By Rick Newell, MD, MPH, FACEP

The Centers for Medicare and Medicaid Services (CMS) currently mandates that one perecent of reimbursement for hospital care be based on measures of value and patient satisfaction. This program is called Value Based Purchasing (VBP). Implementation of VBP started on September 1, 2012 and is the beginning of CMS’ transition from paying for volume to paying for value.  In 2014, VBP will increase the percentage of CMS hospital reimbursement at risk under the VBP program and will include outcome measures.  Now, CMS is planning to extend this program to physicians and physician groups under the new Value Based Payment Modifier (VBM).

Starting on January 1, 2015 VBM will apply to large physician groups (those with more than 100 physicians under the same Tax ID Number) and will transition to all physicians and physician groups by January 1, 2017. Although the reimbursement changes will not occur until 2015, CMS will use 2013 data to calculate the 2015 VBM reimbursements.  In addition, physician groups must select their data reporting methodology in 2013.  So, although the actual change goes into effect two years from now, we need to start preparing now.

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 Theo Koury, MD, FACEP

Hospitals across the country are starting to feel the effects of healthcare reform. Beginning in fiscal year 2013 (September 1, 2012), part of hospital reimbursement has been based on a value-based purchasing (VBP) plan that has been created by the Centers for Medicare and Medicaid Services (CMS). This is the first step in a process that will transform the current fee-for-service system into to a fee-for-performance system. This transformation will be taking place gradually, so those who prepare now will improve their strategic position for the future.

CMS established VBP with two goals in mind: to decrease healthcare costs and to improve outcomes for healthcare services. In order to create incentives for hospitals to achieve these goals, they have developed quality criteria which include both clinical process measures and patient experience measures. To start off, CMS will withhold one percent of all hospital payments, and will remit that one percent to hospitals only if they meet the new criteria. The amount withheld will increase annually, finally reaching two percent in 2017.

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.

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.

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:

By Wesley Fields, MD, FACEP

As Chief of Thoracic and Vascular Trauma at the Shock Trauma Center in Maryland, Dr. James O’Connor knows the difference between sick and well.  With decades of experience at the leading statewide trauma program in America, Dr. O’Connor and his colleagues are actively engaged in expanding the critical care services for trauma patients to include Maryland’s sickest patients needing medical intensive care.  As he recently explained to an expert panel gathered to assist the editors of Health Affairs to frame a special edition on ‘Reinventing Emergency Care,’ the reason is very simple. It is increasingly true that health care consumers have “one set of doctors when they are well, and another set when they are sick.”

Regardless of their specialty training, physicians are more and more likely to choose between practicing in office settings or hospitals.  In some cases, full-time hospital practice for surgical subspecialists like Dr. O’Connor is a matter of necessity.  Outside military theaters, no one would dream of doing an open-chest procedure outside the best equipped hospital available.  Further, regionalization of advanced trauma care, speeding access to premier specialists like Jim and his colleagues at Shock Trauma, has been shown to save lives and improve medical outcomes.