Where does emergency medicine fit in the emerging and evolving new health care world? Who will define how emergency medicine fits into this world? Does it matter?

The first question is perhaps the most difficult as the world is changing so rapidly. The current era is arguably the most extensive because the health care world was last shaped with the advent of managed care. In that prior era, emergency medicine certainly took its share of hits, which were to a great extent reimbursement and revenue based with claims denials, inappropriate bundling of services, etc. But the overall structure and function of the specialty remained intact.

The current evolving world mandates the specialty takes a firm stand on its presence, but also very importantly on the central role and value it brings to the table. The evolving world of ACOs is the new world. Becker’s Hospital Review reported in February that there are 428 ACOs in 49 states and that the “physician group sponsored” ACOs is fast gaining ground on the “hospital-sponsored ACOs.”

As emergency physicians, you are at the forefront of the entire spectrum of patient care, making daily decisions for your patients that ramify throughout the health care world. An emergency physician’s decision to admit a patient is one of the most significant triggers impacting the bottom line revenue of every hospital. These decisions impact the constantly shifting balance of outpatient and inpatient services that is critical for the survival of every hospital.

As emergency physicians, you fulfill a central role in the entire system. Despite fulfilling this central role, defining how emergency medicine fits into this emerging new world is fast becoming one where others are moving toward defining the metrics and indices of cost and quality by which emergency medicine will be measured. Emergency medicine has an audience of three. Understanding the audiences will lead to fortifying the specialty’s role and function in the system. These are as follows:

Know Your Audience

Medicare-CMS

Private Payers

Hospital C-Suite

For Medicare/CMS, the issue will typically be focused on the reimbursement for the various levels of care and the justification of these levels as evidenced by physician documentation supporting them. So far, the quality related indices from CMS are the Maintenance of Certification (MOC), Physician Quality Reporting System (PQRS) and the upcoming Value Based Modifier (VBM). Remember the PQRS system started out as a “pay for reporting” system and has evolved into today’s “pay for performance” system.