The IOM Reports on the Hill: Will Legislation Gain Momentum?

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The Institute of Medicine’s (IOM) 3 reports on the future of US emergency care have catalyzed a revival of dormant legislation in Congress that begins to address the overburdened and underfunded conditions of emergency departments (EDs).

The newly introduced bills (H.R. 882 in the House, S. 1003 in the Senate), styled the “Access to Emergency Medical Services Act,” were first introduced in 2005 but didn’t gain wide enough approval. The biggest difference between the original versions of these bills and the new legislation is that a provision for medical liability reform has been dropped.

“Liability reform is a distant hope in the current climate of Congress,” said Gordon Wheeler, Associate Executive Director for Public Affairs for the American College of Emergency Physicians (ACEP).

Emergency medicine officials are hopeful the IOM reports, and tweaks to the bills, will push them further in the 110^th Congress.

What follows is a summary of the main provisions of the 2007 House bill—creation of a special commission, funding for EMTALA-related care, and action on boarding—which is sponsored by US Representatives Bart Gordon, D-Tennessee, and Pete Sessions, R-Texas:


1.Following the IOM recommendation, the bill creates a commission that will examine factors, such as ED crowding, the availability of on-call specialists and medical liability issues, which affect delivery of emergency medical services. The commission will be required to make specific recommendations to Congress that would rectify these obstructions to patients receiving care.


2.It authorizes an additional payment through Medicare to all physicians who provide EMTALA-related care, including on-call specialists whose services are needed to stabilize the patient. The additional funding would help ensure emergency and other physician specialists are able to continue providing care to the growing Medicare population. These payments would not increase Medicare beneficiaries’ co-payments and would also be outside the budget neutrality requirements, so they would not negatively impact any other physicians’ Medicare payments.


3.It requires hospitals to report to the Secretary of the Department of Health and Human Services (HHS) the amount of time admitted patients are being held, or “boarded,” in the ED while they wait for inpatient beds to become available. If the data collected justifies the development of a quality measure to ensure improved patient care, then HHS would work with hospitals, physicians, nurses and other affected parties to develop a hospital boarding measure aimed at alleviating this problem, as recommended by the IOM report.



“Last year’s reports from the Institute of Medicine found that underfunding, overcrowding and personnel shortages are serious problems in hospital emergency rooms,” Gordon said. “Emergency departments often can’t find specialists such as orthopedic surgeons and neurosurgeons willing to be on call because of the high number of uninsured patients and the increased liability risks.”

“My bill would shore up the nation’s emergency care system with an immediate 10% increase in Medicare payments for emergency department services. It also requires a commission to look into addressing the specialist shortage problem and requires the hospitals to collect data on how long patients are left in the emergency department, which is a primary cause of overcrowding and ambulance diversions.”

Gordon said he hopes Congress will hold hearings this year on the ED crisis, which he believes would spur passage of the legislation. He urged supporters of the House bill to contact their member of Congress and ask him or her to co-sponsor the bill, and to sign a letter to the House Committee on Energy and Commerce requesting congressional hearings.

The primary difference between the House and Senate bill, introduced by Senators Debbie Stabenow, D-Michigan, and Arlen Specter, R-Pennsylvania, concerns boarding. Instead of following the HHS approach, the Senate bill follows recommendation 4.5 made in the IOM report, which reads as follows:

Hospitals should end the practices of boarding patients in the ED and ambulance diversion, except in the most extreme cases, such as a community mass casualty event. The Centers for Medicare and Medicaid Services should convene a working group that includes experts in emergency care, inpatient critical care, hospital operations management, nursing and other relevant disciplines to develop boarding and diversion standards, as well as guidelines, measures, and incentives for implementation, monitoring, and enforcement of these standards.

The IOM reports have provided considerable bipartisan momentum in favor of the revised legislation, said Dean Wilkerson, ACEP’s Executive Director. The House bill has 35 co-sponsors, and the Senate bill 2. All of the major emergency medicine groups have supported the bills, and the measures won approval from the American Medical Association’s board of trustees in late April. Wilkerson said such approval was key, providing “jet fuel for our bill.” A concerted lobbying effort will be considerably strengthened by the presence of the IOM reports, Wilkerson said.

“I think the IOM report definitely documented some issues and problems, which are consistent with what Congress is trying to do,” he said. “We feel like the IOM reports give us a lot of legitimacy on the Hill.”

The legislative push is but one of several means of seeking change on the federal level, said Brent Asplin, an associate professor of emergency medicine at the University of Minnesota and one of the IOM report authors. It’s important not to ask Congress for too much, and to be pragmatic, he said. That explains why medical liability reform is out, at least for now.

“We are trying for something that might actually pass,” he said. “Focusing the areas that are most likely to be successful, as it is with any political and legislative advocacy, is critical.”