Editorial: Emergency Medicine in the New World Order of Health Care Reform

WASHINGTON — As the nation considers new models of payment reform, including bundled payment systems that reimburse for episodes of care rather than for each service, most models currently do not include emergency medicine, according to a new editorial in Annals of Emergency Medicine. The authors speculate that models are not factoring in the value of operating a high-quality emergency care system and the significant contributions that emergency physicians could make to coordinate medical care. 

“The current methodologies incorrectly presume that patients will have access to medical care, and ignore the significant economic value emergency care provides to America,” said Dr. Michael Granovsky, editorial author and director of ACEP’s coding and reimbursement courses.  “The number of uninsured Americans increased to 50 million in 2009, and a critical shortage of primary care physicians is expected for years to come, which will further complicate care coordination and access to medical care. Some models correctly note that the costs of emergency care are small relative to the episode timeframe, yet the value we bring to the system is significant, and it remains to be seen whether these models will work for emergency medicine.”

The goal of payment reform is to maximize quality of patient care and minimize costs. Editorial authors say that in the future increased pressures likely will be placed on emergency physicians to reduce the use of resources, which will increase the probability of missed diagnoses. This also will increase medical liability risks.  In addition, hospitals will increasingly be challenged to limit hospital admissions and readmission, which will in turn challenge emergency physicians, since they often make the decisions to admit patients to their hospitals.

“Prevention of injury and disease is the ideal health objective, but in the real world, timely treatments, such as addressing hyperglycemia in a diabetic patient or preventing tissue damage in heart attack patients, provide both value and cost savings,” said Dr. David Seaberg, president of ACEP. “Medical emergencies are never planned, and the ability of an emergency department to conduct rapid diagnosis, intervene in acute illness and mobilize multiple resources to care for patients have tremendous value to both society and patients. These are some of the reasons that America relies on emergency care. There were 136 million visits in 2009, up from 124 million in 2008. We are there 24/7 and provide a health care safety net for everyone.”  

Although a handful of emergency physicians have been involved in current episode development projects, none of the projects to date have mentioned emergency medicine.  For example, the value of preventing episodes, such as ruling out ST-segment elevation in myocardial infarction, have not been considered or quantified.

Editorial authors describe the challenges to implementing an episode of care-based payment model, including the fact that multiple medical providers and facilities often are involved in the care of a patient during an episode.

In addition, equitable allocation of payment for services to multiple providers and facilities remains challenging.

“It is clear that additional resources will be needed beyond primary care to coordinate patient care,” said Dr. Seaberg. “Emergency physicians need to play a critical role in coordinating care and make significant contributions toward desirable patient outcomes, especially when the health care delivery system is under-resourced.” 

“Episode of care models may not be a good fit for emergency medicine because most emergency patients present with acute undifferentiated complaints and   medical needs that vary significantly based on their co-morbidities and the availability of local resources to provide ongoing care ,” said Dr. Granovsky. “Hospital emergency departments also have a federal mandate to provide stabilizing treatment for all patients, regardless of ability to pay.  The theoretical benefit of payment reform is to maximize quality and minimize cost, although research suggests that better-quality care may not always cost less. In fact, a recent MIT study found that hospitals that spend more on emergency care are successful in lowering patient mortality rates.”

Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, a national medical society. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. For more information visit www.acep.org.