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September 1, 2014

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AJR9 is the wrong prescription for Nevada

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I am greatly concerned that Assembly Speaker Marilyn Kirkpatrick has proposed legislation to cap expenses in the emergency room with Assembly Joint Resolution 9. As a practicing emergency physician and president of the Nevada chapter of the American College of Emergency Physicians representing 200 doctors, I can tell you that the safety net of medical care in our state is already tenuous. This legislation will destroy it.

On the surface, fixing a price to a multiple of government insurance sounds reasonable, but if you look a little deeper, it is full of danger. Many of my colleagues who are family doctors will see only a small proportion of patients with Tricare or Medicare. Most will see no one with Medicaid. These insurance plans do not reimburse the true cost of health care. Note that these are government insurance plans. To be fair, there is an element of price fixing in our state neighbor to the west. However ,the last time I checked, most Nevadans do not want to be Californians.

We speak of the emergency room as the “safety net.” This is where anyone can go, at any time, for any reason, 24 hours a day, 7 days a week, 365 days a year. Health care providers are bound by law to see anyone who comes to the ER. Most physicians see patients not because it is the law but because seeing patients is simply what we do. In the ER, often I will see a patient who needs more advanced consultation and specialized training beyond emergency care. I rely on a robust call schedule of specialists for help.

However, that call schedule is already strained. Today I worked at a small hospital in Reno where there are already some gaps in the call schedule. If your wife has a stroke, I will need to transfer her away. Are you ready for that ambulance charge? What about driving back and forth to another hospital? In the last year, because I did not have the necessary specialists on-call, I have transferred patients out of state for a bad dental infection and another for a severe eye injury. Recently, I took care of a little girl having a seizure that we could not stop. We placed her into a medically induced coma; she was on full life support for two hours while I tried to find a hospital and doctor to take her in transfer — we did not have the necessary specialist available in Reno. Eventually, we flew her to Las Vegas. We have some of the best pediatric emergency nurses in the nation, but that little girl needed to be in an intensive care unit, not the ER.

If price fixing occurs, transfers will become an even more common occurrence. Patients won’t just be sent to Las Vegas; be prepared for Nevadans being transferred to Sacramento , San Francisco and Salt Lake City. We will see more and more gaps in the call schedule. Doctors who are hospital-based, such as emergency physicians and anesthesiologists, will simply move their practices out of state. Do you think you wait too long to see an ER doctor or to have surgery now? Wait until the doctors stop practicing here and new doctors stop coming.

We should be supporting the work done in Nevada ERs, not punishing it. The Legislature should keep the safety net and reject AJR9.

Greg Juhl, M.D., is the Nevada chapter president of the American College of Emergency Physicians.

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  1. I take exception to your statement "Most physicians see patients not because it is the law but because seeing patients is simply what we do." If that truly was the case, my husband would not have received a letter terminating our relationship with our family physician the minute he turned 65.

  2. In August 2012, Massachusetts passed legislation to put price controls on medical care providers and services. Why? The inflationary pressures that Romneycare put on the state budget and economy. It's a temporary fix with unintended long term consequences. Many of those consequences are explained very well in this article by Doctor Juhl with regard to AJR9.

    Carmine D