatly appreciates the opportunity to comment on the renewal and revision of HCRA as it relates to Emergency Medicine.  My name is Dr. Sam Bosco and I am the Chief of Emergency Medicine at St. Peter's Hospital in Albany as well as Co-Chair of New York ACEP's Governmental Affairs Committee.

First, Assembly Member Gottfried and Assembly Member Grannis, we would like to thank you and your colleagues in the Assembly for your strong support for New York ACEP and Emergency Medicine in New York State.  With the expiration of HCRA this June, we would like to share with you the challenges faced by emergency physicians in today's health care system including chronic overcrowding of hospitals, lack of specialty care within emergency departments, and inadequate Medicaid reimbursement rates.  We look forward to working with you to address these challenges in order to ensure access to the highest quality of emergency care for all New Yorkers.

New York ACEP represents over 1500 emergency physicians across the state that have a shared mission to provide the highest quality emergency medical care for all patients regardless of their ability to pay for care.  Emergency departments and the people who work there play an invaluable role in every community across the State, as the entry point for the health care needs of all New Yorkers.  As you are aware, emergency physicians are one of the largest indigent care providers in the State, providing care 24 hours a day, 365 days a year to every patient who walks in the door, regardless of the patients' ability to pay.  With over 7 million people visiting New York's emergency departments every year and the increased threat of terrorism in New York, it is particularly important for emergency departments to be prepared for the possibility of a large-scale emergency crisis.

Increase In Hospital Crowding

The first challenge that we would like to discuss today is the chronic overcrowding of hospitals throughout the State.  Overcrowding in hospitals is an increasing problem in New York State and nationally and is not caused by misusage or unnecessary visits to emergency departments. Rather, overcrowding has to do with sick patients who have been evaluated, treated and admitted, but who cannot be transferred to inpatient units of the hospital, because rooms are not made available.

Surveys by New York ACEP and the State Department of Health show that hospital crowding and ambulance diversion are significant problems in nearly every geographic area of the State and are not simply due to episodic or seasonal events.  As a result, hospitals sometimes lack the capacity to respond to emergency patient needs and emergency department volume.

In some institutions the situation has reached crisis proportions.  Due to capacity and resource constraints within hospitals, care is delayed for waiting patients or patients are diverted to other hospitals, requiring travel at significant distances in an emergency and compromising continuity of care and patient choice.  When ambulances are diverted, in some cases, patients are not being transported to the hospital of their choice, denying them access to their private physicians. Additionally, patients who have been seen and admitted to the hospital are sometimes boarded in hallways for inordinate amounts of time without comforts like a bathroom, mattress, call light, privacy or confidentiality while awaiting inpatient beds.

Assemblyman Gottfried, thank you for the leadership you have taken on this issue by introducing Assembly bill 3264.  We believe this legislation will be instrumental in reducing hospital crowding and ambulance diversion.  As you are aware, this legislation codifies into law the Department of Health's guidelines on hospital crowding and ambulance diversion and creates new mechanisms to implement and enforce these directives, including a toll free hotline for patients and unannounced annual inspections by the Department of Health. This legislation will ensure timely access to the highest quality of care for all patients who seek emergency medical services. We look forward to working with you and your colleagues on its advancement this session.

Loss of On-call Physician Specialty Services

Another difficult issue facing emergency medicine is the lack of access in the emergency department to specialty care. As mentioned earlier, emergency physicians provide care to every patient who walks into the emergency department.  Increasingly, we do so with reduced specialty physician back up from on-call specialists such as surgeons, neurosurgeons, plastic surgeons, obstetricians, orthopedic surgeons and cardiologists.

Reduced access to on-call specialists results in significant delays for patients awaiting care and increases the number of patients that must be transferred to obtain the required services.  This reduced access to specialists is due to many factors including the high-risk nature of patient needs, difficult working conditions in crowded emergency departments, an increase in uncompensated care, and the fact that many surgeries can now be performed in outpatient settings.

Numerous studies confirm this erosion of on-call coverage of hospital emergency departments including a 2003 GAO report, a 2003 HHS report, and 2003 survey by the American Hospital Association.  While this is a complex problem that may be beyond the control of government, we want you to be aware of it and its implications for patient care. We were particularly concerned during last year's discussions on prohibiting balance billing that the proposals would further reduce patient access to on-call specialists in hospital emergency departments. An unintended effect of the proposals could be to force specialists to make an unpalatable choice of either absorbing further financial losses by accepting inadequate government and commercial insurance rates or further reducing their coverage at hospitals, jeopardizing this important health care safety net.

Inadequate Reimbursement for Mandated Services 

The considerably low Medicaid payment rate is a third factor that undermines the ability of emergency physicians to provide adequate care.  Unlike other physician specialties, emergency physicians are required by state and federal law to serve all patients and yet the Medicaid payment rates are grossly inequitable for emergency care, providing only $17 per visit compared with $30 for a primary care visit. The costs for medical liability insurance, billing, overhead and standard benefits per patient vastly exceed the $17.00 per visit even before considering any compensation for services rendered for patient care evaluation and treatment.

Because of our commitment to patient care, emergency physicians bear a disproportionate financial burden for uninsured and low-income individuals. While we recognize the current fiscal crisis in the State, we believe that Medicaid rates should be enhanced to pay for the actual cost of care delivered in EDs. We ask you to consider a Medicaid fee increase for emergency physicians in the context of the upcoming HCRA expiration and State Budget negotiations.

 Thank you again for the opportunity to testify before the Assembly Standing Committees on Health and Insurance.  The New York Chapter of the American College of Emergency Physicians looks forward to working with you to address the issues we have raised today, in order to ensure access to the highest quality of emergency care for all New Yorkers.