In This Issue:
- President’s Message
- Emergency Department Overcrowding and Patient Satisfaction: A Potential Solution
- Michigan Update
- Resident Corner: Tips and Tricks for the Job Hunt
Michael Walters, MD JD FAAEM
President, GLAAEM Board of Directors
Happy New Year!
Also, we are holding elections this year for several state representatives and a resident representative. So please consider running for a position or nominating someone. This is a great way to get involved in your profession. You can submit a nomination here until January 16, 2016: http://www.glaaem.org/leadership/elections.
Thank you, and see you in Las Vegas for the 22nd Annual AAEM Scientific Assembly (AAEM16)!
Sudhir Baliga, MD FAAEM
Secretary-Treasurer, GLAAEM Board of Directors
No emergency physician would consider emergency department overcrowding synonymous with high patient satisfaction. In fact, most people would think the two terms are diametrically opposed. I certainly have dealt with my fair share of patients who are upset about having to wait to be seen during high volume shifts. It can make a stressful situation feel even more hopeless since you are already trying to dig out of a hole and have patients angry before you have started to care for them. Overcrowding is a strain on patients and emergency care providers.
However, my department may have found a way to help with overcrowding while maintaining patient satisfaction. As a point of reference, I work in an inner-city academic emergency department with an approximate annual census of 95,000 patients. We often have surge overload in our fast track area. To help with the surge overload, our LEAN team proposed that we evaluate certain patients in chairs rather than in stretchers. Chairs take up less space and can be turned over quicker for new patients to be seen than stretchers. This potentially allows us to see more patients and help alleviate overcrowding.
When implementing this plan, many care providers, including myself, questioned if it would actually work and wondered what patients thought of the plan. We decided to find out what patients thought by carrying out a survey for patients seen in chairs.1 The results were quite interesting. Over 89% of the patients surveyed want their ED stay as short as possible, with 81% willing to be seen in a chair than wait for a stretcher to become available. Over 93% felt their privacy was respected while being evaluated in a chair, despite some of the chairs being located in hallways. Over 78% of patients were satisfied with their emergency department experience and over 87% will return to our department for their future emergency care. The study suggests most patients were willing to be in chairs and were satisfied with their experience. Our study was not designed to determine if patient length of stay was decreased or if overcrowding was improved. But it does show that patients want to have a short ED stay and are willing to be seen in chairs to help potentially achieve that goal.
To help maintain patient satisfaction during episodes of overcrowding, especially in a fast track module, you may want to consider evaluating certain patients in chairs instead of waiting for stretchers to open up.
1. Baliga S, Klausner H, Thompson R, Oddo M. “Patient Satisfaction While Receiving Emergency Medical Care in Chairs.” Annals of Emergency Medicine, 2015, 66; 4(supplement):S96.
Robert A. Hoogstra, MD FACP FAAEM
Michigan State Representative, GLAAEM Board of Directors
Courtesy of: Colin J. Ford, Senior Director, State and Federal Government Relations, Michigan State Medical Society
Medicaid: While formal discussions regarding the fiscal year 2017 budget won’t commence until the Executive Budget Proposal from the Governor in January, groundwork to facilitate Medicaid spending into the future is already occurring. Due to a confluence of several factors, the Medicaid budget in Michigan appears to be facing a series of headwinds that will result in a challenging political environment. These challenges are as follows:
- HICA Sunset: The Health Insurance Claims Assessment (HICA) is a financing mechanism that meets the requirements for federal matching for Medicaid. HICA is assessed on nearly all paid health insurance claims, and has been controversial among employer and business groups. HICA became effective in 2012 and is responsible for financing up to $400 million (but the actual collection is closer to $210 million) of the state’s contribution to the Medicaid program. When the legislation was originally passed, it included a sunset provision that requires reauthorization by the legislature. Should the legislature not act, the state would need to make cuts in services totaling more than $600 million to the Medicaid program when the loss of the favorable federal match is added to the loss of state revenue. Currently, legislation to reauthorize HICA is on the floor of the Senate and it is unclear if there is sufficient support to pass this legislation at the current time.
- FMAP Changes: The federal match rate, or FMAP is set by the federal government annually and determines the percentage of spending the federal government contributes to Medicaid in Michigan. FMAP is a trailing calculation that takes into account factors such as unemployment and average income over the last three years. As the economy in Michigan has improved over the last few years, the rate at which the federal government assists in our Medicaid spending is going down correspondingly. The FMAP rate will be adjusting from 65.60% to 65.15%. While this percentage may seem small, it is applied to an expenditure of nearly $13 billion, consequently this change will result in budget shortfall of almost $100 million for the coming fiscal year.
- Medicaid Expansion: Under the Affordable Care Act, the federal government provided 100% funding for the initial three years of coverage, however that figure declines over time to eventually reach 90%. Fiscal year 2017 will be a 95% match from the feds which will require approximately $117 million in new contributions from the state to continue to fund Medicaid expansion in Michigan.
Collectively, these headwinds total a more than $400 million shortfall in state funds for Medicaid which translate into cuts of more than $1.5 billion if left unresolved. While none of this is final, the challenges to maintain spending on Medicaid in the coming year will be sufficiently challenging.
Scope of Practice: Senate Bill 68 and Senate Bill 320 would change the scope of practice for APRNs and CRNAs respectively. These bills were initially introduced to effectively provide that APRNs and CRNAs would be able to function identically to physicians from a legislative and regulatory perspective. These bills were introduced to fairly broad support, however, advocacy from the physician community have helped to diminish legislative interest in these bills. Currently, both bills have stalled in the Senate and are awaiting further action.
Governor’s Prescription Drug and Opioid Abuse Task Force: In an effort to reduce the increased prevalence of the illicit use of prescription drugs and the related increase in the use of heroin when prescription drugs are unavailable or unaffordable, the Governor convened a multi-stakeholder task force that has made the following recommendations:
- Updating or replacing the Michigan Automated Prescription System (MAPS).
- Requiring registration and use of MAPS by those who are prescribing and dispensing prescription drugs.
- Updating regulations on the licensing of pain clinics, which hasn’t been done since 1978.
- Increasing licensing sanctions for health professionals who violate proper prescribing and dispensing practices.
- Providing easier access to Naloxone, a drug that reduces the effects of an opioid overdose.
- Limiting criminal penalties for low-level offenses for those who seek medical assistance with an overdose.
- Increasing access to care through wraparound services and Medication Assisted Treatment programs.
- Requiring additional training for professionals who prescribe controlled substances.
- Reviewing successful drug takeback programs for possible replication and expansion.
- Increasing the number of addiction specialists practicing in Michigan.
- Reviewing programs to eliminate doctor and pharmacy shopping and requiring a bona-fide doctor-patient relationship for prescribing controlled substances.
- Creating a public awareness campaign about the dangers of prescription drug use and abuse and how people can get help for themselves or family members.
- Increasing training for law enforcement in recognizing and dealing with addiction for those officers who do not deal directly with narcotics regularly.
- Considering pilot programs for the development of testing to reduce the increasing incidence of Neonatal Abstinence Syndrome, which leads to severe withdrawal symptoms for babies born to mothers who have been using opioids.
Chase Deobald, DO
Resident Representative, GLAAEM Board of Directors
What an exciting time to be searching for jobs?! Although this article may be arriving late for soon-to-be-graduating residents, I hope it is helpful for residents who will be graduating in 2017 or later. All of this information is coming from my personal experience with the process. I am not an expert but hope you find it useful.
There are a number of websites to search for jobs or leave your contact information for phone or email offers. This is a great way to start your job search. Many websites and recruiters will send you the same job offers repeatedly. But it is difficult to appreciate the positives and negatives of any opening if you’re unsure of basic contract requirements across the country. You will often see only basic details posted for an opening but it may be enough to either pursue a phone interview or stop there. Keep in mind that the job search is a process, some job markets open up during the process while other markets are desirable and rarely have openings. I definitely recommend setting up a separate email for for your job search because the offers will keep coming long after you sign. Websites I used included AAEM Job Bank, emphysician.com, NEJM and JAMA Career Centers, practicmatch.com.
Once you provide your email for a website or even with a recruiter, there is considerable trickle down to recruiters across the country. Though some recruiters are great at following up once you reply to mass generated emails, I was really disappointed at how often I received replies. Do not second guess the strength of your candidacy if you rarely receive replies. Be positive and persistent.
- Direct contact
If you know which marketplace you want to end up in, contact that group (or groups) directly. They will have a primary recruiter who is often better at following up than many national recruiters.
If you have interest in moving to the Western U.S., make contact earlier in the year, roughly July/August. For Midwest positions, September/October should be appropriate. I cannot speak for jobs in the Eastern states. It is obviously difficult for groups to understand their staffing needs one year from the time you make contact so you may be waiting until late in the Fall before you hear from a group.
It is possible to complete multiple interviews in one city over a couple days. Be honest with groups about your timeframes ("I have two hours open to interview that morning. Please excuse my busy residency schedule.") They should work with you, particularly if you purchased your own plane ticket. On the other hand, if a group paid for your flight and/or hotel, be respectful of the interview day they plan. Expect to meet several partners, nursing leadership, and potentially hospital leadership (depending on the length of your interview). Most interviews are pretty calm and less anxiety filled than during medical school/residency interviews. Remember, this is a buyer’s market. You have the power (in most cases).
- Contract review
Not to veer too far off topic but once you make the decision to sign with a group, they will send you a contract to review. The safest plan is to pay for legal review to ensure there are no hidden details in your contract. However, expect that the group will not make any changes to your contract. You can discuss areas of your contract that are vague or concerning, but all group members sign the same contract so do not expect changes to be made. Due to this, the cost of legal review seems like wasted money, but it is not. It is a great time to learn about contract language and ensure you aren't being trapped in a lengthy contract that will come back to bite you at a later time. Expect to pay between $600-1,000, depending on the marketplace you are in and extent of legal review. Also consider finding an attorney who is 1) licensed in the state you are signing and 2) has completed physician contract review in the past, hopefully emergency medicine contracts.
I hope you find this information useful. Appreciate the fact that I am not an expert but learned a few things about the process over the past year. There are a number of resources available online, including your faculty. Barbara Katz is a well respected physician recruiter and writes often for ACEP.
Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM, its chapter divisions or affiliates. These articles are intended for the individual use of AAEM members.