While most healthcare reforms have thus far been focused outside of the ED, they nonetheless have big implications for emergency providers, according to a panel of experts who discussed the future of emergency care at a conference sponsored by the Brookings Institution in Washington, DC. Going forward, the experts noted that emergency providers need to engage on how to most-effectively deliver higher value while also achieving better alignment with primary care providers. And they highlighted reforms that are already delivering results in pioneering EDs.
- Through the use of high-risk care plans, a specialized protocol for chest pain, and other reforms, the ED at the University of Maryland Upper Chesapeake Health System, based in Bel Air, MD, has been able to prevent more than 500 hospital admissions in the past year.
- Working with partners, emergency physicians in Washington state have managed to save the state more than $32 million while also slashing narcotic prescribing to Medicaid recipients by 24%. Their interventions include a prescription drug monitoring program, a mechanism for information sharing on key data points, and the development of care plans for frequent ED utilizers.
- A program called Bridges to Care in Denver, CO, has thus far been able to reduce ED and hospital utilization among frequent utilizers by 40%, generating $2 million in cost-savings to the health care system. The program focuses on identifying the key drivers of utilization, and then addressing these drivers with interventions. Program developers say connecting with patients while they are still in the ED, as opposed to making follow-up phone calls, is key to the program’s success.
AS MANY EXPERTS HAVE NOTED, the continuing push for a more efficient healthcare system has broad implications for emergency care. For instance, reforms focused on limiting “unnecessary” visits to the ED may reduce costs, but also threaten the financial underpinnings of some EDs, which remain a critical resource for delivering around-the-clock acute care services. Further, there is also the reality that even as ED volumes continue to rise, departments in some of the country’s most under-served communities struggle to survive.
Despite these and other challenges, a handful of reformers are implementing delivery system and payment reforms that are having at least some success in improving outcomes and controlling costs while also preserving the critical role that EDs play in healthcare systems across the country. Some of these efforts were recently highlighted during a conference titled Reimagining emergency care: How to integrate care for the acutely ill and injured. The event, which was sponsored by the Brookings Institution in Washington, DC, showed how specific reforms are tackling head-on some long-standing problems that have been vexing emergency providers for years. However, experts cautioned that many obstacles remain.
Be mindful of unintended effects
Mark McClellan, MD, PhD, a senior fellow and director of the Health Care Innovation and Value Initiative at the Brookings Institution, suggested that in considering reforms, policymakers and providers need to recognize that emergency care is a major hub in the healthcare system, and that what takes place in the ED has considerable influence over the trajectory of care. “In many instances this is the first entry point for Americans into the healthcare system, and in many ways, the way that their acute care is provided influences fundamentally many other decisions and many other aspects of their care, healthcare costs, and outcomes,” he explained.
With more than 350 million acute care visits in 2011(ED visits accounted for 136 million of them), McClellan noted that it is not surprising that many reform efforts are targeting acute care. For instance, McClellan pointed out that patient-centered medical homes and care management activities are aimed at reducing the kinds of complications that drive people to access care in the ED. “These activities are occurring largely outside of the ED, though EDs can help in identifying at-risk and frequent-user patients,” he said.
A second aim for many of these initiatives is to shift care to lower acuity and less expensive care settings. McClellan noted that while EDs and the clinicians in EDs are usually not involved with such reforms, some initiatives have shown that there are steps that EDs can take to ensure such shifts are effective at delivering quality care while also making a dent in overall costs.
McClellan stated that a third type of reform involves the creation of clinical pathways and other tools aimed at standardizing evidence-based care for some of the most common conditions that show up in EDs, such as chest pain, headaches, and back pain. “New approaches to care inside the ED and inside the hospital are the main focus of these reforms,” McClellan added.
While many of these reforms are not, in fact, happening in the emergency setting, they nonetheless can have dramatic effects on patients who use EDs and on the resources of busy EDs, McClellan stressed. “Since EDs usually depend on fee-for-service payments for reimbursement, these shifts can have a big impact on ED finances as well as the availability of resources for EDs to handle their critical functions, including acute care emergencies and emergency preparedness for anyone who might need help,” he observed.
Consequently, while there are opportunities to improve emergency care, McClellan noted that decision-makers need to be mindful of the challenges, and to make sure the reforms avoid “unintended effects on critical ED functions.”
Address ED crowding, spiraling costs
Jesse Pines, MD, MBA, MSCE, the director of the Office for Clinical Practice Innovation and associate professor of emergency medicine and health policy at George Washington University in Washington, DC, stressed that the acute care system already delivers tremendous value as the critical staging area for ill and injured patients. “It is always open for emergencies big and small … and it is the front line for disasters like Hurricane Katrina and the Boston Marathon bombing,” he said. “But at the same time, we can do better. Despite delivering top-notch results for the critically sick, our system has its problems, [including] its fragmentation, poor information flow, and lack of connection with the broader healthcare continuum.”
Further, despite the dramatic increase over the past decade in the number of other settings for acutely ill and injured patients, such as urgent care centers, retail clinics, and freestanding EDs, Pines noted that there have also been rapid increases in ED crowding, primarily in hospital-based EDs. “[This is] caused by rising visits, greater intensity of care brought on by expanding life-saving technologies, and greater specialization.”
The emergency system, Pines noted, has opportunities to help address the national issue of spiraling healthcare costs, which he said are projected to comprise one-fifth of the U.S. economy by 2020. “We as frontline providers do lifesaving work every day, but we can do better and do it more efficiently,” he said.
Strive for better alignment
The task will not be easy, as there is no question that more is expected of emergency providers than in years past. Arthur Kellermann, MD, MPH, dean of the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences (USU) in Bethesda, MD, observed that primary care providers (PCP) who used to take the time to evaluate complex patients now routinely refer these patients to the ED. “EDs are becoming more and more diagnostic centers to support primary care physicians, and they are also becoming the gatekeepers across the institution,” he said. “The average ED visit is about one-tenth as expensive as an average hospital admission, and so making that decision of who gets admitted and who doesn’t has profound economic consequences for patients, and it is one of the most important functions that EDs have.”
Further, if a community’s primary care capacity is fragmented or weak, the ED waiting room will be full of patients with non-emergent needs, Kellermann noted. “And if the hospital itself is poorly managed, the entire ED, including the critical care bays, the exam rooms, hallways, and waiting room, will be packed with ill and injured patients, many of whom were evaluated hours or even days earlier, but can’t be admitted, either because there are no beds available and the place is full, or [administrators] are holding beds for better-paying elective admissions.”
Such chinks in a community’s system of care tend to be readily apparent in the emergency setting, Kellerman said. “The ED provides a room with a view to how America’s health system works or doesn’t work, and how healthcare functions at the community level,” he observed. “If you want to know here in Washington, DC, or wherever how healthcare [functions] in the community, go to the local ED. If public health is under-resourced or poorly managed, you will see patients with vaccine-preventable diseases, smoking-related problems, preventable injuries, and food-borne illnesses.”
How does one go about fixing such problems? Kellerman recommended better alignment between EDs and PCPs in an integrated system that promotes collaboration rather than competition where the patient is pushed back and forth between health care settings. “To do this, we are going to have to figure out how to easily and seamlessly share the health information that should always accompany the patient, so that whenever care is given, that information is accessible, available, and can be readily sent back to the patient’s medical home and PCP.”
Incentivize value, cost-efficiency
Some health systems have already begun to make strides in achieving the kind of alignment that Kellerman outlined. For example, working together with the Maryland Emergency Medicine Network, the University of Maryland Upper Chesapeake Health System, based in Bel Air, MD, has developed several programs aimed at making sure that the right patients are seen in the right setting at the right time in the most cost-efficient manner, explained Fermin Barrueto, MD, FACEP, FAAEM, FACMT, chairman of the Department of Emergency Medicine in the Upper Chesapeake Health System (UCHS).
Incentivizing many of these changes is the health system’s participation in the state’s Global Budget Revenue (GBR) program, “which essentially caps hospital revenue and changes [hospitals] from volume to value-based reimbursement,” Barrueto said. “At the same time, the physicians remain on a volume-based reimbursement for their professional fees, and together we are trying to find ways to produce win/win situations where we can maintain high quality, because we know that we can’t cost-cut our way to greatness.”
Barrueto noted that one of the first programs implemented as part of this collaboration was a low-risk chest pain protocol aimed at decreasing clinical variation in the way chest pain patients are treated. “In just the first six months of that program we have been able to avert more than 200 hospital admissions for chest pain and provide appropriate outpatient follow-up and outpatient stress tests for these patients so that we can maintain high quality,” he said.
A second initiative involved integrating a high-risk care plan, designed for frequent utilizers, into the health system’s IT infrastructure. As part of this intervention, a one-page summary of the care plan, which incorporates information from multiple healthcare sources, including a prescription drug monitoring program, is incorporated into the emergency physician workflow.
“Our initial pilot of 44 patients showed a decrease in opioid prescriptions by more than 50%, a decrease in inpatient and observation stays by more than 40%, and we were able to decrease CT utilization, MRI utilization, and X-rays by more than 55%,” Barrueto said. Further, now that the care plans have been extended to more than 300 patients, their effectiveness at decreasing acute care utilization has been maintained, he added.
One intervention that was developed internally within the Emergency Medicine Network is a patient callback program, Barrueto explained. “It essentially provides reimbursement to physicians for calling back their own patients,” he said. In addition, this program provides a construct so that patients can get tied into case management or other services. The aim, said Barrueto, is to improve the patient experience while also potentially decreasing the use of hospital resources.
Another ambitious intervention that is in development at UCHS is a comprehensive care clinic — essentially an infrastructure that is focused on chronic disease management, and serves as a follow-up source for emergency providers. Barrueto explained that it is being integrated with the ED, and it is providing emergency physicians with an alternative to hospital admission for appropriate patients as well as a way for the hospital to identify patients who are at risk for hospital admissions or other healthcare utilization. The clinic specifically targets patients who do not have PCPs or lack insurance coverage.
Overall, hospital admissions and observation stays have decreased in the two acute care hospitals that are part of UCHS, although the number of days being utilized by patients in these two settings has continued to increase. “Future challenges will be how [we] can address that piece, but as far as the EDs and partnering with our hospitals — we have seen some tremendous improvements,” Barrueto said. “Right now there are more than 500 hospital admissions just within the past year [for which] we have been able to provide alternatives that maintain quality care.”
Solicit input from physicians
In Washington state, the incentive for reform came from a draconian cost-cutting plan Washington State Medicaid, part of the Washington Health Authority, introduced in 2011. The plan was to limit the number of “non-emergency” ED visits to three in a calendar year. Outraged by this edict, emergency physicians in the state filed a lawsuit that ultimately stopped the plan from taking effect, but they were nonetheless under considerable pressure to fix the problem of high ED utilization and spiraling costs.
“We are the canary in the coal mine, and we are often looked at as the problem when I think we actually do stand at the intersection of all failed policy,” observed Nathan Schlicher, MD, JD, emergency physician and regional director of quality in the ED at St. Joseph Medical Center in Tacoma, WA.
Working with the Washington State Hospital Association and the Washington State Medical Association, the Washington Chapter of the American College of Emergency Physicians came up with a seven-point plan to improve management of emergency services and reduce over-utilization without any provision for denying coverage or care. The seven points included:
- Develop and use interoperable health information exchange (HIE) technology.
- Educate patients about the appropriate use of EDs.
- Identify frequent ED and pre-hospital care users.
- Develop care plans for frequent users.
- Implement guidelines to reduce narcotic-seeking behavior.
- Participate in a prescription drug monitoring program.
- Use feedback information.
For the HIE piece, Schlicher emphasized that the emergency physicians just wanted access to three pieces of information: where the patient accessed healthcare before, when they accessed care, and what the chief complaint was in these prior visits. “Just that simple data can provide the change in direction that we [take],” Schlicher said. “When you have a 42-year-old woman in for her first visit of chest pain, that is a different conversation than [what you would have with a] 42-year-old woman in for her 45th visit for chest pain who got a [diagnostic heart catheterization] last week in a different hospital.”
Similarly, with a prescription drug monitoring program in place and standardized guidelines on how to prescribe opiates and deal with chronic pain, the physicians were prepared to make changes. “We got all the docs to buy into the idea that we cannot be the stop-gap for chronic pain. And we cannot just make it easier on ourselves and on our patients with drug addiction,” Schlicher explained. “We need to take on the hard task of dealing with addiction. And we brought in help, case managers and social workers that work with us in the department in real time … to help us develop care plans, to integrate those into our HIE, and to help people get the actual care that they need, whether that is addiction treatment, mental health[care], or otherwise.”
Schlicher suggested that the seven-point program simply represented common-sense solutions, but the emergency physicians believed it would save the state money, and they were right. “In our first year we saved $32 million for the state,” he said. “We exceeded the budget goal [of $31 million in savings], not by denying care, but by improving care.”
Further, narcotic prescriptions to all patients in the Medicaid program decreased by 24%, and ED utilization by frequent-utilizers fell by 10%; For all Medicaid clients, ED utilization dropped by 12%, Schlicher added.
“The thing that has been borne out of this that I think is revolutionary is that we engaged providers in the conversation about how to improve care. It is a novel concept, but it makes common sense,” Schlicher noted, “because in the busy day-to-day ED where we all work, we can’t reform healthcare by ourselves in one department, but we often see the problems and the challenges. So by working together, we were able to improve the system.”
In fact, with a successful template for change in place, Schlicher noted that all the stakeholders who worked on this program are now continuing to meet every other month to discuss future reforms. “The future is bright when we work together and collaborate rather than mandate reform,” he said.
Find the drivers of utilization
Collaboration is also a key feature of a pilot program in Denver, CO, called Bridges to Care, a coaching model that targets frequent utilizers with the aim of helping them access appropriate preventive care and services so that they don’t end up in the ED or require inpatient care.
Four different organizations, including the University of Colorado School of Medicine, the University of Colorado Hospital, the local qualified health center referred to as the Metro Community Provider Network (MCPN), and Together Colorado, which is a faith-based organization, are working in concert to offer the program with funding through a Centers for Medicare and Medicaid Innovation grant, explained Jennifer Wiler, MD, MBA, FACEP, vice chair and associate professor, Department of Emergency Medicine, University of Colorado, Aurora, CO.
“We are one of four sites that have been charged with looking at the Jeff Brenner Camden Model to see if there is an opportunity to innovate and decrease utilization in EDs and the inpatient setting in different communities,” Wiler said.
Brenner is a PCP, founder and executive director of the Camden Coalition of Healthcare Providers, a network of community-based care and social service providers who work together in teams to deliver comprehensive care to some of the most disadvantaged and complex patients living in Camden, NJ. The model is now being replicated in other cities.
In Denver, Bridges to Care has thus far enrolled 550 patients who meet program criteria. “These are patients who have had three ED visits in six months or two inpatient admissions in the last six months,” Wiler said. “We have included patients who have a mental health diagnosis, which is unique compared to the other models across the country. No other models have included those patients.”
The goal of the program is to educate patients about their health needs and to empower them to access care in the most appropriate settings within the system, but also to identify what the drivers are in terms of utilization, Wiler explained. “We have a two month program where patients get home visits. These include mental health visits and medical visits or shared visits, if necessary,” she observed. “It includes a health coach as well as advocates or patient navigators.”
While no results from the program have been published thus far, Wiler noted that it is nonetheless clear that the program is making a difference. “Eighty percent of our patients have both a mental health diagnosis and a diagnosis related to a chronic pain condition. After our intervention, 90% of patients at six months post-intervention are still utilizing primary care services, which has been a big success,” she observed. “Overall, we have seen a 40% reduction in ED and inpatient visits, and we showed a cost-savings of more than $2 million to the healthcare system, which is about $20,000 per patient.”
Program administrators have also identified what the key challenges are when patients require care. “Patients have said their number one issue in terms of deciding when and where to access healthcare is transportation. Homelessness has also been a very large driver of utilization, and it has been difficult for us to intervene,” Wiler noted. “But we have been able to show marked reductions in utilization related to patients who have both chronic pain and mental health issues.”
The program made a big stride when the local Medicaid provider, Colorado Access, agreed to fund on a per-member, per-month basis an embdded nurse case manager in the ED to touch Medicaid patients. “[Medicaid administrators] said they were having a real challenge trying to identify patients and get them attributed to medical homes, and we said that is because they are in our EDs, so it has been a great opportunity to do that warm touch,” Wiler said.
“What we found in our study is that when we were doing retrospective enrollment of patients after they came to the ED to ask them if they wanted to participate ... we were enrolling about 100 patients per six-month period,” Wiler added. “But after we did a live touch in the ED during the time when a patient was in an acute crisis, and we were able to do coaching and counseling at the bedside, we were able to enroll over 100 patients per month into our program.”
These observations demonstrate how important it is to connect with patients while they are in the ED, Wiler observed. “Data show that phone calls are not as effective as these warm touches at the bedside.”
Push for continued improvement
At the conclusion of the conference, Pines offered some broad recommendations, calling on all healthcare stakeholders to engage with acute care providers on developing clinical pathways and protocols to improve outcomes, value, and efficiency. He also called for better systems to manage acute care demand, making use of telemedicine and other forms of communication to better manage frequent utilizers.
Pines noted that emergency providers need to be engaged in reforms that impact all levels of the care continuum, and to work with data to evaluate interventions and make continued improvements. He added that more quality measures need to be developed to look at such issues as patient access, patient safety, resource utilization, care coordination, and whether the right care is being delivered for specific conditions.
Pines called on the government as well as private payers to develop more acute care payment model pilots that incentivize value, and he emphasized that optimal cost containment depends on achieving the interoperability of health information across facilities.
- Fermin Barrueto, MD, FACEP, FAAEM, FACMT, Chairman, Department of Emergency Medicine, Upper Chesapeake Health System, Bel Air, MD. E-mail: firstname.lastname@example.org.
- Arthur Kellermann, MD, MPH, Dean, F. Edward Hébert School of Medicine, Uniformed Services, University of the Health Sciences (USU) in Bethesda, MD. Phone: (301) 295-9943.
- Mark McClellan, MD, PhD, Senior Fellow and Director, Health Care Innovation and Value Initiative, Brookings Institution, Washington, DC. Phone: (202) 797-6105.
- Jesse Pines, MD, MBA, MSCE, Director, Office for Clinical Practice Innovation, Associate Professor, Emergency Medicine and Health Policy, George Washington University, Washington, DC. E-mail: email@example.com.
- Nathan Schlicher, MD, JD, Emergency Physician and Regional Director of Quality, Emergency Department, St. Joseph Medical Center, Tacoma, WA. E-mail: firstname.lastname@example.org.
- Jennifer Wiler, MD, MBA, FACEP, Vice Chair and Associate Professor, Department of Emergency Medicine, University of Colorado, Denver, CO. E-mail: email@example.com.