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Abstract

  1. Top of page
  2. Abstract
  3. The Status of Medical Care in The United States of America
  4. Defining Value in Emergency Medicine
  5. Episodes of Care and Their Impact on The Delivery of Health Care in The ED
  6. Proposed Health Care Strategies: Potential “Preventables”
  7. Research and Policy Gaps
  8. EM At Academic Medical Centers: Leading The Transformation of The U.S. Health Care System
  9. Conclusions
  10. References

ACADEMIC EMERGENCY MEDICINE 2012; 19:1204–1211 © 2012 by the Society for Academic Emergency Medicine

Abstract

The Patient Protection and Affordable Care Act (ACA), passed in 2010, has important implications for emergency physicians (EPs). In addition to dramatically reducing the number of uninsured in the United States, this comprehensive health care reform legislation seeks to curb the escalating costs of health care delivery, optimize resource utilization, eliminate waste, and improve the quality of service delivered by the health care system. At the annual Association of American Medical Colleges (AAMC) meeting on November 5, 2011, an expert panel from public health, emergency medicine, and health services research was convened by the Association of Academic Chairs of Emergency Medicine (AACEM) and the Society for Academic Emergency Medicine (SAEM) to discuss possible future models for the emergency care system and academic emergency medicine in the era of the ACA.

Resumen

La Ley para la Protección del Paciente y para un Cuidado de la Salud Asequible (Patient Protection and Affordable Care Act), aprobada en 2010, tiene importantes implicaciones para los urgenciólogos. Además de la alarmante reducción en el número de no asegurados en Estados Unidos, esta reforma legislativa de la asistencia sanitaria global busca frenar el incremento de los costes de la asistencia sanitaria, optimizar el uso de recursos, eliminar el despilfarro y mejorar la calidad de los servicios prestados por el sistema sanitario. En la reunión anual de la Association of American Medical Colleges el 5 de Noviembre del 2011, un grupo de expertos en salud pública, en medicina de urgencias y emergencias y en investigación en servicios sanitarios se reunieron para la Association of Academic Chairs of Emergency Medicine y la Society for Academic Emergency Medicine para discutir sobre posibles futuros modelos para el sistema de atención urgente y la medicina de urgencias y emergencias en la era de la Ley del Cuidado Asequible (Affordable Care Act).

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA) into law.1,2 This comprehensive, health care reform legislation includes numerous provisions, including measures to create health insurance exchanges, mandate that individuals buy health insurance, broaden Medicaid eligibility, and raise the maximum age of dependent health insurance eligibility. A goal of the ACA is to curb the escalating costs of health care delivery, optimize resource utilization, eliminate waste, and improve the quality of service delivered by the health care system. One strategy legislatively mandated to achieve these goals is comprehensive payment reform.

Other provisions of the ACA seek to improve the quality of care and service delivered by the health care system and to curb the escalating costs of health care by optimizing resource utilization and eliminating waste. To encourage a more organized approach to care during an episode of illness, the ACA also proposes comprehensive payment reform, focused on shifting from fee-for-service reimbursement to alternative payment methodologies (e.g. “bundled payments”), which are designed to encourage a more organized approach to care delivered during an illness episode by aligning incentives (e.g., shared payments) for health care providers. The creation of “accountable care organizations” is intended to improve care coordination and service delivery by rewarding organizations when evidence-based, high-quality care is delivered.

Emergency departments (EDs) serve as the ultimate health care safety net for the nation. In fact, emergency care is the only health care to which Americans have a legal right, regardless of their ability to pay.3 Changes in ED utilization are a bellwether for how our overall health care system is functioning.4 One goal of the ACA legislation is to shift, to the degree possible, the site of service delivery from costly inpatient and ED settings to outpatient care.5 As the gatekeepers to the hospital, providers of emergency care will be called upon to play an increasingly more important role in the U.S. health care system.6 The economics and forces driving health reform are likely to have particularly pronounced effects on academic medical centers, which are not only expected to provide highly sophisticated (and therefore costly) care, but also to teach residents and conduct basic and applied research to improve health care delivery. Maximizing the value of services while minimizing the cost of delivery is the most challenging task to implement. On June 28, 2012, the Supreme Court upheld the ACA as constitutional, and now going forward, physicians and other health care providers must address what “value” means in the context of the practice of medicine.

At the annual meeting of the Association of American Medical Colleges (AAMC) meeting, November 5, 2011, an expert panel representing the perspectives of public health, clinical emergency medicine (EM), and health services research was convened by the Association of Academic Chairs of Emergency Medicine (AACEM) and the Society for Academic Emergency Medicine (SAEM). Members of the panel were chosen because they have national reputations in health policy issues and public health from the perspectives of the role of EM at academic medical centers (AMCs) (Dr. Arthur Kellermann, President, RAND Health), value in EM (Dr. David Magid, Director, Colorado Permanente Medical Group), value-based purchasing in EM (Dr. Dennis Beck, former chair, American College of Emergency Physicians Reimbursement Committee), and the role of EM in the public’s health (Dr. Chris Urbina, Executive Director and Chief Medical Officer, Colorado Department of Public Health and Environment). The speakers were vetted and selected by a small committee comprised of AACEM and SAEM leaders and representatives to the AAMC. The goal was to identify nationally known speakers considered high-level content experts, who would provide an evidence-based, nonpartisan approach to the question of the “value of emergency care in an era of health reform.” They were asked to predict the future of emergency care and particularly the role emergency physicians (EPs) would be called upon to play in AMCs. The goals of this panel were to: 1) provide updates on the current state of medicine and how health care reform is being implemented, 2) provide a working definition of what value in EM can be, 3) identify the key challenges for EM in the implementation of certain aspects of the health care legislation, 4) identify research and policy gaps, and 5) propose solutions to better equip EPs to handle these changes in this rapidly changing health care environment. This article summarizes the conclusions of this expert panel.

The Status of Medical Care in The United States of America

  1. Top of page
  2. Abstract
  3. The Status of Medical Care in The United States of America
  4. Defining Value in Emergency Medicine
  5. Episodes of Care and Their Impact on The Delivery of Health Care in The ED
  6. Proposed Health Care Strategies: Potential “Preventables”
  7. Research and Policy Gaps
  8. EM At Academic Medical Centers: Leading The Transformation of The U.S. Health Care System
  9. Conclusions
  10. References

To understand how initiatives to improve value may be implemented in EDs, it is important to understand the current state of health care delivery in the United States. In 2008, the Commonwealth Fund produced a report card that compared the U.S. health care system to those of five other countries (Australia, Canada, Germany, New Zealand, and the United Kingdom). In the five categories that were measured (access, affordability/efficiency, quality, equity, and health outcomes), the United States ranked fifth or sixth in each.7 Hospital EDs play a pivotal role in four of these domains: access, quality, outcomes, and affordability.

Access

In the past 2 years alone, more than 54% of adult patients with chronic medical conditions reported problems accessing care due to cost. Most of these patients noted that they did not fill a prescription or skipped doses of a needed medication; failed to see a physician for a medical problem; or did not obtain physician-recommended testing, treatment, or follow-up. The percentage of American adults reporting problems with access is the highest in the world among first-world countries, more than double the percentage for Canada (25%), and four times the percentage reporting problems in the United Kingdom (13%).8

Due to the job losses that accompanied the great recession, the number of uninsured Americans today (50 million) is higher than at any time since World War II.9 Rates of uninsurance are highest among young, working age adults. Regionally, uninsurance is most common in the South and West. The percentage of working age adults without health insurance has grown from 17% to more than 20% in just 5 years.10

Because the uninsured often struggle to pay their medical bills, many office-based primary care and specialist physicians are reluctant to treat them. As a result, many turn to EDs for care because they know they cannot be turned away. A 2011 analysis published in the journal Health Affairs determined that the 4% of physicians who mainly practice in EDs handle 11% of all outpatient visits in the United States, 28% of all acute care visits, half of all acute care visits by Medicaid and Childrens’ Health Insurance Program (CHIP) beneficiaries, and two-thirds of all acute care visits by the uninsured.11

Rising levels of uncompensated care have put EDs under tremendous strain, particularly those located in safety-net hospitals.12 Although the number of ED visits grew at a faster rate than the U.S. population annually for each of the past 20 years, the number of EDs in non-rural areas has declined by over 27% during the same time period.13 EDs located in highly competitive markets, and those that treat a high percentage of patients living in poverty, were most likely to close.

Quality/Outcomes

Although American health care is the most expensive in the world, it often falls short of expectations. A 2003 RAND Corporation study conducted in 12 major U.S. cities determined that Americans receive recommended preventive, chronic, and acute care from their physicians only 55% of the time.14 Failure to consistently deliver recommended care has consequences: a recent transnational study of deaths from treatable conditions such as diabetes, ischemic heart disease, stroke, and bacterial infections ranked the United States 16th out of 16 wealthy nations, with an amenable mortality rate nearly twice that of the top-performing country.15

Affordability

Today, the United States spends far more money annually on health care, whether measured per capita (nearly $8,000), or as a percentage of GDP (almost 18%), than any other nation. However, according to the Organization of Economic Co-operation and Development (OECD), the United States ranks rank 27th out of 34 countries for life expectancy and below the average for all OECD countries (78.2 years in the United States compared to the average for OECD countries of 79.5 years). Infant mortality is also higher in the United States (6.5 deaths per 1,000 live births) than the average for the OECD countries (4.4 deaths per 1,000 live births).16

Relentless growth in health care spending has extracted a major toll on the U.S. economy, the competitiveness of American businesses, and the financial security of middle class families. In a recent 10-year period, the average family health insurance premium paid by U.S. employers grew by 119%; the amount contributed by employees increased 117%.17 A 2011 economic analysis that took all types of health care spending into account (including insurance premiums, out-of-pocket payments, and the share of taxes devoted to health care) determined that a decade of health care cost growth basically wiped out the income gains of average American families.18 According to an Institute of Medicine Report in 2010,19 over $750 billion of wasteful health care spending occurs each year for inefficient services, excessive administrative costs, high prices, medical fraud, and missed opportunities for prevention.

Defining Value in Emergency Medicine

  1. Top of page
  2. Abstract
  3. The Status of Medical Care in The United States of America
  4. Defining Value in Emergency Medicine
  5. Episodes of Care and Their Impact on The Delivery of Health Care in The ED
  6. Proposed Health Care Strategies: Potential “Preventables”
  7. Research and Policy Gaps
  8. EM At Academic Medical Centers: Leading The Transformation of The U.S. Health Care System
  9. Conclusions
  10. References

In light of these findings, it is evident that the American health care system is not consistently providing high-quality, affordable care. As our nation struggles with how best to pursue health care reform, the concept of “value” becomes increasingly important. Health economists measure value as the ratio between costs and health outcomes. As is evident by HealthGrades, one of the U.S. report card evaluation systems, the high cost of health care delivery is not associated with superior outcomes (e.g., lower rates of infant mortality or longer life span for adults) and therefore generates a poor return on our investment. Experts estimate that over 75% of national health expenditures in the United States are attributed to managing chronic diseases,20 but unlike other countries, much of this expensive care is due to an absence of care coordination, lack of primary care, and a high percentage of uninsured and does not focus on primary or secondary prevention. Just 5% of the U.S. population accounted for over half of all medical expenditures in 2009.21 Further, marked geographic variation in health care utilization and costs does not correspond with lower rates of mortality or better health outcomes; in other words, high-spending communities and regions do not enjoy better health than lower-spending communities and regions.20,22

According to some health policy experts, “value, neither an abstract ideal nor a code word for cost reduction, should define the framework for performance improvement in health care. Rigorous, disciplined measurement and improvement of value is the best way to drive system progress. Yet value in health care remains largely unmeasured and is misunderstood.”5,23

Accordingly, Porter23 proposed a framework that considers the contribution of appropriate, effective, safe, and timely care for defining patient outcomes. Value is then a derivative of the factors that create an outcome, which are then considered in relation to the costs associated with providing this service. This methodology not only considers the contribution of evidence-based care metrics, but also includes factors that influence the patient experience, something notably missing from other definitions of value. The factors that contribute to the overall patient experience include whether the care was appropriate, safe, effective, and timely, in its effect on the patient’s overall health outcome. These four constructs must be factored into the health economists’ equation of value as it relates to the outcome and cost relationship.

Current Physician Payment System

The ultimate goal of many health care reform strategies is to cut or curtail costs. Although reducing the cost of physician services has been identified by many policymakers as a way to generate significant health care savings, physician services account for only 21% of total U.S. health care expenditures.24 Hospital care (31%), prescription drugs (10%), program administration (7%), and other professional services (6%) account for an additional 54% of the total expenditures.

The Relative Value Unit System of Reimbursement for Physicians’ Services

In 1992, Medicare initiated the Resource-based Relative Value Scale (RBRVS) as a means to change the way that physicians’ services were paid. Instead of basing payments on usual and customary charges, the RBRVS system bases values on the resource costs needed to provide a service.25 Values are determined by the components of physician work, practice expense, and professional liability insurance.26,27 The American Medical Association (AMA) Relative Value System Update Committee (RUC) was developed in 1991 to make recommendations to the Centers for Medicare and Medicaid Services (CMS) about the relative value units (RVUs) to be assigned to Current Procedural Terminology (CPT) codes. CPT codes are maintained by a 17-member AMA-convened editorial panel.

The Medicare Physician Fee Schedule is determined by multiplying the combined RVUs for a service (e.g., work + practice expense + liability) by a conversion factor (a monetary amount determined annually by CMS based on the Sustainable Growth Rate [SGR] formula). The payment for physician services by Medicare has a strong influence on physician compensation in the private commercial market. As part of the ACA, there will be a new value-based modifier that will be added to this equation. It is intended to reward providers who demonstrate “value” as far as quality and resource utilization.28 The details of how the value-based modifier program will be initiated and integrated into the current reimbursement system is still under discussion.

There are many pitfalls with the current reimbursement process. Initially developed as a means to control overall health care costs, the SGR does not reflect actual physician expenditures. As a result, drastic decreases in the conversion factor, and subsequent physician payments, have been halted by congressional action 13 times since 2002. The current accumulated “bad debt” generated by these congressional SGR fixes is around 290 billion dollars. Some have also noted that RBRVS favors procedural specialties and disadvantages those that are primarily cognitive (e.g., pediatricians, internists, family practitioners). CMS and the RUC are currently evaluating strategies to place greater value on primary care, medical “homes,” and care coordination. As new technologies or procedures are developed, specialties have the opportunity to request that new CPT codes be developed, which subsequently improve the chance for reimbursement in the current fee-for-service environment.29 There is also concern that the fee-for-service environment encourages utilization and not necessarily good health outcomes.30,31 Some have suggested that it would be better to align payment incentives and reimbursement based on provider performance;32 however, this is still under discussion at the federal level.

Episodes of Care and Their Impact on The Delivery of Health Care in The ED

  1. Top of page
  2. Abstract
  3. The Status of Medical Care in The United States of America
  4. Defining Value in Emergency Medicine
  5. Episodes of Care and Their Impact on The Delivery of Health Care in The ED
  6. Proposed Health Care Strategies: Potential “Preventables”
  7. Research and Policy Gaps
  8. EM At Academic Medical Centers: Leading The Transformation of The U.S. Health Care System
  9. Conclusions
  10. References

Legislated to start in 2013, payments for some services will be based on a care “episode.” Episodes have yet to be defined, but will be based on all care provided for certain acute and chronic health conditions or procedures over a defined period of time (e.g., 1 year).33 Reimbursement for a care episode will be adjusted based on the severity of illness (risk adjustment) and provider performance of certain quality metrics.34 Payment for episodes will be bundled, meaning that it will include the cost of care delivered by all providers and all ancillary service costs (e.g., pharmaceuticals, practice expense, etc.) involved in the care of the patient throughout the duration of the episode. There is notable methodological complexity when anticipating the total costs for a given patient or population of patients. Although the methodology may be more straightforward for some elective surgical procedures (e.g., hip replacement in an otherwise healthy 60-year-old), it becomes increasingly challenging to develop a sound payment methodology for chronic disease management in patients with comorbid conditions (e.g., 1-year treatment of a patient with hypertension and diabetes, who is admitted to the hospital from the ED for congestive heart failure).35 In addition, on average, seven providers see a typical Medicare beneficiary during his or her episode of care.36 The proportion of money that is distributed across these providers, who may or may not be at the same institution, will be difficult to determine.

There are challenges with including emergency medical care in the current episode of care methodologies (Table 1).37 Many episodes-of-care payment models do not include ED care, with a notable exception being initiation of an acute myocardial infarction episode. The acute exacerbation of chronic disease commonly presents to the ED, and the value of emergency care provided to patients who are part of an episode group has not been defined. Many episode groups include an ED visit as a complication of care and an indication of poor quality, with subsequent payment reduction to the other providers managing the patient’s episode. The additional pressures of balancing resource utilization with the necessary demands of providing care to previously unestablished patients make the attribution and risk adjustment methodologies of current episode groups more challenging when applied to the ED setting. No current episode models address the patient who comes to the ED with an undifferentiated presenting complaint (as opposed to a diagnosis-defined episode).

Table 1.    Episodes of Care and the Potential Challenges of Implementation in the ED
PolicyEffective DateRationaleChallenges of Implementation
Episodes of care2013• Current system does not encourage coordination of care across providers and care settings • Patients may receive inferior care quality due to poor communication and lack of data integration, and duplication of resource utilization may occur, resulting in inefficient and more costly care • Aligning incentives of providers by bundled payment methodology expected to improve care coordination and delivery• Lack of clarity about: 1) definition of “care episode”; 2) how bundled payments will be allocated to individual providers and who will make this determination; 3) how quality metrics will be developed, measured, and reported; and 4) how patient care data will be integrated despite fragmented information systems between providers • Unclear how payments will be allocated between providers at different institutions • Unclear how inherent differences in liability risk will be adjusted in payment attribution (e.g., ED physicians are less likely to have established patient relationships and provide care to higher acuity patient populations than typical primary care practice) • Unclear how Emergency Medical Treatment and Active Labor Act--mandated care will be reimbursed

In response to these concerns, some have recommended that emergency medical care be excluded from a bundled episode payment and retain the current fee-for-service model.37,38 This recommendation is based on the unique issues inherent to emergency care, including lack of predictability of unscheduled acute care, lack of diagnostic clarity at the time of presentation, and lack of available resources for care coordination (e.g., access to electronic medical records, assurance of follow-up care). Although this carve-out for EM may be very difficult, it may be that a fee-for-performance model with pay-for-performance incentives may be a better interim alternative to the current and proposed systems.

Proposed Health Care Strategies: Potential “Preventables”

  1. Top of page
  2. Abstract
  3. The Status of Medical Care in The United States of America
  4. Defining Value in Emergency Medicine
  5. Episodes of Care and Their Impact on The Delivery of Health Care in The ED
  6. Proposed Health Care Strategies: Potential “Preventables”
  7. Research and Policy Gaps
  8. EM At Academic Medical Centers: Leading The Transformation of The U.S. Health Care System
  9. Conclusions
  10. References

The Medicare Payment Advisory Commission (MedPAC) is also considering additional health care reform strategies that are focused on five types of potentially “preventable” health care situations: ED visits, ancillary service utilization, procedure complications, hospital admissions, and hospital readmissions. To deter these events, discussions include limiting reimbursement if they occur. Although all five of these areas have the potential to affect EM, the two most significant to EM are “preventable” ED visits and hospital readmissions (Table 2). These two issues have implications for how EPs will be reimbursed for the care they provide to patients. Hospitals will be incentivized to limit admissions of patients who return within a short period of time after hospital discharge.

Table 2.    Proposed Health Care Reform Strategies on Potentially Preventables and the Potential Challenges of Implementation in the ED
InitiativeRationaleChallenges of Implementation
Potentially preventable emergency visits• Contribute to rising health care costs and could be due to difficulty in accessing timely care in an ambulatory care setting, lack of access to care, or rapid or inappropriate discharge from the hospital• Difficulty in defining the criteria for a preventable visit • Does not take into consideration access to health care, differences due to insurance status, socioeconomic status, or geographic availability of resources • May worsen known health disparities by no longer reimbursing care in ED settings • Difficulty in defining the criteria for inappropriate readmissions • Does not take into consideration access to health care differences due to insurance status, socioeconomic status, or geographic availability of resources • May worsen known health disparities by no longer reimbursing care in ED settings
Readmissions• Readmissions to the hospital are costly and may reflect suboptimal care or inappropriate discharge from the hospital for a patient

Potentially Preventable ED Visits

Some policy makers have noted the potential cost savings of changing the site of service for nonurgent visits. The work commonly cited is by Billings et al.,39 who developed an algorithm to evaluate administrative claims data for six million ED visits to New York City hospitals between 1994 and 1998. They categorized patients into four groups: nonemergent (care not required within 12 hours); emergent/primary care treatable (treatment required within 12 hours, in a primary care setting); emergent/ED care required but preventable or avoidable; and emergent/ED care needed, not preventable or avoidable. The concerning limitation is that this algorithm used disposition diagnosis to retrospectively determine the categorization of the patient, and the findings have not consistently been applied to other large patient populations.40 Although there are notable barriers to access to outpatient primary care, payment would be denied based on CMS’s interpretation of potentially preventable ED visits (PPVs) to the ED.41 Discussion about the denial of payment for services rendered to Medicaid patients based on site of service has already occurred in many settings in the United States.42 As the definition of PPVs may be more subjective and difficult to define than current initiatives assume, it will create challenges for EM to define the value of these visits in the new ACA landscape.

Readmissions

It has been noted that 22% of Medicare beneficiaries are readmitted to the hospital within 60 days.43 The ACA asks for a methodology to decrease hospital readmissions, because readmissions are thought to reflect health care system inefficiencies and suboptimal care. The etiology of hospital readmissions is notably multifactorial, and may not reflect quality,44 and in part may be related to patient factors.45 A health care policy that penalizes readmissions may in fact further increase health disparities. Patients from lower socioeconomic status, minority racial and ethnic groups, and rural areas disproportionately have challenges in accessing care, which is one aspect of care transitions and potential hospital readmission.41,46 A valid method of discerning between “appropriate” and “inappropriate” readmissions to the hospital is needed and has yet to be developed.

Research and Policy Gaps

  1. Top of page
  2. Abstract
  3. The Status of Medical Care in The United States of America
  4. Defining Value in Emergency Medicine
  5. Episodes of Care and Their Impact on The Delivery of Health Care in The ED
  6. Proposed Health Care Strategies: Potential “Preventables”
  7. Research and Policy Gaps
  8. EM At Academic Medical Centers: Leading The Transformation of The U.S. Health Care System
  9. Conclusions
  10. References

There are notable gaps in our understanding and knowledge of how EM will fit into the health care reform landscape being shaped by the ACA. These research gaps can be stratified into two areas: broad-based for the entire medical community, and those that are more specific to EM.

Research and Policy Gaps in Medicine

  •  How will value in medicine be defined?
  •  How should we pay for a patient’s care? Should this be done as episodic care groups, rather than the fee-for-service, or another model that is currently being used?
  •  How will we make the health care system of care accountable for the whole episode of care provided to a patient? How will provider attribution and reimbursement be determined for the care delivered during an episode?
  •  What patient-centered outcomes will be used to measure and evaluate the influence of policy changes on health outcomes of individuals and populations?
  •  How is resource utilization measured and tracked?
  •  How are costs and outcomes measured across institutions?
  •  How are data integrated across the health care system, including but not limited to integrating prehospital, ED, inpatient, and outpatient care?

Research and Policy Gaps Specific to EM

  •  Can a cohesive database be created to evaluate patients as they come into the ED and analyze the care that they are provided, the costs incurred, and their ultimate outcomes?
  •  What are meaningful quality measures to evaluate physician and hospital-level performance?
  •  Clinical guidelines are needed that address overuse and identify appropriate resource use.
  •  What are internal metrics, tracking, and performance feedback mechanisms that can be implemented to provide information to EPs on their use of resources?
  •  How is resource utilization affected by the lack of relationships and follow-up care for patients seen in the ED?
  •  Teaching, education, and research are central missions of the AMC, but how do we support these missions for EM?
  •  Should we be developing more than just the next generation of physicians in the ED? What will be the role of nurse practitioners, physician assistants, and the team-based approach to care in the ED?
  •  How can data be integrated both locally and nationally so that the health care system can reduce costs by not duplicating services and improve care by having better information about patients?
  •  Transparency of cost information for both providers and patients is extremely important; however, how will this occur and how will patients and providers react to these data specifically when obtaining emergency medical care?

EM At Academic Medical Centers: Leading The Transformation of The U.S. Health Care System

  1. Top of page
  2. Abstract
  3. The Status of Medical Care in The United States of America
  4. Defining Value in Emergency Medicine
  5. Episodes of Care and Their Impact on The Delivery of Health Care in The ED
  6. Proposed Health Care Strategies: Potential “Preventables”
  7. Research and Policy Gaps
  8. EM At Academic Medical Centers: Leading The Transformation of The U.S. Health Care System
  9. Conclusions
  10. References

The central missions of AMCs are clinical care, medical education, and research. Experts in each of these areas work together on a daily basis to provide quality care for patients and to teach the newest generation of physicians. As a result, AMCs are uniquely positioned to address the knowledge and policy gaps outlined above and to share in the transformation of the U.S. health care system.

Clinical care will be dramatically affected by the ACA health care reforms, specifically as it relates to patient care coordination, health information technology, and reimbursement of services. There is a new shift toward a “shared incentive” approach that will seek to improve access to medical records, improve communication between providers, improve care coordination across settings, foster shared accountability among providers, support development of shared electronic health records, and improve transitions between settings. The AMC will serve a central role in coordinating the different pieces of the patient care experience. Because emergency medical care is so closely linked to timely access to high-quality data, AMCs will need to play a central role in the discussion of integrating disparate health IT data sources so that they can be shared and used to improve the care of patients and reduce unnecessary testing and duplication of resources. Reimbursement, although in flux, will also be based on this shared incentive approach, which will shift payments from a fee-for-service to an episodic care model. The fiscal effect this will have on AMCs will need to be better understood. As a result, future research will need to be conducted to better understand how the changes to patient care coordination, health information technology, and reimbursement will affect the clinical mission of the AMCs.

The ACA will also have a significant effect on the medical education mission of AMCs, most of which have multiple providers (e.g., medical students, resident physicians, attending physicians) seeing each patient. With a new movement toward more timely, less costly, and more efficient evidence-based care, this model may have to change. This could have a dramatic effect on student and resident physician training. A role for the AMCs may be to change the traditional paradigm of medical education and explore innovative approaches to facilitating the educational process for trainees, while still improving the efficiency of the health care experience for the patient. There may also be more emphasis placed on using evidence to drive ED care and cutting back on unnecessary diagnostic tests. All of these proposed changes will affect how students and resident physicians are trained in the AMC, and future research will need to be conducted to examine the effect of these legislative reforms on the education of trainees.

Finally, research will play a central role in addressing the research and policy gaps that have been outlined. Currently, EM research comprises less than 1% of the National Institutes of Health research budget.47 A large proportion of research conducted in the EDs is not led by EPs. As a result, the AMCs will be charged with placing even greater emphasis on promoting emergency medical research, by training more EPs in research, promoting more opportunities for mentorship and research development, and carving out niches in the federal funding structure to increase the level of funding and the number of studies that are occurring in the ED.

Conclusions

  1. Top of page
  2. Abstract
  3. The Status of Medical Care in The United States of America
  4. Defining Value in Emergency Medicine
  5. Episodes of Care and Their Impact on The Delivery of Health Care in The ED
  6. Proposed Health Care Strategies: Potential “Preventables”
  7. Research and Policy Gaps
  8. EM At Academic Medical Centers: Leading The Transformation of The U.S. Health Care System
  9. Conclusions
  10. References

Emergency medicine and academic medical centers are in the center of a national debate about health care reform. The challenge to EM will be whether it is willing to step up to help spearhead the transformation of the U.S. health care system or if it will be resigned to follow the status quo and wait for change to happen.48 Emergency medicine is poised as a specialty to respond to health care changes and to lead the charge in transforming a disconnected, inefficient, and costly system.

References

  1. Top of page
  2. Abstract
  3. The Status of Medical Care in The United States of America
  4. Defining Value in Emergency Medicine
  5. Episodes of Care and Their Impact on The Delivery of Health Care in The ED
  6. Proposed Health Care Strategies: Potential “Preventables”
  7. Research and Policy Gaps
  8. EM At Academic Medical Centers: Leading The Transformation of The U.S. Health Care System
  9. Conclusions
  10. References