Posts Tagged Health Care Reform
As you may know, today the United States Supreme Court decided to uphold The Patient Protection and Affordable Care Act. (Read the 193-page decision here.)
This decision will impact emergency medicine because it is clear that the amount of visits to the nation’s emergency department will continue to increase even with the implementation of health care reform.
As I stated in a press release today, the nation’s emergency physicians fully support the emergency care provisions in the law, such as inclusion of emergency services as an essential part of any health benefits package and the prudent layperson standard, which guarantees that health plans base coverage on the patient’s symptoms, not the final diagnosis.
And regardless of the Supreme Court’s decision, it does not change the mission of emergency physicians — we pledge to be there for our patients.
However, while there are provisions in the law to benefit emergency patients, it is clear that emergency visits will increase, as we have already seen nationwide. There are physician shortages and there are also drug shortages and serious mismatches between patient needs and available resources.
The College will continue to urge lawmakers and regulatory agencies to ensure that the implementation of the health care reform law does not endanger patient care or threaten the practice of emergency medicine.
ACEP has worked with — and will continue to work with — members of Congress to find solutions to improve the safety and efficiency of emergency care for all Americans. Emergency departments are a critical, life-or-death part of our health care system and we need help now. This crisis in emergency care is everyone’s problem, because every person is only one step away from a medical emergency.
According to the most recent GAO report, emergency patients who need care in 1 to 14 minutes are being seen in more than twice that timeframe — 37 minutes.
Significant growth of Medicaid is intended as one of the means of expanding coverage. Increasing the number of patients on Medicaid without an equivalent increase in the number of physicians willing to take that insurance will surely increase the flood of patients into our nation’s emergency departments.
Coverage does not equal access and critical problems facing emergency patients are not going away.
A recent study in Annals of Emergency Medicine shows that crowding in emergency departments is growing twice as fast as the rate of ED visits, principally because emergency patients are showing up sicker and with more complicated health problems.
As the nation moves forward with implementing the health care reform law, we urge the Senate to follow the lead of the House in repealing the Independent Payment Advisory Board (IPAB), which was included in the law. The IPAB panel does not have any accountability to Congress, health care providers or the public and will harm Medicare patients’ access to medical care.
This law also includes medical liability dispute resolution alternatives, but that the scope is extremely limited, which limits its potential effectiveness. America’s medical liability system is broken and without true medical liability reform, patients’ access to lifesaving care will continue to suffer.
ACEP will continue to fight for meaningful medical liability reform and other emergency medicine issues. You can aid in this battle. Contributions to NEMPAC will support candidates who can positively impact emergency physicians and your patient care. Consider donating at the Give-A-shift level for maximum leverage of your PAC contribution.
Participation in the Emergency Medicine Action Fund is now more important than ever. With the Supreme Court decision upholding the law, an avalanche of regulations are being written and emergency physicians desperately need the EM Action Fund to keep them out of the regulatory and legal crossfire between payers, patients, policymakers and hospitals.
The EM Action Fund has unified the house of emergency medicine and become a powerful and influential voice in federal regulatory and legal issues that matter to you and your colleagues. Join the EM Action Fund today.
In a widely read article in the January 2011 issue of The New Yorker by Atul Gawande that details the efforts of Dr. Jeffrey Brennerto improve care to a number of high-cost patients in Camden, NJ; Dr. Brenner was quoted as saying “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise.” This observation has often been quoted by any number of health care policy wonks, health plan advocates, and politicians in efforts to justify their particular distaste for ‘unnecessary’ ER care. Like many such generalizations, Dr. Brenner’s comments are often taken out of context or misinterpreted, and in some cases have been used to denigrate the care provided in ERs, or the patients that rely on the ER. Dr. Brenner was referring to “failures of prevention and of timely, effective care” in the rest of the health care system, and I cannot disagree with him that ERs are often called upon to address these failures. Nonetheless, my antipathy for Dr. Brenner’s observation is that it is glib, and too easy to misconstrue.
Emergency Departments provide such a broad scope of services, and play so many roles in health care, that it is rather short-sighted to view ER visits as the if they were almost inevitably the result of misuse, abuse, inattention, inappropriate delay, or a failure of prevention. If someone falls off a ladder and breaks their leg, that obviously is not a failure of the health care system, unless of course you plan to hold the health care system responsible for poor ladder design. Likewise, not all heart attacks or strokes can be prevented by good primary care, Lipitor, aspirin, and exercise; and not all pneumonias represent a failure to immunize or prescribe controller inhalers for asthma. The reasons why the number of ER visits have grown so rapidly go way beyond the fact that the health care system often fails us; or that the ER is open 24/7; or the EMTALA mandate to treat everyone regardless of insurance status or ability to pay.
ERs have become the diagnostic centers of the health care system; and many patients are sent to the ER by their doctor specifically because of the broad array of diagnostic services available, ER physician expertise as ‘diagnosticologists’, the ready availability of specialist expertise, and the efficiency of ER workups. It would not surprise me if more than a third of all cancers in the chest and abdomen are first detected in the course of an ER visit. In addition, the ER fills many roles that, if they had to be met by other health care providers and venues, would render those providers or venues overwhelmed, even more inefficient, and often just unavailable. Imagine if primary care doctors, or even urgent care centers, had to repair all lacerations, or treat all kidney stones, or manage every alcoholic who drank himself into a stupor. Think what it would cost if those offices and facilities had to stay open until 2 am to accommodate those who were not able to get their care during office hours. You don’t have to imagine closing every ER in the country to realize that ER care is not just some regrettable but necessary safety net established to manage the failures of the health care system. Just watch what happens when the last ER in a community closes: you will find that ERs represent what is often the best of what the health care system offers: timeliness, efficiency, effectiveness, scope, availability, responsiveness, surge capacity, compassion, and decisiveness; and this will be sorely missed by the residents of that community.
The tendency of many to misconstrue comments like those of Dr. Brenner is reflected in a host of similar aspersions cast on the ER. Jane Stevens also wrote an article about Dr. Brenner, and about a similar effort to reduce costs through an ER diversion program in Bend, Oregon, designed to help patients who frequently landed on the doorstep of the ER to get access to other, more appropriate places to get the things they needed, some health care related, but often focused on social service needs. The title of this article was “Improve health, lower health care costs by reducing emergency room visits”, implying that simply by blocking the door to our ERs, we could solve what is wrong with health care. At least, this is how many readers were likely to interpret the message. Taken to an extreme, this is the kind of message that leads policy makers and legislators to believe that if they just stopped paying for ER visits, they could keep everyone healthy AND solve their budget crises.
Dr. Brenner’s linkage of ER visits to failure has also become insinuated into even the most thoughtful discussions about health care reform. Brad Wright wrote a post in the Kevin MD blog that pointed out the mistaken belief by many that universal health insurance would lead to a reduction in ER use. He noted that “people go to the emergency room for a host of reasons that have nothing to do with their insurance status. Among these reasons are low health literacy, a health care system that is often complicated to navigate and inaccessible for people who can’t get off work during typical business hours, and a lack of continuity of care that arises for a host of reasons. Waiting to be seen in the ER is no picnic, but for many people it is a more easily understood process than trying to get a referral to a specialist from their primary care physician–assuming they even have one.” As I have noted above, this accounts for just a fraction of the reasons why patients use the ER. Mr. Wright notes that consequently, reduced ER use should NOT be considered a measure of the success of health reform.
I believe that ER use is an indicator of many things, some reflecting the failures of our health care system and our social safety net; others reflecting great advances in acute care, resuscitation, and diagnostic services; and still others reflecting our society’s need for, and desire for, efficiency, availability, and timeliness of care. You can’t hope to cover all of these attributes in a single, facile observation, no matter how well intended.
This post also appears in The Fickle Finger.
Health Care reform proposals to cover more of the uninsured by expanding the Medicaid program inevitably stumble over several potholes and obstructions: there aren’t enough providers to cover existing Medicaid enrollees, let alone millions more; Medicaid Managed Care doesn’t seem to save enough money; states can’t afford to pay for it; the feds can’t afford to subsidize it; and most importantly, the poor don’t vote or contribute to election campaigns. Not to worry: I say with all modesty that I believe I have a solution.
Let me tell you a true story about a successful Medicaid Managed Care plan that works. If you wanted a model for such a plan, this would be a good one. Partnership Health Plan (PHP) in Northern California is one of 5 fully capitated County Organized Health Systems (COHS) in the state, covering Sonoma, Lake, Mendocino, Marin, Solano, Napa, Yolo and Sonoma Counties. It has over 200,000 enrollees, of which 31% are seniors and persons with disabilities. PHP has 240 Employees and a $700 million annual budget, and a remarkable 95% Medical Loss Ratio (i.e. 95% of funds go to medical services). Administrative costs for the Medi-Cal product (Medicaid in California) are currently less than 3.5%. PHP actually believes in managing care, they take it seriously, and they generate serious cost-savings as a result, with a 380% ROI in complex case management, and a 220% ROI on a care transitions program to reduce or prevent hospital readmissions.
PHP pays their capitated PCPs very well, and it pays networked FFS specialists better than any other Medicaid Managed Care plan in California, at rates of 120-160% of the state’s MediCal fee schedule. The plan pays claims quickly (less than 10 days on clean claims), and without relying on the typical down-coding and bundling schemes to underpay EMTALA obligated providers. PHP is so well received by providers that its network participation with the primary care and specialist provider market in its assigned counties is remarkably broad and deep. Ninety-seven percent of PCPs and specialists contracted with PHP expressed satisfaction with the plan – you just do not see this kind of thing in most Medicaid Managed Care organizations. Recently, despite California’s scheduled 10% reduction in MediCal rates and capitation payments to MMC plans; PHP decided to maintain current provider rates in order to maintain patient access to these services. So how did PHP accomplish this? Partnership Health Plan is a not-for-profit Medicaid Managed Care Plan.
All over the country, health care policy wonks have been advocating for the expansion of Medicaid through a for-profit managed care structure, ignoring the fact that there just isn’t enough meat on the bone in Medicaid programs to support quality care for enrollees, case management for the chronically ill, reasonable payment to providers, sufficient access to specialty services, and generate profits to Wall Street or equity investors and excessive management fees to overpaid CEOs. The drive for profits, and limited financial support from strapped governments, leads these for-profit plans to adopt strategies that result in provider underpayment, lost claims, selective dis-enrollment, inappropriate denials of coverage, limited access, financial insolvency, and delays in necessary care. Why are so few advocating for a non-profit approach to Medicaid Managed Care? The presumption is that the profit motive should drive creativity and cost-effectiveness, but if policy-makers fail to accurately measure access to care and quality, and only look at the cost side of the equation: it’s easy to get fooled about the value and success of government sponsored for-profit health-care enterprises. The ability of PHP to succeed in the context of such a lean, nearly meatless, Medicaid program as exists in California should cause everyone, everywhere, to reconsider the not-for-profit approach to Medicaid expansion.
This post also published in The Fickle Finger
Value based purchasing is a strategy for health care financing that attempts to hold the provider accountable for both quality and cost, through a combination of reductions in inappropriate or ineffective care and rewards for those providers that are ‘the best performers’. 1 Unfortunately, most insurance plans, and employer purchasers of health care, are simply looking to reduce payments to providers, and they all but ignoring the issue of quality or even cost-effectiveness. When it comes to the purchase of emergency care, the payers really seem to have taken a wrong turn, predicated on a lot of misconceptions about the role of the emergency department and the value equation for emergency care services.
This blog is aimed at the primary purchasers of health care: the plans, employers, and government programs that purportedly aim to adopt value based purchasing as an adjunct to, or replacement for, fee for service medicine. For every ‘don’t do that’ I will include a ‘consider doing this’, because up until now many emergency care advocates have either advocated some sort of carve-out for emergency medicine, or focused on the defense of the emergency care value proposition (like ACEP’s ‘just 2% campaign‘). Emergency care providers have to become part of the solution to the cost-of-care conundrum if they hope to retain any credibility with insurers and legislators. In Part II, I will outline some do’s and don’ts for providers under value based purchasing. So, I suggest that the purchasers:
• Don”t expect emergency physicians to act as ‘gatekeepers for acute care’. Emergency physicians are trained and motivated to provide care, not deny care. Coercing emergency physicians to ‘defer ER care’ for so-called non-urgent patients by down-coding claims or denying coverage is a low-gain, moderately high risk strategy that is a distraction from pursuing more cost-effective strategies (see:
Do encourage and incent primary care physicians and clinics to provide more after hours and next-day appointments. It is better to pull patients who do not need to go to the ED into other venues than to insist that ED physicians push them out.
• Don’t punish emergency care providers through non-payment and under-payment with the expectation that it will teach patients not to misuse the ED.
Do consider assisting EDs in identifying patients who use the ED repeatedly for acute exacerbations of chronic conditions, and who could benefit from active case management starting in the ED (and compensate providers for this case management – this is a strategy with an excellent ROI).
• Don’t assume that if a patient is admitted from the ED to an observation unit, and then subsequently admitted as an inpatient; this necessarily represents ‘double-dipping’ by the emergency physician. Payment for observation services is a cost-effective way to keep patients out of the hospital, and identify patients who, if discharged inappropriately, might return later for more expensive service.
Do provide feedback to emergency care providers about the population-based financial consequences of their use of chest pain centers and observation units, so that these services can be used more cost-effectively.
• Don’t use coercive contracting of EMTALA-obligated providers as a means of achieving cost-savings: it is abusive, and undermines the financial viability of the emergency care safety net. Commercially insured enrollees and their insurance plans depend on the availability of qualified emergency physicians and on-call specialists to SAVE them from unnecessary disability and higher costs down the road.
Do consider implementing shared-savings, utilization risk-pools, case-limit rates, and other contractual incentives (with appropriate guidelines and benchmarks) to encourage emergency physicians to adopt cost-effective care strategies in the ED, when the hospital is appropriately aligned with such strategies in their financial models.
• Don’t try to undermine, work around, or revoke the prudent layperson standard through the use of ‘non-emergency diagnoses’ lists or high ED visit co-pays. This standard ensures that enrollees will go to the ED when they should, reducing avoidable delays in care that result in unnecessary long-term disability and even greater long term costs to insurers. A single case of a missed opportunity to treat a stroke can cost insurers far more than it costs to treat fifty patients in the ED whose symptoms turn out to be non-serious.
• Do focus on where the ‘real money’ is spent, that is, where the major health care costs, on a population basis, are incurred, and the real opportunities for cost-savings and quality improvement exist. No doubt the ED is one place where such opportunities lie, but at only 3% of the health care dollar, the ED is by no means the target of opportunity that it is made out to be.
• Don’t automatically down-code ED physician claims, especially E&M level 4 and 5 claims, simply because these providers have to care for your enrollees whether they get paid appropriately or not. It is also abusive, and undermines your credibility as an insurer or payer.
Do, if you identify outliers who appear to be overcoding claims, utilize medical records audits by trained coders and recognized standards of coding, to explore these apparent overcoders in depth, and offer to adjudicate these claims in a fair and reasonable process.
If any of you have additional do and don’t suggestions, please reply below.
It strikes me that in developing payment reform related, compensation driven cost-containment strategies aimed at constraining the cost of emergency care, policy makers, emergency physicians, and health insurers should adhere to certain principles. ACEP should be at the forefront when it comes to establishing these principles, which I hope will be focused on protecting our patients first, and our specialty second.
The concept and practice of ‘managed care’ has raised some very reasonable concerns about the way some physicians’ commitments to the welfare of their patients has been compromised by the financial incentives inherent in compensation arrangements like capitation and risk-pools. If emergency physicians are going to be engaged, willingly or reluctantly, in cost-containment oriented incentive compensation programs; we need to make sure that the competing interests of patients, providers and insurers (including the government) are balanced properly, and morally.
I thought I would take a shot at formulating a few of these principles, and encourage readers of this blog to suggest changes and propose additions.
1. Cost containment strategies for emergency care should focus first and foremost on cost-effective care, with the emphasis on effective.
2. Shared-savings, pay-for-performance, capitation, risk-pools, and similar payment reform programs designed to incentivize emergency physicians to reduce the cost of providing emergency care must not result in a reduction in necessary care, an unreasonable delay in the provision of care, a significant increase in medical risk to patients, or a significant decrease in patient satisfaction with care; or shift the burden of care to those who are unwilling and/or unable to provide this care.
3. Cost-effective care strategies should be evidence-based where possible, though common sense strategies should also be considered even if evidence in favor of such strategies is not abundant.
4. The proportion of total reimbursement that emergency physicians derive from the successful adoption of cost-containment strategies, relative to the proportion derived from payment for services rendered, should be limited in order to ensure that these cost-containment incentives do not overwhelm service-driven and outcome-driven medical decision-making.
5. Strategies that rely on the deferral of care in the ED should be considered as relatively high-risk, low-reward strategies when compared to others that are focused on cost-effective care and high-cost services.
6. Cost-containment strategies for emergency care should be transparent to patients, providers, insurers, and policy-makers.
Any other ideas out there?
You will notice that the title of this blog is not ‘independent vs. employee model’: I readily acknowledge that I know little about being an employed emergency physician. Having spent my entire career as, initially, an independent contractor, and then as a partner in a large EM partnership; I am not the guy to be making a comparison between these modes of EM practice. However, I recently heard from one of ACEP’s Board members (Dr. Kivela) that approximately 55% of emergency physicians in this country are now employed by hospitals (or was that employed by someone?). In either case, this fact led me inevitably to reflect on these two modes of practice, and the many variations on these themes, and how this trend towards more EP employees and fewer EPs practicing as independent contractors or partners is likely to impact the practice of EM, our patients, our hospitals, and our specialty.
Of course, this is a topic that could never be covered in a blog, perhaps not even in a textbook, but I hope to generate some discussion of these issues here in The Central Line and elsewhere. I have far more questions than answers to offer, as you will see; but these are questions that we should try to answer before they are answered for us. Health Reform is going to put even more pressure on the independent EP practice model as policy makers and insurers push to consolidate providers into vertically integrated health care systems to foster accountability and coordination of care (euphemisms for risk-sharing and cost-cutting). How our specialty and the house of medicine respond to this pressure will have a major impact on the practice of EM, from the choice of meds we use to the professional affiliations we make.
One of the first questions that come to mind when exploring independent and employee models of practice revolve around the corporate practice of medicine. There are only a handful of states that have a bar against the corporate practice of medicine, and enforcement of these bars vary considerably. The rationale for prohibiting corporations from influencing the practice of medicine is nicely summarized by the CA Medical Board: and the gist is that this bar is “intended to prevent unlicensed persons from interfering with or influencing the physician’s professional judgment”. The Medical Board provides examples of “types of behaviors and subtle controls that the corporate practice doctrine is intended to prevent”. Hospitals are sometimes exempted from such state bars, as hospitals are also licensed, but the concept is premised on an obligation to protect consumers (patients) from profiteers, and hospitals are no strangers to the profit motive. First question: Are EPs who are employed by hospitals more or less subject to controls and subtle pressures impacting medical decision-making than EPs who are employed by a medical group, or EPs who are part of a medical partnership, or EPs that are independent contractors? I know for a fact that EPs who practice in the ‘independent mode’ can be subjected to such pressures, geared towards improving the hospital’s bottom line, especially since EM group–hospital staffing contracts can be, and have been, canceled for ‘no cause’; and I suspect that employed EPs are regularly subjected to subtle (and not so subtle) pressures to adjust their practices to accommodate hospital employer expectations and financial goals. Put another way: if you were a patient in an ED, would you have more trust in an EP who was a hospital employee or an independent contractor or a partner in the EM practice? How about if he or she was an employee of your insurance plan? There probably isn’t any data to support your preference, but perhaps there should be. The rise of managed care, risk-sharing ventures, IT demands on investment capital, and the surge of interest in ACOs is going to put increasing pressure on states to eliminate or modify corporate bars on the practice of medicine. Wouldn’t it be appropriate for legislators to know how ‘corporate influences’ impact the care we provide, and how patients feel about that?
Here are some more questions that deserve to be answered: Which practice mode pays EPs more appropriately? Which contributes more towards enhancing the value of EM practice? Is a hospital CEO more likely or less likely to appreciate excellent EP care and service if the EP is an employee or a member of a contract staffing group? To whom do employed EPs look when seeking support for improved salaries or working conditions? Should ACEP develop into a union for these physicians? I heard a rumor that some hospitals have discouraged their EPs from joining ACEP – is that true?
Which mode of EM practice provides greater encouragement or incentive to document their care appropriately so as to assure appropriate third party reimbursement? Are hospital-employed EP salaries indirectly dependent on the ability of staffing-contract EPs to collect fair payment from health plans? Do independent mode EPs have greater or fewer opportunities to move to new communities and keep their ‘tenured’ pay rate? Are they happier with their practice setting? Which has the better malpractice experience? Which offers more support when the provider is sued?
I could go on, but you get the gist. There may be no good way to really answer many of these questions, but this shouldn’t deter us from discussing the issues. Let me give you just one example of why these considerations need to be aired. ACEP is going to be developing strategies for EP participation in ACO risk-sharing, payment bundling, and shared savings arrangements under health reform. I have no doubt that these strategies may be very different for hospital-employed EPs, for academic group EPs, staffing contract model EPs, and medical group employed EPs. ACEP may not have the resources to address each of these strategies for each of these member groups, so where should the emphasis be made? Here’s another: ACEP is increasing its advocacy role in DC, and reaching out to EPs to financially support this effort separate from ACEP dues. Which EPs are more likely to contribute to this effort? Should some ACEP advocacy resources be expended to support the independent practice of EM, or should ACEP be advocating for the right to represent employed EPs, or both?
If you are worried that discussing these questions exposes the soft underbelly of EM, or somehow might precipitate the deconstruction of the cooperative venture that ACEP represents: get over it. The forces aligned to divide and conquer the practice of emergency medicine, and the practice of medicine in general, have already begun their work, and everything that defines our profession is now in play.
If the perception is that a visit to the ED represents a failure of the health care system, it sure makes it difficult for ACEP to assert that emergency physicians routinely provide valuable services to patients and insurers. Apparently, many policy makers hold this perception. It reflects the consequence of cost shifting (especially by hospitals) to cover the care of the under- and uninsured, which makes it appear that EPs are wasteful and inefficient. Health plans have aggressively promoted this mis-perception, using very distorted data. A good example is a recent study (“Many-ED Visits Could be Managed at Urgent Care Centers and Retail Clinics”) from the California Health Care Foundation , a very pro-managed care organization. Is it reasonable to compare the cost of treating strep throat in the ED versus the Urgent Care Center when the UCC turns away every patient with no money and no insurance? The attitude of the Health Plans is: “the uninsured are not our problem”, and would prefer to ignore our service to the uninsured in calculations of the value based proposition. The uninsured are not going away with Health Reform, and emergency physicians need to make sure that, in the value based purchasing calculation, no one takes for granted our mission to provide care to everyone regardless of ability to pay .
Fortunately, it’s really not all that difficult to challenge mis-perceptions about the value of ED care. The continuing growth in ED visits every year is perhaps the best testimony of the value that our patients ascribe to the care and service they receive in the emergency department. There are innumerable examples of the failure of our health care system in this country. A visit to the ED for acute appendicitis does not represent a failure of managed care, whereas a ruptured appendix that results from a patient being encouraged to wait until the morning to see their primary care physician certainly might.
With the demise of the idea of a national emergency care patient registry, it may not be easy to prove the value proposition for emergency medicine; but we don’t really need to prove our value so much as we need to substantiate it. First, we need to make sure that in comparing care in the ED to care in the office based practice; apples are compared to apples. Would all those assertions about ED patients not meeting the prudent layperson standard hold up if, for example, we could show that the incidence of peri-tonsilar abscess in patients with sore throat was three times the incidence of this complication in the PCP’s office? I think ED physicians all believe that children with fever in the ED are different than children with fever in the UCC, but try convincing a pediatrician. This will take some studies directed specifically at the value-based proposition, and that is where we should put the Emergency Medicine Foundation’s contributions to work. We heard at this year’s Council meeting about a compilation of hundreds of studies showing the value of good ED care (early antibiotic treatment in pneumonia, ED physician activation of cath labs, etc). This compilation needs to be translated into an easily digested summary with bullet points for the media and policy makers.
Although I am not a great fan of public relations, when you are faced with a perception problem, you need a well-financed, highly organized campaign. The ED has become the premier provider of diagnostic services and acute care; and in some EDs, half the patients who are discharged from the ED were sent to the ED by their PCP for evaluation and treatment. ED physicians provide four times as much charity care as any other specialty. These types of factoids need to be widely disseminated, because they change perceptions, and re-frame the value proposition. ACEP needs to provide the science, the sound bites, and perhaps the professional PR team; but this is not just a challenge for ACEP’s D.C. office, it is a challenge for every state chapter, and every emergency physician in every ED and every state. The next time you hear someone say how expensive ED services are, take the time to explain cost shifting, talk about 24/7/365, remind them about all the patients we manage to keep out of the ICU. With ACOs, bundled payments, and cost-containment, we are in a fight for the economic survival of our specialty.
Risk sharing is our third challenge. I will try to cover that in PART III.
Imagine that you are the medical director of an ED, and you decide to take to your hospital administrator a new set of cost-effective care policies that are designed to reduce the percent of admissions from your ED from 17% to 15%. In some hospitals, you might be met with incredulity: why would you do something like this when if would cost your hospital hundreds of thousands of dollars in revenue every month? You might be looking for another job. If you worked at a Kaiser hospital, you might be looking at a raise. If you worked at a hospital that was heavily involved in capitated managed care, your proposal might be welcome, but if the administrator of this hospital was particularly unscrupulous, you might be asked to apply these policies only to patients who are enrolled in the HMOs that had capitated the hospital for inpatient care, and not to those patients who were enrolled in a fee-for-service PPO. Is it any wonder, then, that here in Lost Vegas at the ACEP Council meeting, everyone seems to be having considerable difficulty figuring out how to define value based emergency care, or how to demonstrate to policy makers, insurance plans, regulators, legislators, hospital administrators, and patients that emergency physicians provide a valuable service and deserve to be fairly and generously compensated for this service?
With the Value Based Emergency Care Task Force’s report last year, it appeared that ACEP was taking some positive steps to prepare our specialty to respond to the value based reimbursement paradigm that was represented in health care reform legislation through Accountable Care Organization and pay for quality initiatives. Unfortunately, it would appear that the development of an Emergency Care Patient Registry database, which ACEP hoped to use to quantify the value we bring to our patients and our health care system, is impractical and too expensive. It also looks like those emergency medicine episodes of care, that would have allowed emergency physicians to participate appropriately in bundled payments, are likely to be pretty complicated and difficult to develop; and might unintentionally result in EP services being ‘classified as devoid of value’. Finally, the imperative to define how emergency physicians will integrate into the risk-sharing, pay for quality, accountable hospital-health plan-medical provider delivery models (the newly designated solution to our flawed health care system in this country) has been held hostage to the lack of clear indications as to how these organizations will actually work, and the variability that will evolve under different state regulations, different hospital systems, and different insurance plans. Given these problems and uncertainties, it is difficult indeed for ACEP to, as Gretzky once suggested, skate to where the puck is going to be.
I think part of the problem is that it’s really difficult to pin down the value-based concept. Is it more about the cost of care, or more about the effectiveness of care? For example (and I am making up these numbers), EPs could spend $10,000 a patient to generate a 55% survival from sepsis, or $30,000 a patient to generate a 65% survival rate. Which is the more ‘valuable’ protocol? You might think organizations like Kaiser have the answers, but Kaiser premiums are going up too. The perception out there is that EPs spend $35,000 per sepsis patient to achieve a 50% survival rate, and $500 to treat a strep throat when primary care docs spend $40. No wonder it seems like a nearly impossible task to identify the paths to emergency medicine participation in value based purchasing. ACEP will be turning to expert consultants to help define these approaches, but really, who knows our business better than our own members? I think the solution to this problem lies in the recognition that the question of quality or effectiveness of care is assumed to be a given; and that the expectation of legislators and regulators is that we need to provide high quality care at less cost, not the best possible outcomes at the least possible cost. This may seem like a nuance, but it is much easier to address the value proposition when value is defined by the real driver here. Let’s face it, as we are faced with looming national bankruptcy, the driver is cost, and where we need to focus is on the development of cost-effective care protocols, the identification of the best opportunities for cost savings, and the wide dissemination and adoption of these protocols so as to reduce the variability in emergency medicine practice that undermines cost-effective care. Whatever we are spending to achieve survival in sepsis, or treat the strep throat, it’s probably too much.
Another part of the problem we face with value based purchasing is a perception problem. More about that soon in PART II.
When I saw that ACEP had published on its website its proposed new priorities and tactics for addressing the provisions of the Patient Protection and Affordable Care Act of 2010, I read through this document with great interest. The health care reform act passed earlier this year contains a number of important edicts that will impact the practice of emergency medicine for years to come, and I was curious to see the strategies the ACEP Board of Directors had developed in response to this new set of laws, and the regulations that would eventually be hammered out to implement the Act.
I found that ACEP’s ‘High Priority Provisions’ document was cogent, well thought out, and pretty focused, considering the 2000 pages in the Act that had to be reviewed, screened for relevancy to emergency medicine, prioritized, and condensed into a set of strategies that would carry ACEP, its committees, and its lobbyists in D.C. forward for the next several years as health reform evolves. All of these strategies were referenced to the goals and objectives in ACEP’s larger strategic plan. As you would expect from a planning and strategy summary, there aren’t a lot of specifics in the priorities document; and these specifics will likely be spelled out in greater detail as each of the provisions of the Act are addressed in the coming regulations, and as each of the new concepts in health reform, like Accountable Care Organizations and bundled payments, evolve in the marketplace. As you may know, some of ACEP’s strategic goals and objectives, like coverage for emergency care in all health plans, prudent layperson, and the elimination of prior authorization, were in fact incorporated into the Act; and the strategy here will be to make sure that the regulations covering these patient protections are clear and enforceable, and eventually apply to all health plans, including those currently ‘grandfathered’. Other goals in ACEP’s strategic plan, like extending Federal Tort Claims Act liability protections to physicians providing EMTALA-related services, are not part of the Patient Protection Act per se, but they are clearly identified as a strategic priority for consideration in the regulations implementing liability reform in the Act. So, far, so good; the Board has produced a very credible piece of work.
Unfortunately, there is something important that is missing from ACEP’s high priority provisions document. This plan includes several strategies to address the provisions of the Act that address how emergency physicians will be paid for our services, and who will pay us, and how performance will be applied to these payments; but there is no strategy addressing HOW MUCH emergency physicians will be paid for the care we provide. You might be surprised to learn that the Patient Protection Act DOES include provisions that will be used to determine the value of an emergency physician’s services; but you probably would not be surprised to hear that you might not like these provisions very much. Specifically, the Act states that when a plan pays a non-contracted emergency physician, the amount paid must be the greater of a) what plans normally pay for non-contracted emergency physician services, or b) what plans normally pay for discounted, contracted emergency physician services, or c) the Medicare payment. Allow me to summarize: according to the Act, the commercial value of an emergency physician’s services will now (and possibly forever) be determined by the health plan.
You might say, so what? Why is this important to me as an emergency physician, especially if I am an employee of a hospital, or a salaried academician? The answer to these questions lies in the recognition that emergency medicine is not just a profession, it is also a livelihood, a thing that pays for the roof over your head, puts food on the table, and pays for your kid’s college tuition. Now I am pleased that for emergency physicians and for ACEP, our profession and the care of our patients comes before our reimbursement. That is part of our mission: to provide care for all regardless of their ability to pay. We cannot, however, recruit and retain qualified physicians into our EDs to fulfill that mission if we are not paid the fair value of our services, especially by commercial health plans. Here’s another truth that should be recognized: when something comes along that undermines the commercial value of an emergency physician’s services, like a balance billing prohibition in California, or a state regulation equating the value of an emergency physician’s service to a percentage of Medicare rates in Maryland; this doesn’t just affect what emergency physicians in those states get paid, it affects what all emergency physicians in every state get paid, whether they are fee-for-service contractors, or hospital employees, or salaried by a university. The provision in the Patient Protection Act that allows health plans to determine, unilaterally, the commercial value of a non-contracted emergency physician’s services will have DISASTROUS consequences for all emergency physicians in this country. These provisions in the Act completely undermine the concept that our usual, customary and reasonable charges, which are subject to many different market forces, should define the market value of our services.
I don’t know why this part of the health reform act was not specifically addressed in ACEP’s document outlining strategies for the High Priority Provisions of the Patient Protection and Affordable Care Act of 2010; but I think of this strategic plan as a living document, subject to ongoing modification, improvement, and expansion, as all good strategic plans must be. There are a lot of smart docs on ACEP’s Board who understand the importance of this issue. I am optimistic that the question of ‘how much’ our services will be valued, and the standards in the Act that will be used to determine this value, will soon become part of ACEP’s strategic considerations for health reform and the interim final rules that will soon become regulation. Our ability to fulfill our mission depends on it.
This is just a very quick off the cuff, personal assessment, from many miles away from Capitol Hill, of what ACEP can learn from the health reform process we have just gone through.
ACEP talked to our Congressmen and women and our President’s staff about how EMTALA was an unfunded mandate that left hospitals and ED physicians holding the bag for all the uninsured patients and illegal aliens seeking care in the ED. Section 1011 funding was not renewed in the bill. Universal coverage was not achieved, and guess who will be taking care of those patients who still won’t be covered.
ACEP talked about how coverage did not mean access to care, and that we were losing money every time we treated Medicaid patients in the ED, and that our on-call backup specialty panels were degrading because Medicaid reimbursement sucked. Medicaid reimbursement rates will not increase under the new health reform bill, there will not be any incentive for PCPs to pick up all these new Medicaid patients, and guess who will be taking care of these patients?
ACEP cited the need for a fix to the Medicare SGR. Nope, not in the bill.
ACEP requested an increase in Medicare rates for emergency care, to beef up our on-call backup panels and make up for the unfunded EMTALA burden we will still be charged with bearing. Didn’t happen.
ACEP pleaded for malpractice reform so we could provide cost-effective care in the ED without fear of the inevitable malpractice hammer. Don’t blink, you will miss it.
That’s not to say ACEP did not prevail in some of our advocacy efforts: prudent layperson – in there; emergency care as a basic benefit package – in there; research funding – some; and there is more, which I will be happy to let ACEP’s leadership tout and justifiably proclaim.
I don’t think the question is: were we heard? I suspect that ACEP was not just heard, we were appreciated, respected, given consideration, even supported. We just weren’t powerful enough to make as big a difference as we ought to have made, considering what ACEP physicians bring to the table: considering our knowledge of the system, our fingers in the dike, our white hats, our key roles in care management; our substantial national PAC, our excellent advocacy staff in DC, our leadership’s enormous contribution of time and commitment, and our public image.
Why, you might reasonably ask. What can we learn from the recent experience. Personally, I think what we should learn is that we haven’t dug deeply enough into our own pockets to evidence our commitment to advocacy. The trial lawyers do it, so do the chiropractors and the prison guards. Doctors generally don’t, and we don’t. In light of the recent decision by the Supreme Court to allow corporations like Anthem and HealthNet free reign to contribute their amassed wealth to wrangling the political process; what we have been willing to contribute to advocacy will have even less impact. Fortunately, the level of contributions to advocacy we have been making is relatively meager, so as a specialty we have lots of room to make a difference without having to sacrifice a pound of flesh to have an impact. Furthermore, with a little reformulation of our approach to advocacy funding similar to that which CAL/ACEP has done in California; ACEP could find ways to not only greatly expand our presence and impact in D.C., but do so without having any adverse impact on college services to our members. Perhaps, just the opposite.
Maybe, if we had a serious horse to ride in on, more folks on Capitol Hill would notice the white hat.