Written by James Augustine, MD, FACEP , Director of Clinical Operations- Emergency Medicine John G. Holstein, Director of Business Development, Zotec Partners Andrew Sama, MD, FACEP, President, Progressive Emergency Physicians Management

JK Wall reports “Now there are a plethora of doorways to medical care; employer clinics, medical clinics in drug stores and urgent care centers in strip malls.” Is the ED losing its once lauded status as the front door into every hospital? Let’s take stock of several major issues transforming the healthcare landscape that have, or likely will have an impact on emergency medicine.

First, Daly reports EDs are likely looking at increasing volumes, particularly due to shifts (i.e. decreases) in primary care reimbursement from Medicaid.2 The wildcard here is roughly one year ago many thought Medicaid expansion would depress ED utilization as primary care providers were predicted to absorb a sizeable percentage of the newly insured. It is of course not solely a reimbursement issue, there is a manpower issue. As noted in the NY Times “the Association of American Medical Colleges warns of a shortfall of 45,000 primary care physicians and 46,000 surgeons and medical specialists by 2020.”3

Second, the out-of-network and associated issue of patient balance billing continues to be an omni-present revenue threat for many ED practices. To a great extent this is a state-by-state issue, and typically receives significant play in the lay press as well. The effect on ED volume and access does not appear to be significant.

Third, the continued boom of the urgent care industry. A key, emerging differentiator however also noted by Wall (see below) is hospitals starting to build urgent care centers specifically in formerly “high-traffic areas as well as other areas that historically have generated high numbers of ED visits.”

Fourth, hospitals are continuing to move into the insurance business. Indeed Brill goes so far as to suggest this intimate linkage between provider and insurer is a macro solution to healthcare’s triple aim.4

Fifth, the substantial and dramatic increase in patient high deductible insurance plans. The self-pay patient has always been a challenge for emergency medicine, hospitals and other specialties; the high deductible, self-pay patient escalates the issue to an entirely different level of discussion. Emergency medicine practices chasing these dollars using protocols and technology from the 1980s, 1990s and even early 2000s are at significant financial risk with these patients today, with the added public relations issues that are inevitably concomitant with the financial component. Unger and O’Donnell report on the double digit increase in these plans and the related aspect of the issue of patients purposely delaying care. This component has all of the ingredients for increasing ED volumes.5

Sixth, the retailization of healthcare. Voices outside healthcare6 are calling for the consideration and potential implementation within healthcare of consumer type metrics of price transparency, call center performance metrics, roadside claim adjudication and accelerated claims payments, all designed to drive customer loyalty and satisfaction for a product everyone hopes they’ll never have to use…”

The issue of transparency for charges, collections, and insurance coverage of ED visits has been a long term issue, and featured in many lay press pieces. As the average ED bill increases above $3,000 there is even more issue with collection of very high self-pay, co-pay, and post-deductible charges. Emergency care and hospital leaders should be aware of the information available from AHRQ and its’ MEPS study.

Another noteworthy shift in healthcare worth EM’s vigilance is the increasing emphasis at the c-suite level for reliance on evidence-based solutions of care. Rosin notes this and Gamble reports on Steven Klasko, MD’s vision of healthcare, quoting him, “The gauntlet I’ve thrown down is I want Jefferson to be the first academic medical center where you can advance your career based on entrepreneurism and innovation.”7,8

The ED at Jefferson is a focal point of this evolution. Agrawal and Conway note how EM can provide answers and solutions for healthcare’s triple aim of better health, better care and lower costs.9

These include EM serving as the nexus of care coordination which will require the following indices:

  1. Substantial integration of coordinated care models.
  2. Development of reliable and actionable data on ED quality, population health and cost outcomes.
  3. Specific initiatives to control and optimize ED utilization.
  4. Payment models which preserve surge and disaster response capacity.

At this year’s ACEP 2015 Reimbursement conference several EM-specific solutions were proposed and included the following:

  1. EM-run observation care.
  2. EM’s key role in addressing the hospital’s re-admission issue.
  3. EM asserting itself into the issues surrounding post discharge care and monitoring of patients. In this context cardiologists are taking a hard and fast look at discharge summaries and their impact on patient outcomes, as noted by Bushko. “These findings may provide more impetus for thoughtful improvements in discharge-summary quality and provide  some guidance as to the key aspects of discharge-summary preparation on which to focus improvement efforts.”10
  4. EM working with hospitals to address the issue of price transparency of charges, and what the patient will ultimately be required to pay out of pocket.
  5. The appropriate and compliant collection of true self-pay balances today requires sophisticated technology, patient-friendly portals and flexible processes that are managed by  experienced billing personnel fully knowledgeable in the issues of the evolving healthcare environment. As the industry and landscape continues to change and evolve, Susa Nedza, MD offered a classic quote about EM, stating “No one manages uncertainty better than emergency physicians.”11 The issue here is not that EM does not have solutions in this evolving post ACA world. To the contrary Augustine reports EM does in fact not only have solutions, no, EM has the data metrics and analytics to support its solutions.12 These include:
  • 68% of all hospital admissions come through the ED. Certainly hospitals are shifting more and more care into outpatient settings however, hospitals still need revenue and EM is providing a substantial proportion of it.
  • Patient flow is predictable.
  • EDs are seeing older, complex and high acuity patients.
  • The highest injury rates are patients over 75 years.
  • Metrics on ED numerous diagnostics, therapeutics, critical care and mental health are available and crucially important to constantly monitor.
  • ED processes typically turn on thresholds of 20,000 visits, producing ED cohorts that are predictable and manageable with data analytics.
  • EDs seeing predominantly adult versus pediatric populations are fundamentally different in terms of both structure and functioning.
  • Correlations exist between EMS arrival and admission rates.
  • Acuities continue to increase in our nation’s busiest EDs.
  • Rapid diagnostics and intervention continue as hallmarks of EM.
  • ED visits, despite all efforts, are on the rise.

The challenge of and to the specialty is not a lack of information and data. The challenge is for the specialty to become a difference maker, a game changer, driving solutions in today’s healthcare world. The available tools are the following:

  • Existent benchmark data.
  • Constant monitoring of ED demographics, payer and acuity mixes and insurer payment rates.
  • Strong and creative technology solutions that are patient friendly, particularly for today’s high deductible patients. Technology and processes that are from the 1980s through the early 2000s are outdated and add on the potentially even more volatile public relations issues over and above the revenue loss issue.
  • Integration of clinical diagnostics into the value proposition of each ED.
  • Openness to direct involvement in new and creative post treatment models.
  • Laying claim to the ED’s role in the care continuum.
  • Providing a broader range of services.
  • The ability of hospitals and emergency physicians to cooperate to address the transparency issues in charges and out-of-pocket expenses.
  • These indices can become the value proposition of EM. This is a day and time of great opportunity for EM to emerge as a true leader in this era of great change in our nation’s healthcare delivery system. Despite multiple new access points, it appears that when patients are significantly ill or injured, the ED still remains the front door to the hospital.


1Wall, JK. “IU Health’s New Sense of Urgency.” December 18, 2014. http://www.ibj.com/blogs/12-the-dose/post/51005-iu-healths-new-sense-of-urgency?utm_source=ibj-north-of-96&utm_medium=newsletter&utm_content=the-dose&utm_campaign=2014-12-19
2Daly, Rich. Changes in Medicaid Payments Could Trigger Surge in Emergency Department Use in 2015.” hfm. December 2014.
3Editorial Board. “Bottlenecks in Training Doctors.” NY Times. July 19, 2014.
4Brill, Stephen.
5Unger, Laura, O’Donnell, Jayne. “Dilemma over Deductibles: Costs crippling the middle class.” USA Today. January 2, 2015
6Riley, Joe. “In 2015, Consumer Will Be King in Healthcare. January 4, 2015. http://techcrunch.com/20-15/01/04/in-2015-consumer-will-be-king-in-healthcare/
7Rosin, Tamara. “4 Hospital & Health System CEOs Define Challenges and Resolutions for 2015.” Becker’s Hospital Review. January 6, 2015.
8Gamble, Molly. “Jefferson Health’s CEO Has Big Hopes for New Innovation Hub. ” Becker’s Hospital Review. January 8, 2015.
9Agrawal, Shantanu; Conway, Patrick H. “Aligning emergency care with the triple aim: Opportunities and future directions after healthcare reform.” Elsevier. Healthcare 2; Volume 2, Issue 3, September 2014.
10Bushko, Marlene. “Heart-Failure Discharge Summaries Often Poor Quality, Perhaps Affecting Outcomes. Medscape. January 16, 2015.
11Nedza, Susan.”Commercial Payers, ACOs, and Future ED reimbursement.”ACEP Reimbursement 2015. January 12, 2015.
12Augustine, James. “How Do You Measure Up? ED Benchmarking and Hospital Perception.” ACEP Reimbursement 2015. January, 13, 2015.

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