By Gary Li, MD, FACEP

In most of the prior blogs you have heard a lot about the inexorable forces of change in our healthcare system which are leading to consolidation of health care entities, integration of service lines, accountable care organizations, and so on. Fundamentally, these forces are the oft-state three mandates of improving quality, improving access, and decreasing costs. Keith Bontrager of mountain bike building fame used to say “strong, light, cheap—pick two out of three.” Well, perhaps carbon fiber has changed that paradigm for bikes. Going forward, in medicine, we are also expected to go three for three. Here I would like get into the weeds a bit and ponder resource utilization in clinical practice and the relationship with the Acute Care Continuum.

Analogous to fast food “supersize” meals, more medical care does not always mean better care. Gradually, many healthcare providers and members of the public are beginning to understand this. The “Choosing Wisely” initiative of the American Board of Internal Medicine Foundation is indicative of this recognition and concern. In this program, each medical specialty identifies five diagnostic or therapeutic interventions that may be of questionable value. Programs like this are encouraging medical providers to let go of tests and procedures that are not helpful, may be harmful, and are expensive.

By Ted Kloth, MD, FACEP

The time is coming when consolidation and transparency will reign supreme, and the effects are already being felt throughout the healthcare arena.

Looking at the healthcare landscape and how the major players are reacting to the effects of reform, it is obvious to me that the need to consolidate is becoming a reality for many physician groups and service providers. Health systems are merging with larger health systems and clinical outsourcing groups are entering into joint ventures with their long-time clients to provide care at a lower cost. The rationale behind this shift is the belief that integrated systems reduce costs and increase profits for all parties involved. And with fewer reimbursement dollars at play, it seems most are looking for ways to increase profit margins by doing more for less.

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.

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 Steven Larsen, MD

When I hear people talk about lack of access to healthcare in our society, I realize right away that they are not talking about where I work.  At our Urgent Care Center (UCC), our mission is to help people feel better as soon as possible and to transition them quickly to the additional service they may need.  Our Center is designed to increase access to medical care for low-income patients and for low-acuity patients who do not have a primary care physician. 

The UCC concept of making access to healthcare more convenient appears to be resonating with the ‘fix it now’ mentality of our society.  The number of UCCs in the country is growing fast.  Of the 8,700 UCCs currently operating in the US, only about half of them have been in business for over five years. 

By Wes Fields, MD, FACEP

One of the ironies of our intensely divisive political season is that Republican and Democratic candidates agree that universal access to health care already exists in the United States, and preceded the Affordable Care Act by 24 years.

The Emergency Treatment and Active Labor Act (EMTALA) will continue to define unscheduled ambulatory care and acute hospitalization for the entire US population, regardless of how the elections for the White House and Congress impact ACA, the Fiscal Cliff, and the precipice in Medicare for physicians known as the Sustainable Growth Rate.

Taken together, the patient protections of EMTALA structured as mandates on Medicare participating hospitals touch nearly half of all costs in the current US health care system.  Inpatient hospital care accounts for more than one third of expenditures(pdf). And more than half of all admissions are direct results of ED visits for patients who are too unstable to be discharged home.  Ambulatory ED visits account for nearly one third of all unscheduled visits. A far larger proportion of first contact conditions of higher risk and higher cost are performed in EDs. This high-acuity effect is compounded for those who are uninsured, or underinsured.