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the
Acute Care
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5 Years After ACEP’s Warning, Access to Emergency Care Remains in Jeopardy

By Martin Ogle, MD, FACEP

On Jan. 16, 2014, ACEP released the latest version of its National Report Card on the State of Emergency Medicine. The report rates both the nation and individual states in five areas:

  • Access to Emergency Care
  • Quality & Patient Safety Environment
  • Medical Liability Environment
  • Public Health & Injury Prevention
  • Disaster Preparedness

  • In its last report released in 2009, ACEP gave the nation an overall grade of C-. In 2014, we earned a D+.

    Both reports identified Access to Emergency Care as the area of greatest need. (In fact, the nation earned a D- in this area in both 2009 and 2014.) The access grade evaluates:

  • Availability of providers
  • Availability of treatment centers
  • Financial barriers
  • Hospital capacity

  • Access is the highest-weighted of the five categories, accounting for 40 percent of the overall grade.

    So is it true that we've made virtually no progress at improving the average person’s access to emergency care? As someone involved in healthcare advocacy, I'd have to agree that we haven't made a whole lot of progress. I do feel we've done a good job defining some real quantitative measures of access. But there's been relatively little political, regulatory or legislative movement to use these measures to guide policy.

    Access, Not Coverage, Is the True Crux of Healthcare Reform

    By Martin Ogle, MD, FACEP

    By the time you notice America's doctor shortage, it will be too late.

    That's the ominous tagline of a campaign by the Association of American Medical Colleges, which is lobbying Congress for increased graduate medical education funding. The association predicts a national shortage of 90,000 physicians by 2020 — half of them in primary care.

    The scary part is, people are already starting to notice.

    According to a recent study by the University of California, San Francisco, the number of ED visits in California rose by 13.2 percent between 2005 and 2010.

    This in itself is a dramatic finding. But what's most interesting is not how many came to the ED, but who. Patients covered by Medi-Cal, the California version of Medicaid, increased their ED utilization by a whopping 35 percent during the study period.

    A Bump in the Road to Payment Reform

    In 2013 and 2014 as part of the Patient Protection and Affordable Care Act (ACA) a “primary care payment bump” will become effective. This is a program where for two years primary care physicians (PCPs) will receive the Medicare level reimbursement for the Medicaid patients they see. This is not a small change, considering Medicaid rates have been estimated to be about 66 cents to the dollar when compared to Medicare primary care rates. In fact, the investment the Feds are making for this program is estimated to be $11 billion and will increase PCP Medicaid reimbursement by 34%.

    Physicians eligible for this program are those with a specialty in family medicine, internal medicine, pediatric medicine, and obstetrics. The policy considerations behind this pay bump are consistent with the ACAs goal of expanding the availability of health care. Medicaid expansion is a critical component of how increased care will be provided across the country under the ACA.

    Integrating a New Player in the Acute Care Continuum

    The move toward care integration is intensifying, and some of the solutions I see emerging right now might have looked like science fiction a few years back. I don’t think anyone envisioned so many departments coming together under one umbrella in a hospital setting and working with agile outside entities such as a Federally Qualified Healthcare Center (FQHC). But scenarios like this are being fueled by both the government and hospitals.

    The Federal government sees cost savings associated with integration and uses incentives such as bundled payments to bring departments together. With the budget crisis and patient boom, hospitals are harnessing this power of collaboration and working to build the seamless transfer of care between departments.

    Imagine this: an integrated team that includes the ED, hospitalists, intensivists, primary care physicians (PCPs) as Chronic Disease Management specialists, and even post-acute care done though a FQHC. FQHCs are publicly-funded health clinics that provide primary care services for underserved patients. They also provide, or have an agreement with another organization to provide, dental services, mental health services, as well as hospital and specialty care. FQHCs are quickly entering the healthcare landscape as they gain financial resources. The Affordable Care Act in 2010 included $11 billion for FQHCs over a period of 5 years. Considering this influx of money, you can understand why FQHCs are gaining prominence and emerging in the hospital setting.

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