ED Push - July 2016 Second Issue

Freestanding EDs Growing in Number; Tend to Serve Privately Insured

BOSTON – The number of freestanding emergency departments (EDs) has increased rapidly during the past few years, according to a study seeking to better understand the phenomenon and what patients are being served.

The report, which looked at EDs physically separate from acute care hospitals but available 24/7 for emergency care, was published recently in the Annals of Emergency Medicine.

For the study, Brigham and Women's Hospital researchers created a national inventory of freestanding EDs, identifying 360 in 30 states as of March 31, 2015, a sharp increase from 222 in 2009.

Conducting ZIP code level geographic analysis in the three states with the highest number of freestanding EDs — Texas, Ohio, and Colorado — the study team found that the facilities tend to be located in areas with population growth, higher incomes, a higher proportion of the population with private insurance, a lower proportion of the population with Medicaid, and, interestingly, in locations with a greater number of hospital EDs.

"Freestanding EDs are an innovative model of acute care delivery with the potential to reshape the market for emergency care. As many EDs nationwide experience crowding and long wait times, especially those in urban areas, freestanding EDs offer the potential to improve access to emergency care," explained corresponding author Jeremiah Schuur, MD, MHS, vice chair of Clinical Affairs, Department of Emergency Medicine at Brigham and Women's. "But in the states with the most freestanding EDs, it seems less likely that they will expand access to underserved populations as they are preferentially located in areas where people had more available health services, higher rates of private health insurance, lower rates of Medicaid, and higher median incomes.”

In Texas and Ohio, for example, freestanding EDs were located in ZIP codes with a higher proportion of privately insured residents. In Texas, with nearly 200 freestanding EDs, most were highly concentrated around several metropolitan areas and were located in ZIP codes that had fewer Hispanics, a greater number of hospital-based EDs and physician offices, and more physician visits and medical spending per year than ZIP codes without a freestanding ED.

Nationally, 54.2% of freestanding EDs were owned by, or affiliated with, hospitals, and 36.6% were independently run by physician groups or other entrepreneurs. In addition, 45.3% of freestanding EDs were for-profit and 43.9% were non-profit.

The percentage of freestanding EDs associated with hospitals was lower in Texas (22.1%), while the percentage of those with for-profit status was higher (71.3%). The for-profit facilities were more likely to be located in ZIP codes with existing hospital EDs, according to study authors.

In Ohio, with 34 freestanding EDs, however, all but one were affiliated with hospitals, while only 5.8% were for-profit, and they were more likely to be located in areas without hospital EDs. Of Colorado’s 24 freestanding EDs, 45.8% were affiliated with hospitals, and 61.9% were for-profit.

"Our findings, which addressed the distribution of freestanding EDs in relation to underserved populations and populations with fewer health services, can help inform ongoing policy discussions on how to regulate and pay freestanding EDs,” Schuur said in a Brigham and Women’s press release. “Policymakers should review state regulations and payment policies to encourage the expansion of freestanding EDs in ways that will improve access and reduce cost, not duplicate services.”

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ACEP Files Federal Lawsuit to Improve Out-of-Network Payment

WASHINGTON, DC – Frustrated with low out-of-network reimbursements for emergency care, the American College of Emergency Physicians (ACEP) has gone to court to try to do something about it.

The federal lawsuit, American College of Emergency Physicians v. Burwell et al, maintains that an Affordable Care Act regulation related to emergency-care reimbursement fails to ensure reasonable payment to out-of-network providers. The case was filed recently in the U.S. District Court for the District of Columbia.

The regulation in question was issued jointly in November 2015 by the U.S. Department of Health and Human Services, the Department of Labor, and the Department of the Treasury. Under the 2015 rule, health insurers must give out-of-network emergency medicine providers the greatest of three payments: the plan’s in-network amount, the Medicare amount, or the usual, customary, and reasonable (UCR) amount.

The emergency physicians group wants insurance companies to provide more transparency about what data are being used to determine payment, as well as a clarification of the UCR amount.

"Patients can't choose where and when they will need emergency care and should not be punished financially for having emergencies," said Jay Kaplan, MD, ACEP president. "Health insurance companies need to be transparent about the data they are using to pay for services provided by out-of-network providers. They have a history of data manipulation and not paying for emergency care. They are shifting their responsibility to our patients, and that is just wrong. “

According to Kaplan, “The federal government has done an injustice to emergency patients and emergency physicians by giving carte blanche to insurance companies to pay whatever they want. Historically we know that amounts to as little as possible."

Kaplan said ACEP was shocked by the final rule that allows insurance companies to arbitrarily set their own rates and shift costs they should be paying to patients because the physician organization has worked for four years with the Centers for Medicare & Medicaid Services (CMS) to address the out-of-network issue.

The lawsuit points out that, according to the new rule, even “minimum standards of payment are not necessary” in states that have banned balance billing, maintaining the government is essentially allowing insurance companies to set whatever prices they want, despite the devastating effect on patients, healthcare providers, and the nation’s medical safety net.

"Health insurance companies have taken gross advantage of patients and emergency medical providers since the ACA, arbitrarily slashing payments by as much as 70%," Kaplan emphasized.

Because the Emergency Medical Treatment and Labor Act requires that any individual who enters an ED receive care, regardless of their ability to pay, emergency physicians tend to treat more patients out-of-network than other specialists.

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New Assessment Tool Helps Determine If Syncope Cause Is Serious

OTTAWA, CANADA – Syncope makes up between 1% and 3% of all emergency department visits, and about 10% of those patients go on to experience an adverse event within a week or month of the visit, according to a recent study.

The dilemma for emergency medicine is determining when fainting is a symptom of a serious problem.

Now, a report published recently in the Canadian Medical Association Journal includes a simple nine-question tool to help emergency physicians determine if a hidden condition caused the fainting incident.

The Canadian Syncope Risk Score was created by researchers from The Ottawa Hospital and the University of Ottawa to help predict the risk of a patient experiencing an adverse event, such as potentially fatal irregular heart rhythm, heart attack and other cardiac events, gastrointestinal bleeding, and even death, within a month after fainting.

"Fainting is a big problem," explained Venkatesh Thiruganasambandamoorthy, MBBS, CCFP-EM, MSc. "The way fainting patients are examined in emergency rooms varies greatly between physicians and hospitals. We hope that this screening tool will make the process more consistent and improve the detection of serious conditions related to fainting."

For the study, the research team focused on 4,030 patients presenting with fainting at six Canadian hospitals. Of those, 147 patients experienced a serious event in the month following discharge.

Study authors identified eight factors that physicians can use to help determine future risk of an adverse event. Those are:

• the presumed cause of fainting at the end of emergency department assessment;
• whether fainting was triggered by the patient being in a warm or crowded place, standing for a long time, or experiencing intense fear, emotion, or pain;
• a history of heart disease;
• abnormal electrocardiogram measurements;
• high levels of troponin, a protein that indicates damage to the heart if detected in blood; and,
• abnormal blood pressure reading during the emergency visit.

Results indicate that the risk of a serious adverse event within 30 days ranged from 0.4% for a score of −3 to 83.6% for a score of 11.

“The Canadian Syncope Risk Score showed good discrimination and calibration for 30-day risk of serious adverse events after disposition from the emergency department,” study authors conclude. “Once validated, the tool will be able to accurately stratify the risk of serious adverse events among patients presenting with syncope, including those at low risk who can be discharged home quickly.”

"If our tool can discharge low-risk patients quickly and safely, then I think we can reduce emergency room wait times and open up those resources to other patients," Thiruganasambandamoorthy added.

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Causes of Persistent Diarrhea Identifiable Through New Testing Methods

HOUSTON – Emergency department clinicians need to be alert when diagnosing persistent vs. acute diarrhea in patients, according to a new journal article suggesting that many physicians fail to focus on how long patients have had the condition.

Persistent diarrhea, which lasts at least 14 days, is an illness typically caused by parasites or bacteria and requires accurate diagnosis to determine what treatment to provide, according to a literature review published recently in the Journal of the American Medical Association.

In the review, Herbert L. DuPont, MD, director of the Center for Infectious Diseases at The University of Texas Health Science Center at Houston School of Public Health, warns that persistent diarrhea from some causes can result in serious nutritional disorders and malnutrition.

"I'd like to educate doctors about the importance of taking the history and assessing duration of illness,” DuPont writes. “For acute diarrhea, the lab has a minimal role, restricted to patients passing bloody stools. If a patient has had diarrhea for two weeks or more, the doctor should focus on the cause of the disease through laboratory testing, with an emphasis on parasites.”

According to the review, acute diarrhea lasts less than two weeks and typically is caused by viruses or toxins.

Persistent diarrhea, on the other hand, is caused most commonly by bacteria or parasites, including Giardia, Cryptosporidium, and Cyclospora or, less commonly, Entamoeba histolytica, Dientamoeba fragilis, Strongyloides stercoralis, and Microsporidia species.

The parasites can be contracted through food, water, or from other people and are commonly picked up while traveling. They also can be detected in laboratory testing, DuPont points out.

During the past year, he notes, a new testing method — multiplex polymerase chain reaction (PCR) — was developed, and the simultaneous, single test identifies unique DNA sequences to detect a panel of causes of diarrhea.

Two platforms have been approved by the Food and Drug Administration for use, according to the article. In the past, researchers had to culture bacteria from a stool sample and examine it for isolated bacteria, or look under a microscope for parasites. In addition, commercial enzyme immunoassay could be used to identify three of the parasites. Yet, those methods were limited in their ability to pinpoint causation.

"These new tests are easy to use, are capable of detecting a broad range of pathogens and represent a significant improvement over culture-based diagnostic approaches,” DuPont explains. “The technology needs to be more widely available. Diagnosis is critical when treating persistent diarrhea.”

In terms of treatment, he emphasizes, a lab-established diagnosis is necessary before instituting antimicrobial therapy. Nitazoxanide is a drug that treats a broad spectrum of parasites and can be used as treatment for patients with persistent diarrhea who test negative for a pathogen in the lab, DuPont adds.

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