Like many specialties, especially those engaged in hospital-based practice, emergency medicine (EM) finds itself facing a number of challenges related to healthcare and payment reform, the most immediate of which is to maintain its current share of healthcare revenues in the face of resistance on many levels. There will always be a role for emergency physicians (EPs) in managing seriously and critically ill and injured patients, but there is a real question about the ability of the specialty to maintain economic viability focusing solely in this space. In a recent article in ACEP Now, John Holstein and Andy Sama, MD, listed a number of emerging trends that are likely to impact the practice of emergency medicine, and deserve the attention of the specialty as a whole.
These trends included:
- Patients self-directing their care.
- The explosion of the urgent care industry.
- Hospitals moving into the insurance business.
- Telemedicine and its potential applications for EM.
- Increasing demand for quality and value metrics.
- Retail competition in the delivery of healthcare 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.
These trends raised, in my mind, the need to have a parallel focus on several systems issues for emergency departments (EDs) and EM groups that will be important to the successful adoption, implementation and participation in these newer reimbursement and risk-sharing methods. Our specialty will also be expected to step into partnerships and expanded roles afforded by these trends, and EPs will need to develop systems and processes to meet these challenges. Some of these systems require sophisticated, integrated information technology, but many can be accomplished by inexpensive communication and process tools. These system solutions have been adopted to a lesser or greater degree across the spectrum of EDs and EM groups, but have also been often overlooked.
Each and every one of the 10 significant trends and challenges listed in the article necessitate supporting systems and processes, such as the following:
- Better discharge instructions, post-ED discharge help lines
- Re-priced in-ED fast tracks
- Integration/data sharing between hospital and ED group billing systems
- More sophisticated transfer agreements and other arrangements to improve communication between hospitals and skilled nursing facilities, etc.
- Better mechanisms for proper attribution of treatment and diagnostic testing decision-making/ordering in the ED
- Automated feedback to ED physicians and staff on outcomes for admitted patients
- Consideration of cost of care in the development of department treatment protocols, procedure trays, etc.
- Point-of-care financial counseling, improved and coordinated in-ED collection and payment systems
- Training in contract negotiation strategies
- Facilitated communication between ED providers and primary care physicians, health plans, referral specialists, and care coordinators
Even though excellence in the development and implementation of such systems is facilitated by competition, I think the greatest difficulty the specialty faces is that, in many cases, achieving excellence will necessitate cooperation and sharing of ideas and data across all venues of EM practice. Currently, such cooperation and sharing between EM groups is inhibited by competition for practice opportunities and proprietary ownership (of the groups and of the systems and processes), and by the direct employment of EPs by hospitals. Somehow, the specialty of EM has to find a way to encourage recognition that a ‘rising tide lifting all boats’ is the best way to secure the future of emergency medicine.
This post originally appeared March 18, 2015, at The Fickle Finger healthcare blog.
[Image credit: "Gorey Harbour at low tide" by FoxyOrange licensed under CC BY-SA 3.0]
