Should emergency physicians advocate that they be carved-out of payment reform? There may be no easy answer to this question, at least not yet; and in any case, advocating to be an exception to the transition from fee-for-service to pay-for-performance and risk-sharing may be a waste of time and effort. The tide is clearly turning, though not as quickly as payers and government regulators might wish; and it would appear that eventually, every physician and hospital will be subjected to various incentives and disincentives to provide better care for less money, or perhaps less care for less money. Even if the Affordable Care Act is killed by the Supreme Court, along with the provision of this act that mandates “paying more to doctors who provide quality care at lower cost to Medicare, and reducing payments to physicians who run up Medicare’s costs without better results”; this snowball is already rolling. The question for ACEP and emergency physicians is: do we scramble to get out of the way, or hitch a ride?
One of the considerations at issue is the attribution problem. Lots of different providers impact the care of emergency department patients, and what gets done to and for them. Unlike most physicians’ offices, the ED is an open practice. Physicians often send their patients to the ED to get tests and procedures and treatments that the physician could perform, or order, in a lab or outpatient radiology suite, or consultant’s office. One-stop shopping is quick, its easy, and it gets the patient out of the doctor’s office, allowing better turn-around. Consultants call or come to the ED and order all sorts of tests and treatments, and sometimes these orders are attributed to the treating ED physician. When physicians are financially at risk for the cost of caring for their patients, or are simply tracked and compared with each other regarding these costs; attribution is an important issue. Under payment reform, determining how a physician’s decisions impact the cost of care involves many complicated adjustments related to the patient’s health care issues, and the roles of other physicians involved in the patient’s care. According to Dr. Berwick, the former administrator of CMS, this “may be the most difficult measurement challenge in the whole world of value-based purchasing”. These adjustments are even more difficult to make in an open practice like the ED, where the most expensive care is often the result of a multi-provider team effort.
Another consideration relates to the impact of payment reform incentives and risk-sharing on medical decision-making in the context of a medical emergency. In the middle of a heart attack, do you really want your ED physician factoring in how he or she will be judged, or compensated, by how little is spent on your care; or trying to shift critical time dependent decisions to some other provider down the road? Here’s an example: the ED physician can look at your ECG and make the expensive decision to call in the cath lab team in order to reduce the time it takes to get your coronary artery open, saving heart muscle and maybe your life. Or, he can call the cardiologist to come in and make that decision, wasting critical minutes, but putting the cardiologist on the hook for the cost of this decision. Of course, the obvious answer is to make the entire team responsible not only for costs but also outcomes, which is what bundled payments, capitation, ACOs, and integrated health care systems are designed to address. But don’t think for a minute that paying the entire team for performance is going to entirely mitigate the impact of these cost-cutting incentives. Ask seniors how they feel about health care payment reform under Medicare: for the elderly, and most everyone, incentives for physicians to skimp on needed care is frightening.
So far, things like bundled payments and capitation have been focused on scheduled, elective, non-emergency care, because it is easier to predict and monitor the relative contribution of the surgeon, the anesthesiologist, the primary care doc, the pathologist, and so on. In an emergency, care is less predictable, and it’s more difficult to attribute medical decision-making to one or another provider; and frankly, cost-cutting is a bit more risky, and cost-effective care perhaps more difficult to achieve. I suspect, however, that this will not deter the payers, because emergency care is also more expensive. If emergency care providers expect to be able to ride the train of fee-for-service forever, carving themselves out of payment reform, they will likely be disappointed. Either they will be tagged as an expensive commodity that payers will try to work around (using the EMTALA mandate as cover, and non-payment as one of the tactics – as in the Washington State Medicaid non-payment policy), or they will be subsumed into hospital employment or mandated participation in PHOs or ACOs or other risk-sharing ventures that undoubtedly will undervalue emergency physicians’ services and undermine their current paychecks. Unless, that is, these emergency care providers find ways to practice cost-effective care, and participate successfully in shared-savings and other at-risk incentive programs, in a responsible, caring, and efficient manner that ensures good outcomes, saves patients and payers money, and incidentally preserves their own incomes.
This post also appears in The Fickle Finger: www.ficklefinger.net/blog/