By Kevin Kruse

While acute care hospitals are veterans in the fight to contain costs, healthcare reform is bringing greater focus to other aspects of care including patient satisfaction, provider preventable conditions and readmission rates. One highly effective yet underutilized tool for achieving these goals is employee engagement.

So, what is employee engagement anyway? Let’s start with what it’s not…

By Josh Sheridan, MD, MS

The hospital system I work for has an ED and two Urgent Care Centers (UCCs) in the same city. Between the two UCCs, we serve all payer populations so that everyone in the community can access urgent care services when needed. In this way, we try to be highly available for everyone who needs immediate care. At the same time, we have also made the decision to have limited testing facilities in the urgent cares and to focus them on particular patient populations. While our UCC set up is not the standard, the results have been beneficial for both patients and the hospital.

Our first UCC is referred to as the Community Clinic. It is located in a very accessible area and provides care predominantly to underserved patients who have no insurance and who are at risk for slipping through the cracks. This center is staffed by mid-level providers and is subsidized by the hospital system so that it can treat all comers regardless of whether they can pay for services. At times, patients use the community clinic for primary care services, and while the UCC is not an ideal supplier of primary care medicine, it does provide important preventative services. Patients will also occasionally receive follow-up care after hospitalizations if needed. The goal here is that patients released from the hospital are hopefully less likely to return to the ED. Just as Steven Larsen, MD describes at his UCC, even in cases where the UCC receives no payment, the hospital system as a whole can experience a net financial gain. We see a financial gain here in two ways: the UCC services are significantly less expensive to the hospital than equivalent care provided in the ED, so treating patients in the UCC reduces financial losses to the hospital. Secondly, our hospital readmission rate is going down and thus our hospital system is avoiding penalties for readmission imposed by Medicare.

By Phil Piccinini, MD

As health reform moves forward, we will need to work with fewer resources and find innovative ways to streamline care. One such solution is what my group calls “Team Care”—medical personnel working together to optimize efficiency. As ED visits go up and the patient traffic increases without any increase in structural capacity, Team Care adds functional capacity by reducing overall time in the department.

For example, Team Care is cutting the throughput times for patients in our EDs. Recent studies have shown that crowded EDs are more than just a financial drain and risk management concern for hospital; they are actually bad for patients’ health. Waiting in an ED is like a layover in an airport. Nobody likes sitting around in airports waiting for departures that never seem to happen. In an ED, it’s even worse: the people who have to wait are anxious and in pain. For some patients, waiting for care can be life threatening. But even for patients who are not critically ill, long lines in the ED can lead to dissatisfaction. ED patients need to get checked in quickly, and then be either admitted to the hospital or released to go home as soon as possible. And Team Care helps this happen.

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.

With an additional 30 million people to be added to the rolls of the medically insured in this country over the next year, common wisdom is that they will all be going to the emergency department (ED). That’s what happened when Massachusetts added more enrollees to their state funded insurance program, to the tune of 3 million additional ED visits between 2004 and 2008. A key driver behind this was that there were not enough primary care physicians (PCPs) to meet the need. As the Affordable Care Act (ACA) now rolls out across the country seniors will increasingly feel the pinch. Their numbers are increasing as the baby boom ages, while at the same time many PCPs are becoming reluctant to take on Medicare patients due to payment reductions.

I predict that non-physician providers and new models of providing primary care will present themselves to fill the gap in primary care.  Nurse practitioners (NPs) are already trying to rewrite state laws to allow themselves to practice independently, and several states already give NPs many of the powers the physicians have. The American Association of Colleges of Nursing is also proposing that they add a "PhD" to their training; and California Healthline is reporting that California State Senator Ed Hernandez is planning on introducing legislation this month to enable nurse practitioners to establish independent practices.  Physician Assistants (PAs) will also see new opportunities to increase the scope of their practices in the reports of this proposed legislation. Over forty percent of CEP America’s clinical hours are already provided by PAs and NPs, and I believe we will surpass 50% or more in the very near future.

By Brian Bearie, MD

I regularly exchange my white coat for a jacket and tie as I take off my clinical hat and put on my administrative hat.  When doing this, my perspective changes slightly─to how I can best serve my patients while at the same time keeping a sustainable business. 

Upon learning of the “triage out” concept, my initial visceral reaction was strong opposition.  This practice, which sends low acuity ED patients to primary care venues, seemed to conflict with my commitment to patient care.  But as the landscape changes and there is an overwhelming increase in primary care patients presenting to the ED, I  now see the triage out option as a viable way to not only serve the needs of the ED, but also to steer patients towards the primary care they need.

Much has been written about the Affordable Care Act (ACA) and one of its ongoing experiments is known as Accountable Care Organizations (ACOs). Recently The Wall Street Journal published an opinion with the headline “The Coming Failure of ‘Accountable Care’”. While I agree with the authors that many ACOs will fail, I believe that they will fail for different reasons.

I have two different perspectives on this. One is based on 30 years of experience as an emergency physician in clinical practice, remembering the early days of managed care when HMOs were created to do much of what is expected from ACOs. A second perspective is as the CEO of a physician management company with almost 100 client hospitals. I believe that physicians and hospitals will indeed change their behaviors, and rapidly, once the ACA takes effect and they get paid based on value and not for the number of billable services provided. Otherwise, they simply won’t be able to compete with physicians and hospitals which are more efficient and provide better quality at a lower cost.