Recently, Drs. Lee, Schurr, and Zinc published an article in Annals of Emergency Medicine that detailed three different approaches to estimating the percentage of total national healthcare costs that were expended for emergency department care. The statement in this article that most healthcare journalists have picked up on is related to the authors’ assertion that spending on ER care could amount to as much as 10% of the national healthcare budget. This clashes significantly with ACEP’s assertion that these costs represent just 2% of overall healthcare outlays. However, the key takeaway from this article is that we really don’t have accurate models and reliable data to be able to determine with any certainty just how much money is spent on ER care in our country. I even have doubts about the accuracy of the $2.6 trillion denominator (total costs for all care) used in calculating this percentage. In any case, the authors assert that “rather than minimize the issue of cost, we should recognize the economic and strategic importance of the ED within the healthcare system and demonstrate that costs are commensurate with value.” I am not sure how it will be possible to demonstrate the true value of emergency department care if we can not accurately determine the true cost of this care; but I agree with the authors that the question of how much is spent on ER care is not nearly as important as the question of how to maximize the value of this spending.

The perception that many people, in particular uninsured and Medicaid patients, use the ER inappropriately, is one reason why CMS proposed new rules to allow states to increase Medicaid cost-sharing for ER services.  Of course, there is some truth to the assertion that a certain percentage of ER patients could, or should, get their care in a clinic, urgent care center, or primary care provider’s office.  In many of these cases (though definitely not all), the cost of care would be lower.  Considering for example the advantages of continuity of care, for some of these patients, the care might even be more appropriate, on the other hand, many attempts to divert patients from the ER, dissuade patients from going to the ER, or limit the services provided to patients who present to the ER, carry the potential for adverse consequences for providers, patients, the ER safety net, and the community.  Any effort to reduce the inappropriate use of the ER must carefully weigh the possible risks and benefits of the strategy, and lean towards what is in the best interests of patient care.

The Centers for Medicare & Medicaid Services (CMS) just published some newly proposed rules that enable States to impose increased cost sharing on Medicaid patients for non-emergency care in the ER.  These rules open the door even wider for these States to abuse ER providers and hospitals, and discourage Medicaid patients from seeking needed care.  Sadly, CMS did not even bother to consult with the American College of Emergency Physicians before drafting these rules, which makes it a lot more difficult to put some of the more problematic provisions back into Pandora’s box. There is a good article on these proposed rules in the NY Times if you want a thousand foot view.  I’ve done a pretty thorough review of these rules, and will try to highlight the pertinent language and possible consequences of the provisions related to emergency care; so lets get into the weeds:

The recent 60 Minutes broadcast – “The Cost of Admission”, and a comparable article in the NY Times, have raised a very controversial issue in emergency medicine and put this issue prominently in the public eye. The issue is: when is it inappropriate to try to influence physician behavior, and when do incentives become coercive?

Clearly, there are times when protocols, policies, performance goals, and even financial incentives can be helpful in getting physicians to adopt practices that are in patients’ best interests. The bottom line, though, is that if the goals of these incentives are not directed first and foremost to improving outcomes and providing cost effective, efficient, patient directed, quality driven objectives; such incentives deserve to be viewed with great skepticism, if not condemned outright. Unfortunately, the line between appropriate incentives and inappropriate incentives is not always easy to determine without a very thorough review. Thus, a protocol, or software driven set of admission criteria, that incentivizes providers to admit patients who rarely need to be admitted rather obviously steps over the line; but a protocol that encourages a physician to reconsider admission in patients who meet certain criteria in order to reduce the likelihood of an adverse outcome if the patient is discharged home could well be in patients’ best interests.

This is Part 2. Read the first part here.

How will the debt crisis deal affect Medicare?  The only thing that will prevent the US from taking a long slide down the debt chute is shifting more of the cost of care for seniors on to the backs of those seniors that can afford it.  Everyone knows this, and seniors, especially those with grandkids, would probably go along with it if push came to shove.  Unfortunately, our political leadership is so worried about voting seniors pushing back that even retired politicians have a tough time telling the truth to the electorate.  Thus:

• The Fickle Finger predicts that any effort to pare down the trillions of dollars in future unfunded Medicare liabilities in 2013 will get no farther than a bit of trimming around the edges.  Not even Republicans have the gumption to push for more than a face saving gesture.

Will Congress come up with a permanent and long term fix for the Medicare SGR problem in 2013?

The folks at Perspectives on the Acute Care Continuum asked me to take a stab at some predictions for “things that will matter” in 2013.  That’s a bit like asking someone to stroll out on to the center of an iced-over lake to see if the ice is thick enough to support their weight, but I am game considering that it is unlikely anyone will bother looking back at these predictions come the end of the year.  I am going to try to stick to issues and events that are likely to impact health care in the coming year, to narrow the scope of the request.

First, let’s get the most important, and most aggravating, question out of the way.  What is going to happen to the whole debt crisis thing?  I have to say that I was correct in predicting, in my last blog, that we would go over the fiscal cliff – we actually did, even though at the last minute the government grabbed a protruding root that will allow the country to hang on for another two months or so.  To boil a lot of political froth down to its essence, this was because the House Republicans who signed the Grover Norquist tax pledge had to wait for the Bush tax cuts to expire for everyone so they only had to cut taxes (for the 98%) rather than raise them (for the 2%).  The fact that this pledge cost the Republicans the opportunity to get the entitlement reforms and spending cuts they now deride the ‘deal’ for ignoring seems not to have led to any revision in strategy.  No surprise there, but now what?

Perspectives on The Acute Care Continuum gives a tip of the cap to Myles Riner, MD for his prodigious year of blogging, including our number 2 most popular blog from 2012:

One of the topics that attracts a lot of attention when emergency physicians and those interested in ED practice management get together to discuss how emergency medicine can remain relevant in, and become integrated into, the new health care reform and value based purchasing paradigms, is the concept of care coordination.  In theory, since the ED is linked to such a wide range of diagnostic testing resources, care facilities, and providers, and sits at the intersection of outpatient and inpatient care for many of the patients who are hospitalized:  emergency physicians ought to be able to play an important role in the coordination of care, both for the acutely and for the chronically ill.  In practice, many of the systems support structures that need to be in place to facilitate this role have often been ignored or neglected, or deferred on the assumption that they will be addressed with the adoption of the electronic medical record.  

If emergency physicians and EDs are going to assume the role of master care coordinators (something that family physicians staffing the medical home might consider within THEIR scope), they are going to have to define this role carefully, invest in the systems and staffing to support it, and integrate the concept into everyday practice.  Until now, few payers have been willing to pay for this service, and few hospitals and ED groups have been willing to invest significantly in the systems and staff to support it.  Suddenly, care coordination is the latest buzzword, and the presumptive salvation for what is often perceived as a frequently too expensive and often inappropriately utilized drain on the health care system:  the ED as poster-child for ‘the ‘failure of health care’.