Governor Reverses Veto Threat, Takes Action on Hundreds of Bills

 

The California Healthline

Before the midnight deadline Sunday, Gov. Arnold Schwarzenegger (R) signed 478 of the 707 bills before him, the Sacramento Bee reports.

The governor’s last-minute actions included vetoes and signings on a number of health care-related measures (Sanders, Sacramento Bee, 10/13).

Although Schwarzenegger previously threatened to veto all legislation if lawmakers failed to strike a deal to resolve water issues, he backed down from his threat because he said legislators had achieved significant progress in water negotiations (Buchanan,San Francisco Chronicle, 10/12).

The governor said he would call a special legislative session to discuss water issues sometime this week.

Bills Signed

The bills that Schwarzenegger approved will take effect Jan. 1, 2010. Summaries of the health-related bills he signed appear below.

-SBX318 by Sen. Denise Ducheny (D-San Diego) aims to reduce the state’s prison population to 25,000, down 20,000 from its current level (Bailey/Halper, Los Angeles Times, 10/12). In August, a panel of federal judges cited overcrowding as the primary driver of inadequate health care in the prison system (California Healthline, 8/5).

-SB 630 by Senate President Pro Tempore Darrell Steinberg (D-Sacramento) amends current state law to require insurers to cover medically necessary dental and orthodontic services for cleft palates.

-AB 108 by Assembly member Mary Hayashi (D-Castro Valley) bars insurers from rescinding, canceling or limiting individual coverage because of fraud after someone has had a policy for two years (Colliver, San Francisco Chronicle, 10/13).

-AB 119 by Assembly member Dave Jones (D-Sacramento) prohibits health insurance companies from charging different premium rates based on gender.

-SB 148 by Sen. Jenny Oropeza (D-Long Beach) requires clinicians who conduct mammograms to publicize any health violations identified by a Department of Health inspection.

-AB 1383 also by Jones imposes a fee on hospitals in order to draw down increased federal reimbursements for Medi-Cal, California’s Medicaid program. In his signing message, Schwarzenegger noted that separate legislation will be necessary to implement the bill (Sanders, Sacramento Bee, 10/12).

-AB 1544 by Jones and Assembly member Nathan Fletcher (R-San Diego) aims to streamline the approval process for hospital-operated outpatient primary care clinics (Robertson, Sacramento Business Journal, 10/12).

Bills Vetoed

Summaries of health-related bills that Schwarzenegger rejected appear below.

-SB 674 by Sen. Gloria Negrete McLeod (D-Chino) would have established greater oversight for fertility clinics. Schwarzenegger said the bill did not go far enough in enacting stronger regulations (Los Angeles Times, 10/12).

-SB 161 by Sen. Roderick Wright (D-South Central Los Angeles) would have required insurers to expand coverage of orally administered cancer drugs.

-SB 820 also by Negrete McLeod would have permitted the Medical Board of California to get involved in physician discipline cases earlier (Sacramento Business Journal, 10/12).

-AB 2 by Assembly member Hector De La Torre (D-South Gate) would have restricted the ability of health insurers to rescind an individual’s health insurance policy. Schwarzenegger said the bill would have benefited attorneys more than consumers.

-AB 98 also by De La Torre would have required health insurers to cover maternity services. Schwarzenegger said the bill would contribute to rising health care costs. This is the third time the governor has vetoed such a measure (Sacramento Bee, 10/12).

-AB 120 by Hayashi was intended to boost the oversight and discipline system for doctors in California (Sacramento Business Journal, 10/12).

-AB 513 by Assembly member Kevin De Leon (D-Los Angeles) would have required health plans to cover lactation consultation and breast pump rental. Schwarzenegger said this bill would increase health care costs.

-AB 911 by Assembly member Ted Lieu (D-Torrance) sought to ease emergency department overcrowding by requiring hospitals to calculate ED crowding scores. Schwarzenegger said the bill was unnecessary (Sacramento Bee, 10/12).

October 7, 2009

Gov. Weighing Bill To Combat Overcrowding in Emergency Departments

The California Healthline

Gov. Arnold Schwarzenegger (R) is considering legislation (AB 911) that would create a new system for monitoring overcrowding in the state’s emergency departments, theSacramento Bee reports.

ED traffic rose by 12% year-to-year during the first half of 2009, according to the Office of Statewide Health Planning and Development, and is expected to increase if the H1N1 influenza becomes more widespread.

The measurement system would be based on:

-How many people are in ED waiting rooms;

-How many available beds the department has;

-How quickly the patients are seen; and

-Other variables.

The bill, by Assembly member Ted Lieu (D-Torrance), was easily approved by the Assembly and Senate.

Gov. Schwarzenegger has until Sunday to sign or veto the bill, or it will become law without his signature.

Support, Opposition

The California Chapter of the American College of Emergency Physicians supports passage of the measure, but the state Department of Public Health opposed the bill in a letter sent to Lieu in June.

The California Hospital Association has taken a neutral stance on the current measure, but opposed an earlier version of the bill (Calvan, Sacramento Bee, 10/7).

Abid Mogannam &
Brian Potts MD, MBA
Managing Editors, CAL/AAEM News Service
University of California, Irvine

 

 

Retail clinics competing with physicians to treat complex illnesses.

The American Medical Association

On the front page of its Marketplace section, the Wall Street Journal (9/10, B1, Merrick) reports that retail health clinics are increasingly treating patients’ chronic diseases, and in turn, posing as greater competition for doctors’ groups and hospitals. Chains are also pushing for increased insurance coverage as they begin offering more complex and expensive treatments. For their part, some physicians argue that in-store clinics are not appropriate places to treat complex conditions.

Abid Mogannam &
Brian Potts MD, MBA
Managing Editors, CAL/AAEM News Service
University of California, Irvine

Shortage of primary-care physicians seen as driving many patients to emergency departments.

The American Medical Association

USA Today (9/9. Szabo) reports, “Uninsured patients aren’t the only ones using the [emergency department (ED)] for non-urgent care. With too few primary-care doctors to go around, many patients turn to the [ED] when they can’t get an appointment with their regular physician, says Sandra Schneider, president of the American College of Emergency Physicians.” Ted Epperly, president of the American Academy of Family Physicians, pointed out that “in some ways, insurance payments contribute to the shortage…by discouraging physicians from going into primary care.” Medicare “pays doctors far more to perform procedures than to monitor a patient’s overall health, Epperly says. In the past decade, only 10 percent of new doctors — who graduate from medical school with an average of $140,000 in student loans — have gone into primary care,” according to Epperly.

School Site Coordinator & Education Committee Member – American Academy of Emergency Medicine (AAEM) / RSA

3. Rules of the Road: Aug/Sept – Time to start applying!

1)  Ideally, take your EM rotation as early as possible.
2)  Request letters of recommendation.
3)  Meet with advisors, and have them review your personal statement and CV.
4)  Work on completing applications by early October.

Emergency Medicine Clerkship – How to be a STAR!!
Chapter 18, “Rules of the Road for Medical Students”

Time to Shine!

-Work hard: be enthusiastic, work well with the entire team.
-Be punctual and expect to stay late: don’t sign out simple tasks you could complete yourself. Ensure that your patients are stable, labs and imaging have been reviewed and everything is documented in the chart.
-Dress professional: if you’re not sure about scrubs or business casual, contact the clerkship coordinator ahead of time.
-Keep supplies on hand: white lab coat, stethoscope, penlight, eye protection and trauma shears.
-Use your down time wisely: for education or being helpful.
-Keep some useful pocket resources: “Pocket Pharmacopoeia,” “Sanford’s Guide to Antimicrobial Therapy” and “House Officer Series Emergency Medicine” are a few suggestions.
-Orient yourself to the ED and know your limits!
-Learn the names (and get along with!) the nurses you will be working with.
-When you receive a chart, pay attention to the nursing triage notes and the patient’s chief complaint.  Use this to formulate a broad differential diagnosis that will help direct your history and physical.
-Review vital signs (including pain level and oxygen saturation), and alert the senior or attending if there are unstable alterations in levels of consciousness or if the patient has a chief complaint of chest pain or shortness of breath.
-Introduce yourself to the patient by shaking hands, and make your initial observations (distress? diaphoretic? writhing in pain? etc.).
-Perform your history and physical, respecting the department’s policies on having a chaperone for sensitive parts of the exam.
-Revise your differential diagnosis, and take a moment to get organized before presenting your concise and pertinent case including differential diagnosis and treatment plan to your senior/attending.
-Ensure that your plan is accomplished by checking rather than pestering.  Consider placing IV’s yourself (if you know how and have communicated with the nurse), drawing labs/specimens and labeling them properly.
-Consider serial examinations, especially if your patient has chest or abdominal pain, and after an intervention.
-Document EVERYTHING, and include the time meds were ordered, consults were paged, etc.  Make sure the chart reflects the physical exam, as confirmed by your resident.

Non-Clinical Time

-Read about patients you had during shifts, as well as the “bread and butter topics” discussed during lectures.
-Always attend conference and journal club.

Evaluations

-Some important aspects that will be evaluated by the numerous attendings and residents that you work with are:
* Your work ethic, interest and enthusiasm for EM.
* Your ability to rapidly apply new learning.
* Your ability to perform a focused history and physical.
* Your ability to critically evaluate abnormal exam findings.
* Your ability to evaluate abnormal laboratory data.
* Your ability to create a complete differential diagnosis.
* Your ability to develop an appropriate treatment plan.
* Your ability to work well with others (i.e., nurses, techs, consultants, etc.).
* Your ability to demonstrate empathy and compassion.

Ask for feedback at the end of each shift. Have your attending or resident review things you did well, as well as things you still need to work on. Do not wait until the last few days of your rotation to ask for feedback. You do not want to learn about repetitive mistakes that could have been easily corrected earlier had you inquired.

AAEM/RSA QUICK LINKS:
www.aaemrsa.org – our newly re-designed website is your first stop for everything emergency medicine!
http://www.aaem.org/education/scientificassembly/ – mark your calendars for the 16th Annual Scientific Assembly in Las Vegas, NV!
https://ssl18.pair.com/aaemorg/membership/application_residentstudent.php – join!  Email your friends, and ask them to join – they reap the benefits of our large organization, and their membership supports our advocacy efforts across the country!
http://www.aaemrsa.org/resources/emig-starter-kits.php – plan your next EMIG meeting with our ready-made lectures.
http://www.emselect.org/home.cfm – for the best residency interview tool available!
http://www.facebook.com/ – Find us on Facebook!

AAEM/RSA
555 East Wells Street, Suite 1100
Milwaukee, WI 53202-3823
800-884-2236
Fax: 414-276-3349
Email: info@aaemrsa.org
Website: www.aaemrsa.org

Study indicates immediate intervention may not provide any benefit compared with delayed angioplasty in patients with milder heart attacks

The American College of Emergency Physicians

Bloomberg News (9/2, Ostrow) reports that, according to a study published Sept. 2 in the Journal of the American Medical Association, “patients rushed to the hospital for treatment of a suspected heart attack may fare just as well by waiting until the next day” to undergo “artery-clearing procedures, such as angioplasty or inserting a stent.”

HealthDay (9/1, Edelson) reported that, according to the researchers, “There was no significant difference in key measures of heart damage and one-month death rates in the study of 352 people with the mild form of heart attack called non-ST elevation myocardial infarction between those who had immediate angioplasty and those who waited an average of 21 hours for the procedure.” In fact, the investigators “found the incidence of deaths, second heart attacks, or need for second procedures was higher in the group that had angioplasty within 70 minutes of diagnosis (13.7 percent) than in the group of patients who waited nearly a full day (10.2 percent).”

MedPage Today (9/1, Emery) reported that the study authors concluded that “the strategy of immediate intervention does not appear to provide any benefit or harm in comparison with an intervention postponed to the next working day; it was, however, associated with a significantly shorter hospital stay.” HeartWire (9/1, Hughes) also covered the story.
Abid Mogannam &
Brian Potts MD, MBA
Managing Editors, CAL/AAEM News Service
University of California, Irvine