The health care industry is changing daily and at a very rapid pace. Some of the changes surrounding and impacting emergency medicine are:
Explore This IssueACEP Now: Vol 34 – No 03 – March 2015
- Patients self-directing their care.
- The explosion of the urgent care industry.
- Hospitals moving into the insurance business.
- Telemedine and its potential applications for EM.
- Increasing demand for quality and value metrics.
- Retail competition in the delivery of health care and the issue of cost.
- Dramatic increase in high-deductible insurance plans.
- Medicaid expansion and the changing uninsured population.
- Out-of-network care and the associated patient balance billing issue.
- Increasing shift of patient care from inpatient to outpatient settings.
Where does emergency medicine fit into this emerging framework? Does it fit at all—does it even have to fit, or can it remain effectively outside and immune from this new world order of health care? How do we add value as the transformation occurs? To some degree, in the early days of managed care, the specialty did remain somewhat outside of the industry changes, although the specialty certainly took its hits, especially in the reimbursement arena via inappropriate and erroneous claims denials. Virtually all major insurers saw class action lawsuits filed against them and emergency medicine did recoup a substantial amount of previously lost revenue, but the recoupment came years after the original services were provided.
Today there are certain emerging trends that the specialty will be forced to address and it would be prudent to prepare sooner rather than later. This article is focused on the emerging trends requiring the establishment of metrics for quality and value and, very importantly, who will define these metrics as they apply to EM.
Rappleye includes “persist in driving change” as one of her seven steps to leading health care transformation.1 If EM is, in fact, to emerge as a leader in effecting change and transformation, this may very well include partnering with other specialties, particularly to address the care continuum and continuity of care issues. We in emergency medicine will need to expand our role, especially as it relates to transitions of care. One way or another, it is imperative that EM define and stake out its ground by defining the performance metrics under which it will be measured and judged. The specialty should drive the process of developing and implementing these metrics, especially in the context of how others presently define quality and value. Let us review in terms of financial value.
Three of the most severely ill or injured emergency medicine patients, as described by the American Medical Association in the 2014 CPT manual, are (inclusive of their level of service designation):2
99284: Emergency department visit for a patient with flank pain and hematuria.
99285: Emergency department visit for a patient exhibiting active, upper gastrointestinal bleeding.
99291: First hour of critical care of a 45-year-old who sustained a liver laceration, cerebral hematoma, flailed chest, and pulmonary contusion after being struck by an automobile.
In today’s evolving and very dynamic health care environment there are several determiners of value as it applies to emergency medicine. The industry’s three major sources of financial value metrics are the Centers for Medicare & Medicaid Services (CMS), insurers, and the hospital c-suite. Regarding CMS and insurers, we’ll focus on value as measured in payment rates. Regarding the c-suite, we will present a different set of metrics for review.
The current Medicare 2014 national reimbursement rates for the three levels of care noted above are:
Medicare 2014 Rates
Stark reality hits home here regarding the financial “value” placed on some of the most severely ill or injured patients seen every day in our emergency departments, starting with the Medicare program. In today’s commercial world, people are paying, on average, $200–300 for their new mobile phones; $300 for a 30–39” television, and anywhere from $150–260 for a dinner outside the home for a family of four. The average daily corporate travel per diem rate is currently $293.3 As the retailization of health care continues to evolve, it would seem payers have a way to go to more equitably reimburse emergency physicians, particularly for treatment of our most severely ill and injured patients. More specifically, Medicare reimburses $75 less for a critical care patient than the current price paid by thousands of people every day for their latest phone and $68 less than the current average corporate per diem rate. It gets far worse when scrutinizing our other governmental program, traditional Medicaid. By way of comparison and inclusion, Walmart is diving into the primary care arena at $4/patient visit, driving the economic value of care even lower.4
What are the value metrics used by the hospital c-suite today? These also likely play a role in payer determinations of value in establishing their proffered reimbursement rates. As itemized by Ellison, these metrics are:5
- Average time spent in the ED before patients were admitted to the hospital as an inpatient: 274 minutes.
- Average time spent in the ED after the physician decided to admit them as an inpatient but before leaving the ED for their inpatient room: 98 minutes.
- Average time patients spent in the ED before being sent home: 134 minutes.
- Average time patients spent in the ED before being by a health care professional: 26 minutes.
- Average time patients who came to the ED with broken bones had to wait before receiving pain medication: 57 minutes.
- Percentage of patients who came to the ED with stroke symptoms who received brain scan results within 45 minutes of arrival: 57 percent.
Why are these particular metrics isolated, and what is behind monitoring these types of metrics? Eggbeer and Bowers make two very relevant and cogent points regarding two of the major determiners of value in today’s health care marketplace, namely the hospitals and insurers.6 First, “an estimated 20 percent of health system networks offer either their own insurance product or a co-branded product. An American Hospital Association survey of 100 hospitals last year found that 38 of the hospitals already owned health plans, while an additional 21 were planning to offer a health product in the next three to five years.” In this marketplace hospitals are beginning to forge relationships with payers, and therefore blurring traditional provider/insurer lines of demarcation.
Medicare reimburses $75 less for a critical care patient than the current price paid by thousands of people every day for their latest phone.
The second major point made by these same authors is, “a health plan is fundamentally a risk-selection business, wherein cost control and financial stability are core values. In the emerging consumer market of public and private exchanges, quality, cost, service, and convenience are the major value drivers.” Emergency medicine practices, save for independent, freestanding EDs and their practices, all are housed within hospitals and these hospitals are increasingly viewing every aspect of care and the providers associated with that care from a commercialized and retail-oriented lens. Mellin and Funk go so far as to include physician profiling as one of their six key metrics in population health management.7 Measures of clinical efficiency are coming more frequently to the forefront as the health care landscape continues to take shape. There is a clear message for emergency medicine in Musssallem’s words, “we need to show up with evidence.”8
Regardless of where we look, it is also important to recognize that many of the programs and associated metrics being measured are focused on reducing emergency department visits. We are, therefore, looking at a potential revenue hit for emergency medicine practices, especially in hospitals developing these programs that are many times formed from partnerships of hospitals and insurance plans.
When evaluating an ED practice, Alan Channing, one of our nation’s most respected c-suite executives, uses a very straightforward methodology with the following benchmarks for “keeping the hospital happy”:9
- Build business
- Have rapid throughput
- Achieve high Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) scores
- Have good communications
- Keep referral sources happy
- Simplify management issues
- Earn consistent and high quality scores
- Minimize hospital’s financial participation
- Support mission, vision, and values (specific to the Sinai Health System)
What does all this mean for EM? Where is the specialty going and in what direction? Will it emerge as a leader in effecting change? What are the metrics the specialty believes are critical to its success and legitimate for others to measure us by in this emerging new landscape? What new challenges should we be embracing? How can we help our hospital partners master transitions of care? The opportunities and timing are peaking for emergency medicine.
Mr. Holstein is a director at Zotec Partners in Bala Cynwyd, Pennsylvania.
Dr. Sama is President of Progressive Emergency Physicians Management, LLC, and Past President of ACEP.
- Rappleye E. 8 steps to leading healthcare transformation. Becker’s Hospital Review. November 25, 2014.
- American Medical Association. CPT 2014 Professional Edition. Atlanta, GA: American Medical Association; 2014.
- Davis C. BTN’s 2014 Corporate Travel Index. Business Travel News. March 17, 2014
- Diamond D. Health Care For $4: Are You Ready for Walmart To Be Your Doctor? Forbes. August 8, 2014.
- Ellison A. 200 hospital benchmarks. Becker’s Hospital Review. October 1, 2014.
- Eggbeer B, Bowers K. Health care’s new game changer: thinking like a health plan. Healthc Financ Manage. 2014; 68:52–59.
- Mellin A, Funk C. The 6 lenses of population health management. Healthc Financ Manage. 2014; 68:62-6, 68.
- ‘We need to show up with evidence’: Edwards Lifesciences CEO. Modern Healthcare. January 24, 2015.
- Channing A. What a CEO expects from an EM group. Presented at: AAEM Scientific Assembly; February 11, 2013; Las Vegas, NV.