Attribution and Emergency Medicine, a Payment Reform Conundrum


Several years ago, the medical director of the emergency department I was working in at the time decided to take a closer look at productivity amongst our physician and PA staff. In order to ensure that data on patients seen and visit times was being appropriately attributed to the treating physician or PA, we took a closer look at how the patient and the treating provider were linked in the hospital’s IT system (the data source), since we had a fair amount of double and triple coverage. It was a bit surprising, not to mention perplexing, to discover that at registration, the physician who arrived for the latest shift was assigned in the IT system to all the patients who arrived during this shift, until the next physician arrived, regardless of which provider actually took care of the patient. Thus, all the data related to provider productivity, and the attribution of the ordering provider for diagnostic tests, consults, medications, admissions, etc. which was derived from the IT system, was flawed. An approach initially designed to facilitate speedy order entry was never subjected to reconciliation at the end of the day, as we all assumed. Bummer.

The more we looked at the issue, the more complex it became. How should we attribute an inpatient admission when one ER physician handed off to another in mid-workup at change of shift? What about when a PA was supervised by two different physicians? Should a double bounce-back be attributed to the first treating physician, or the second, or both? You might think that provider-order-entry would solve many of the issues related to attribution of diagnostic test and treatment orders and consults and such; but if a patient is sent in to the ED by their primary care provider to have a work-up for RUQ pain, should the PCP or the ED physician be ‘credited’ with ordering the GB Ultrasound? Is the ED physician, or the hospitalist, responsible for ordering the admission? If a consultant requests a serum porcelain level before he will see the patient in the ED, is the consultant or the ED physician acting as the ordering provider?

You might think all of this is irrelevant, or as I am fond of saying, academic (meaning almost irrelevant); but in light of payment reform and Accountable Care Organizations and the push for cost-effective, error-free care: the need for accurate attribution in the ED is likely to be pretty important. If you can’t count correctly, you can’t have accountability. Since many ED physicians are employees of the hospital or academic institution where they work, accurate attribution might, in an era where cost-effectiveness and resource utilization is likely to be scrutinized at the individual provider level, mean the difference between continuing employment and getting the boot. Attribution might even be more important for contracted ED staffing groups working under contractual agreements with PHOs and hospital-owned or affiliated ACOs in risk-sharing or shared-savings arrangements that predicate payment of withholds or payouts to the ED group on performance against cost-effective care or use-reduction targets. These staffing contracts often have no-cause 90 day cancellation clauses hanging over these ED staffing groups, putting everyone’s job at risk.

I raise the issue of attribution and accountability in ED care because our practice environment is very complex – ED care is a team sport, with many providers having varied positions (sometimes the ED physician is the quarterback, sometimes the trauma surgeon, and sometimes the PA or NP), and the field of play is often unmarked and multidimensional, and the game challenging to track and score. If a quarterback throws a touchdown pass, who gets the credit: the QB, the receiver, or the offensive line? If a patient has wrong-side chest-tube placement, is the ED physician, the radiology tech who mislabeled the film, or the surgeon at the head of the gurney responsible? Who gets credit for the unnecessary dye-enhanced rescan, the risk-averse radiologist who insists he needs more contrast to make the diagnosis, the ED physician who is prepared to make the diagnosis of appendicitis clinically, or the surgeon demanding a scan before doing the consult? I am not advocating that ED care be carved out of the risk-sharing or shared-savings or pay for performance calculation simply because attribution in the ED is complicated. If we get carved out of these arrangements, ED physicians will simply become another expense item, inviting even less favorable treatment. I am just saying that we need to start working on developing systems and standards for the attribution of the work done in the ED now, before this payment reform cake is fully baked.

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