Emergency Medicine Under Pressure

Emergency departments are frequently stereotyped as a hospital’s “money-loser.” Due to the concentration of resources needed to staff an ED, they are expensive to operate and increasingly becoming overcrowded. The Supreme Court’s June 28 ruling pushes forward The Patient Protection and Affordable Care Act, which will extend insurance coverage to millions of uninsured Americans.

Healthcare reform is likely to exacerbate the burden on EDs as health insurance does not guarantee access to care. More than 20 million additional people are expected to receive Medicaid, and it is likely that a substantial number of them will visit the ED because of lack of access to primary care. With an insufficient number of primary care practitioners and unwillingness among many to see Medicaid patients, it is likely EDs will experience a significant increase in visits as the newly insured seek low acuity and routine medical care.

Driven by the pursuit of stimulus funding, many hospitals are rolling out their enterprise clinical information systems in the ED and replacing the best-of-breed systems that are fine tuned for ED operations. Unfortunately, these enterprise systems are designed for an inpatient setting and often do not contain the depth of clinical content or workflow sophistication necessary to handle the complexities specific to an ED.

As a result of such system implementations, it is not unusual to see an ED physician group experience a 15 percent to 30 percent loss in productivity for extended periods of time. Some never recover full productivity and have to resort to scribes or dictation. Further compounding their challenges, ED physician groups—which are already facing pressure from health systems to reduce costs and do more (e.g., see more patients, reduce wait times) and accept lower reimbursement—will most likely need innovative solutions to solve several complex issues.

Across the country a number of ED physician groups are simply compressing their margins to prevent being replaced. This approach is rapidly commoditizing their services and is likely to push smaller groups out of business.

So, what can ED physician groups do to continue to remain viable? To understand the situation better, let’s look at it from a hospital CEO’s perspective:

• Many hospital CEOs view their crowded EDs as a failure of the ambulatory system. Although 50 percent of hospital admissions may come from an ED, 70 percent to 80 percent of patients seen in an ED won’t be admitted. Could those patients be treated elsewhere?

• CEOs care about inpatient admissions. Hospital beds need to be kept full—preferably with patients with good insurance coverage. This means executives must continuously find creative ways to capture market share in an increasingly competitive environment.

• The Readmissions Reduction Program is spurring many CEOs to institute follow-up care initiatives for their patients 30 to 60 days post discharge.

To fight commoditization, an ED physician group can align itself in purposeful ways to hospital strategies. Can they help hospitals implement and manage programs for reducing patient use of the ED for primary care? Could they support hospitals in securing a sustainable referral base? Groups that focus exclusively on ED issues will continue to be viewed narrowly as a cost center. The next group that provides the same services at a lower cost per visit will win the contract.

What are some attainable solutions?

• First, ED physician groups can use technology and LEAN/Six Sigma methods to make their operations as efficient as possible—to keep the patients flowing, keep the beds turning, and support inpatient admissions appropriately.

• Second, physician groups can demonstrate their value by helping hospitals roll out and manage programs that redirect patients to more suitable settings of care—for example, patients experiencing the flu, minor lacerations/sprains, etc.—who could be treated in an outpatient clinic. Enterprising groups can forge partnerships with ambulance companies and other providers to implement various forms of rapid triage programs, real-time transfers to urgent care/mobile care and other programs to reduce ED volume.

• Third, physician groups can help hospitals capture market share. Because 70 percent to 80 percent of a hospital’s patients are seen and discharged from the ED, ensuring that those patients stay in the hospital network can have a significant impact on the hospital’s long-term financial success. The patient who arrived in the ED with chest pain, but is released after observation, could be connected with a specialist in the community who will appreciate the referral and direct patients to the hospital in the future.

This type of action can strengthen hospital-physician alignment, potentially leading to improving patient mix, retaining patients in-network and ultimately generating a healthy bottom line for all. This is good for patient care as well. Patients who receive a warm hand-off to the next care provider are more likely to stay compliant with care plans, undergo a better recovery, and remain loyal to the hospital and physician.

If that isn’t compelling enough, we are facing potentially more regulations geared at incenting providers based on reporting of outcomes and holding them accountable for costs across multiple caregivers and care settings. In the future, establishing effective care coordination will be even more essential for physician groups and hospitals to be successful.

In the end, the practice of emergency medicine must evolve with reform to ensure well-coordinated care for the patient that extends beyond the ED. Physician groups that connect their ED care delivery processes with upstream (urgent care clinics) and downstream (primary care and specialists) caregivers and become key partners in the hospital’s quest for market share will not only be able to further differentiate themselves but also have a significant impact on the quality of patient care.

 Sunny Sanyal is CEO of T-System Inc.