Explore This IssueACEP Now: Vol 33 – No 09 – September 2014
Donald Berwick, MD, first coined the term “Triple Aim” for the goals of the emerging health care world.1 Emergency medicine has clinical ABCs as cornerstones of the specialty. Today, as the new health care world emerges, there are significant challenges and opportunities that will redefine the meaning of EM’s practice management ABCs; a new “EM Triple Aim” is at hand.
The first significant impetus to change was the Centers for Medicare & Medicaid Services (CMS) announcement making provider payment data available to the public.2 This change now provides critical information to everyone on how physicians have been paid by Medicare. In the context of other changes, this initial move by CMS will likely stand as an industry cornerstone/landmark change as it will have an impact throughout the provider community.
The second industry move of importance for physicians was the recent announcement by Aetna, Humana, and UnitedHealthcare of virtually the same change, namely the release of their payment data to the public.3
Along these same lines, it is important to recognize a very important article by Bob Herman, in which he potentially links the first two and begins exploring the potential for Medicare to become the health care industry’s sole payer.4 Although the article itself addresses hospital finances, it is prudent to take note of it. This may not be as far-fetched as one might think. Emergency physicians need to be armed with the facts and prepared to aggressively deal with several related changes and industry maneuverings that could potentially have a dramatic impact on the finances and even the survival of individual EM practices (see sidebar).
What might these changes mean for EM? These are major structural changes and shifts in the macroeconomic and demographic landscape that could have significant impact EM practices. The big-picture issues involve hospitals maneuvering to engage the insurance industry. Medicaid expansion certainly offers the potential for EM reimbursement to increase at least slightly, but it will be dependent on the actual levels of reimbursement. The explosion of the urgent care industry coupled with the retailization of health care definitely have the potential to significantly change the acuity mix of EM practices.
The insurance industry poses a challenge that necessitates constant vigilance of critical indices of EM practices.
Simultaneous, with these changes, we are living in an emerging health care world of physician engagement, alignment, and integration, with the hospital C-suite expecting the physician community to “get on board” with these changes that are beginning to significantly impact hospital finances. A hallmark of EM is its central role in triggering hospital admissions, with the emergency department accounting for at least 68 percent of hospital admissions.5 This landscape is, however, changing as hospitals move toward providing more care in outpatient settings. As the latter occurs, it can have a devastating financial impact on hospital finances, especially if hospital admissions substantially decline, which has been seen recently in suburban Philadelphia.6 The central role of EM in the hospital admission issue remains paramount.