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cost-effective care « The Central Line

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ACEP Plans List of Tests for National ‘Choosing Wisely’ Campaign

ACEP President Dr. Andy SamaAfter an extensive look at ways to provide cost effective care to emergency department patients, the American College of Emergency Physicians believes there is room to improve the use of specific tests or procedures in emergency medicine to participate in the national “Choosing Wisely” campaign.

“Choosing Wisely” is part of a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation to help physicians be better stewards of finite health care resources. The campaign encourages medical specialty organizations to identify five tests or procedures commonly used in their field, the necessity of which should be questioned and discussed by patients and physicians.

ACEP had previously declined participation in the “Choosing Wisely” campaign because of the challenges of this approach with the unique nature of emergency medicine, liability concerns, and a potential harm to physician reimbursement.

The College meanwhile remained steadfast in its commitment to cost-effective care and a high-value health care system, and last year, Immediate Past President Dr. David Seaberg appointed a Cost Effective Care Task Force, chaired by Dr. David Ross. The Task Force was charged with considering tests, processes and procedures with little or no value to emergency care that might represent meaningful cost savings if eliminated.

In a report to the ACEP Board of Directors this month, Task Force member Dr. Jay Schuur said that their Delphi panel and ongoing member surveys have suggested that a number of tests will meet the criteria of the “Choosing Wisely” campaign. They also determined that these tests would not increase the physician’s liability, and would not negatively impact payments for emergency physicians.

After being reviewed by experts, emergency medicine leaders, and the ACEP Board, the report’s data indicates that it would be appropriate for emergency medicine to participate in the campaign. A letter of ACEP’s intention to participate was sent to the ABIM Foundation today.

The list of recommendations should be established by June. ACEP’s Task Force is finalizing the evidence base for these recommendations, in part though the Emergency Medicine Practice Research Network (EMPRN). Attaching estimates of potential real-dollar savings to the recommendations is also being completed. Members of the Task Force and the ACEP Board believe this responsible approach will validate the substance of our recommendations, and provide assurance that there will be a real savings to the health care system while not impacting patient care.

But joining this national campaign is not the only approach ACEP is using its in journey to identify cost savings measures without compromising patient care.

In order for there to be a serious reduction in unnecessary tests and costs of defensive medicine over time, meaningful liability reform and safe harbors are vital. ACEP is encouraging ABIM and its campaign partners to lend their voices to the need for medical liability reform. This remains a top priority in ACEP’s advocacy agenda.

Additionally, the College is working on other significant and impactful efforts, including proposing an elimination of the 3-day-stay rule and better management of transitions of care.

A variety of recommendations that strive to improve patient care and provide meaningful cost savings continue to be initiated, developed, and adopted by ACEP.  We are dedicated to ensuring that our specialty can be leaders in health care system efficiency while maintaining a high quality of emergency care and patient safety.

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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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