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Value-Based Approaches for Emergency Care in a New Era
HEALTH POLICY/CONCEPTS
Value-Based Approaches for Emergency Care in a New Era Laura Medford-Davis, MD*; David Marcozzi, MD; Shantanu Agrawal, MD; Brendan G. Carr, MD; Emily Carrier, MD *Corresponding Author. E-mail: [email protected], Twitter: @MedfordDavis.
Although emergency departments (EDs) play an integral role in the delivery of acute unscheduled care, they have not been fully integrated into broader health care reform efforts. Communication and coordination with the ambulatory environment remain limited, leaving ED care disconnected from patients’ longitudinal care. In a value-based environment focused on improving quality, decreasing costs, enhancing population health, and improving the patient experience, this oversight represents a missed opportunity for emergency care. When integrated with primary and subspecialty care, emergency care might meet the needs of patients, providers, and payers more efficiently than yet realized. This article uses the Merit-Based Incentive Payment System from the Medicare Access and CHIP Reauthorization Act as a framework to outline a strategy for improving the value of emergency care, including integrating quality and resource use measures across health care delivery settings and populations, encouraging care coordination from the ED, and implementing robust health information exchange systems. [Ann Emerg Med. 2016;-:1-9.] 0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.10.031
SEE EDITORIAL, P. XX. INTRODUCTION Health care value is defined by an equation that considers health outcomes achieved per unit cost.1 Health and Human Services has already tied 30% of traditional fee-for-service Medicare payments to alternative payment models based on value and anticipates that 50% of payments will be value based by 2018.2,3 This change creates incentives for physicians to engage in illness prevention, high-quality care, and better health outcomes while reducing total costs.2-5 On April 16, 2015, the Medicare Access and CHIP Reauthorization Act of 2015 was signed into law, further amplifying value-based efforts by repealing the sustainable growth rate formula for updates to the Medicare physician fee schedule and replacing it with valuebased payment adjustments. This reimbursement trend toward value-based purchasing is not limited to Medicare because Medicaid and many commercial contracts are also adopting value-based payment schemes.6,7 These new reimbursement models will increasingly require physicians, including providers of emergency care, to demonstrate the value of their care. THE MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT OF 2015 The act provides an opportunity to develop a higher-quality emergency care system that more effectively links outpatient and inpatient services across the continuum of care. Under this new law, Medicare will adjust physician fee schedule payments Volume
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through one of 2 value-based mechanisms: the Merit-Based Incentive Payment System (MIPS) or alternative payment model participation. Although emergency departments (EDs) will encounter some patients whose longitudinal providers participate in various alternative payment models, we focus here on MIPS because initially most emergency physicians’ reimbursement will be affected by it. The MIPS ties a portion of fee-for-service payments to value and replaces 3 current Medicare programs—the Physician Quality Reporting System, the Physician Value-Based Payment Modifier, and the Medicare Electronic Health Record Incentive Program—with 1 composite physician performance measure calculated from 4 categories: quality, resource use, clinical practice improvement activities, and advancing care information (information technology) (Figure). Each of these 4 categories contributes a percentage weight adding up to 100%, but their relative weights will change. Physicians will be scored during performance periods, the first of which begins on January 1, 2017, and beginning in 2019 Medicare fee-for-service payments will either be increased or decreased for all physicians, including emergency physicians, depending on their MIPS score during the corresponding performance period. INTEGRATING EMERGENCY CARE TO INCREASE VALUE For patients with critical, time-sensitive illness or injury, our nation’s EDs offer lifesaving and limb-saving benefits Annals of Emergency Medicine 1
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factor for alternative payment models such as accountable care organizations that track quality and total costs of care. Therefore, this article outlines a strategy for improving the value of emergency care, using the 4 categories of physician performance from MIPS: quality, resource use, clinical practice improvement activities, and advancing care information (information technology).
Figure. Percentage weight of 4 MIPS categories over time.
to all age groups.8,9 The ED is recognized as a place where reliable care is available to patients when they are acutely ill, and as a constantly available hub for the health care system that provides comprehensive evaluation, diagnosis, treatment, and disposition for any patient.10 For the acutely ill, the value of emergency care is clearly understood. In contrast, for nonemergency cases the value of the ED is harder to quantify. With the rare exception of a health care system such as Kaiser Permanente, most EDs are not fully integrated into the broader health care delivery system. They do not always communicate with longitudinal care providers and focus more on ruling out or stabilizing acute threats to life than on diagnosis and coordination with long-term treatment plans. For this reason, EDs are commonly viewed as providing fragmented care that is insufficiently integrated into the longitudinal care system. Better integration of emergency care into the health care delivery system could be of great benefit to the goal of improving the quality of care while decreasing costs, in which measurement and reimbursement mechanisms are based on the value of care. Complex patient care continues to shift to the outpatient setting, and the ED, as a key interface with the community, has become an increasingly important component of the continuum of care delivery.11,12 For example, although not the most cost-effective approach, ambulatory care settings are increasingly using the ED to expedite the evaluation of patients with worsening or undifferentiated conditions.13,14 EDs have a gatekeeper role in hospital admissions: the fraction of admissions that come through the ED increased by more than 30% between the 1990s and 2000s and continues to climb because of time pressures on primary physicians that limit their ability to schedule sick visits or to directly admit their patients.15 At the same time, the ED prevents more than 50% of potential hospital readmissions by stabilizing and discharging recently hospitalized patients who present to the ED,16 an important 2 Annals of Emergency Medicine
QUALITY MEASURES THAT ENCOURAGE MEANINGFUL VALUE IN THE ED Quality measurement is a core requirement of value improvement and initially accounts for 50% of the MIPS score.17 Although other measures have been proposed, some of which are in development,18,19 current emergency care quality measures are limited to speed of throughput (door-to-disposition time or length of stay) and a small number of process-of-care measures for time-sensitive diagnoses.20 These measures address only a small proportion of the 6 quality domains endorsed by the Institute of Medicine (safe, effective, patient-centered, timely, efficient, and equitable).21 An expansion of emergency care measures should incorporate diagnostic accuracy and patient experience, and share responsibility and incentives for quality with all providers in a community. In actuality, ED quality measures that emphasize speed of throughput, which are appropriate for urgent conditions such as acute myocardial infarction, have the unintended consequence of increasing health care costs because of premature initiation of treatment and escalations in testing and admission rates.18,22,23 By rewarding faster bed turnover without measuring health outcomes, such measures are uncoupled from value and reinforce many traditional fee-for-service incentives. Certainly, they limit emergency physicians’ incentives to spend time on the activities required for value-based care such as addressing social determinants of health and coordinating care. Other quality-of-care measures applicable to longitudinal providers are based on the routine care of scheduled patients with known diagnoses. In contrast, symptombased quality measures, such as measures of diagnostic accuracy, missed diagnosis, and delayed diagnosis, would better support value in the emergency care system (Table).18,24-26 For example, how often are antibiotics initiated for an accurate diagnosis of pneumonia in the ED? These sorts of measures are more reflective of the ED’s role in making new diagnoses from symptom-based complaints rather than managing known chronic illness. Current measures of patient experience are also less germane to EDs than to other sites where care is provided. An ED, with its 24-hour access to physicians and Volume
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Table. Proposed measures to integrate the ED into the 4 Medicare Access and CHIP Reauthorization Act of 2015 domains for value-based care. Measure
Vision
Quality domain Diagnostic accuracy
Patient experience
Regional systems of care
Resource use domain Symptom-based episodes of care
Admission rates adjusted by diagnostic testing
Track whether patients receive a correct diagnosis. Measure delay from first symptomatic presentation (in any care setting, ED or ambulatory) to the correct diagnosis.
Aligned with symptom-based complaints of patients who present to the ED with undifferentiated diagnoses
Expand current patient satisfaction scores to evaluate the ED’s role in alleviation of patient anxiety. Ask patients to compare their ED experience to their best available alternative option when they sought ED care. Measure health metrics for entire communities and grade all hospitals and EDs caring for those communities on the quality achieved. Examples include: Percentage of STEMI/stroke patients treated in designated catheterization or stroke centers Percentage of trauma patients treated in a designated trauma center with a level appropriate for their severity of injury
Acknowledge patient preference for care location. Incorporate unique roles of the ED in providing continuous and safety-net care.
Develop episodes of care based on symptoms, such as chest pain or abdominal pain, that span all provider visits, diagnostic tests, and treatment costs during a period (eg, 90 days from first abdominal pain ICD code in any care setting). Measure the ratio of diagnostic studies ordered to admission rates for each symptom.
Clinical practice improvement activities domain Safety-net role Measure each ED’s percentage of uninsured and Medicaid patients treated, excluding those dismissed after medical screening examination, and compare to a community benchmark.
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Currently, some facilities may not transfer insured patients with illness acuity that exceeds their capabilities, and this competition for reimbursement is not in the patient’s best interest. Share responsibility for community health and quality metrics between multiple hospitals in a community. Encourage hospitals and EMS agencies to work together to develop appropriate transport protocols regardless of patient location or insurance status. Share responsibility for the costs of diagnostic evaluation and treatment with outpatient and inpatient physicians to avoid costshifting to the ED. Share accountability for speed and accuracy of diagnosis across the care continuum. Consider total cost of care, acknowledging that increased diagnostic testing may simultaneously increase safe discharge rates. Track variations in both admission rates and diagnostic testing rates between providers. Reward EDs providing disproportionate care to underinsured community members. Add a funding mechanism for the EMTALA mandate.
Cons Symptoms evolve over time, and at certain points in the course of disease an accurate diagnosis may not be possible. Difficult to measure “correct” diagnosis or to determine who is correct in cases of disagreement between providers; in some complex cases, there may not be a consensus. Misdiagnosis is inevitable, and we do not yet have a benchmark for the rate we would expect in a high-quality system. Does not account for differences in cost between the ED and alternative options for low-acuity visits
Amount of incentive may not be sufficient to overcome financial competition for insurance reimbursement Will need to determine the appropriate adjustment strategy to equalize nonmodifiable confounders (eg, rural location)
How to address low acuity visits May unfairly penalize providers who care for high-user patients who seek multiple opinions or make multiple visits for the same complaint
May inadvertently encourage overuse of diagnostic testing Must be adjusted by the acuity of practice setting
May encourage low-acuity care provision in the ED for underinsured patients with no other options for care Could reward ED treatment of underinsured patients who subsequently require duplicate ED care at a safety-net ED for their follow-up
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Value-Based Approaches for Emergency Care Table. Continued. Measure Care coordination (social determinants of health)
Transfer coordination
Advancing care information domain Improve bidirectional communication between usual source of care (PCP, specialist) and the ED
Health information exchange
Vision
Pros
Measure appropriate consultations to social work or case management. Track ancillary services ordered from the ED, including physical therapy, home health, durable medical equipment, transportation, and housing. Measure percentage of patients with a follow-up appointment scheduled before leaving the ED. Track new connections for patients without a PCP to a medical home. Transfer times between hospitals from the time that a transfer is first initiated until the patient departs the first ED Community-wide follow-up protocols that allow discharge of patients with minor injuries requiring nonemergency follow-up with specialty providers
Provide incentive for dedicated continuous care coordination staff to assist with nonmedical activities that allow patients to be safely discharged home. Improve completion rates of ED follow-up care. Decrease the current focus on rapid disposition to admission or discharge.
Will require EDs to invest in additional nonclinical staff to robustly meet measure Competes with current throughput measures (eg, length of stay) and physician reimbursement incentive structures
Reduce delays in patient transfer to the appropriate site of care. Avoid unnecessary ED-to-ED transfers for nonemergency care.
Some metrics (eg, ambulance availability at transfer) will be out of the hospitals’ control. Follow-up outside of the ED may not be guaranteed for uninsured or Medicaid patients.
Increase just-in-time communication from the usual source of care, who has a longterm relationship with the patient that can inform the ED provider’s decisionmaking process. Improve completion rates of ED follow-up care.
Requires development of a standardized summary-of-care document, containing all pertinent patient information such as medications, allergies, diagnoses, emergency contact, and code status Need to exclude patients without a PCP or other usual source of care from the denominator
Concurrent availability of a patient’s previous medical testing can reduce the use of laboratory and radiology testing and admission rates.
Developing an HIE is cost prohibitive in many communities. Not all visits will be aided by accessing the HIE. At times, HIE access may increase information overload.
Measure outpatient providers on the ratio of referred patients arriving to the ED with summaryof-care information received within 1 h to all patients referred to the ED. Track rates of summary-of-care documents received by longitudinal providers after an ED visit. Measure whether an HIE is available, how comprehensive the information included is (raw radiographic images preferred above solely information that a radiology test was performed), and whether the ED accessed the information during the ED visit.
Cons
STEMI, ST elevation myocardial infarction; EMS, emergency medical services; ICD, International Classification of Diseases; EMTALA, Emergency Medical Treatment and Labor Act; PCP, primary care provider; HIE, health information exchange.
diagnostics, alleviates a patient’s anxiety and physical discomfort in ways that have little or no effect on currently measured outcomes such as hospitalization or death.27 A patient may place a high value on being able to receive a full diagnostic evaluation in one location, at any time of day or night, rather than taking several sick days during weeks to obtain a series of tests ordered by a primary care provider.28,29 Current patient satisfaction measures do not ask patients how they perceive their ED care in relation to their other available options. Population health is defined as “the health outcomes of a group of individuals, including the distribution of such 4 Annals of Emergency Medicine
outcomes within the group” and considers the determinants of health and how policies and interventions affect those determinants to yield outcomes for the entire population. Currently, most EDs focus on outcomes for the individual patient,30 but population-based metrics would also be helpful to increase the value of ED care, recognizing that almost half of ED patients seek care in multiple hospitals.31 Regional systems of care (such as those for trauma, burn, stroke, and myocardial infarction) focus on geographic access to care.32 Matching population-based outcomes to a population-based measure (eg, community injury survival rate) would offer incentive to regional providers, emergency Volume
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medical services (EMS), and hospitals to improve their coordination of care, with the goal of improving health outcomes within a region. BALANCING RESOURCE USE WITH THE REALITIES OF THE ED Resource use, or the costs of all health care provided to patients, will account for 10% of the MIPS score in its first year (2019) but will increase to 30% by 2021.17 Currently, few performance measures address overuse.33 ED providers have long been criticized for excessive use of imaging and laboratory studies compared with other ambulatory care providers, particularly for patients who are ultimately found to have low-acuity diagnoses that could have been treated safely in alternative settings.34 This viewpoint overlooks important distinctions between ED care and health care delivered elsewhere. Comparisons across provider and setting types fail to recognize that emergency providers typically evaluate patients without the benefit of complete histories or longterm patient relationships and therefore require different strategies than those used by primary care providers. In addition, ED providers encounter a different spectrum of chief complaints than do other ambulatory care providers.35 Although patients with presumed low-acuity complaints tend to have more tests ordered for evaluation in the ED than in a clinic or in urgent care,36 this likely occurs because many patients self-refer to the ED when they have severe or complex symptoms.37,38 Given the short patient relationships and limited availability of patient history, ED providers also have greater concerns about the threat of malpractice litigation.37-40 The use of the ED as a diagnostic center has become a routine practice of ambulatory physicians, who refer their patients with requests for expedited evaluation, imaging, and laboratory tests.13,14 From a fiscal perspective, a primary physician might order all the same outpatient tests as an emergency physician, but they will be scheduled during several days or weeks, spreading out the costs into discrete episodes. In addition, people come to EDs for reasons other than an acute change in health. They might have inadequate preventive care, a gap in chronic disease management, or inadequate postacute care. A return ED presentation could reflect poor ED care or a failure in the inpatient or ambulatory care systems.29,41,42 Therefore, building value requires an approach to quality measures that recognizes care delivered in the ED as part of a continuum of a patient’s comprehensive care, rather than an isolated episode. This could be achieved by a measure that gauges resource use by all physicians involved Volume
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in making a patient diagnosis for a symptom; for example, from the onset of chest pain in the ambulatory or ED setting until an acute myocardial infarction diagnosis is made.43 This approach aligns emergency, ambulatory, and inpatient providers, emphasizing coordination and shared responsibility for effective patient transitions between settings, and counters the pressure that ambulatory or inpatient providers may feel to transfer expensive diagnostic testing to the ED when they are accountable for only their own individual resource use. The creation of bundled payment approaches (eg, joint replacements) also represents an important advance in aligning incentives; more bundles triggered by patient complaints that include the role of the ED in diagnosis and management should be explored. An episode might mirror the MIPS resource use care episodes recently proposed by Centers for Medicare & Medicaid Services, such as acute exacerbation of heart failure; cholecystitis; hip, femur fracture, or dislocation treatment; or asthma or chronic obstructive pulmonary disease acute exacerbation, which could be expanded to include the emergency care delivered for each condition.13,17 The use of computed tomography (CT) in the ED provides another important example of balancing resource use and value. Emergency physicians use more CT scans than clinic-based providers despite valid concerns about radiation exposure and the risk of overdiagnosis and overtreatment.44,45 Here, too, the story is more complex than simple cost analyses suggest. These decisions are driven by 3 factors, 2 of which were mentioned above. First, emergency physicians are benchmarked on making decisions quickly; waiting for a headache or abdominal pain to evolve with serial examinations may be more time consuming than performing a CT scan to rule out significant threats. Second, as noted above, patients presenting to an ED may have a higher baseline risk of serious conditions than those presenting to their primary physician. Third, and potentially most important from the value perspective, a CT scan changes the treating ED provider’s decision to admit, one of the most expensive decisions he or she makes, in 19% to 25% of cases.13,46 Payment models that rely on incentives to decrease the total cost of care and reduce hospital admissions and readmissions might inadvertently promote the use of imaging studies to support ED discharge rather than admission or observation for serial examinations. Although low-acuity conditions can be managed effectively and inexpensively by primary care providers with the benefit of established patient relationships and background knowledge, patients with such conditions continue to seek care in EDs for a number of reasons, including health literacy, primary care access, and patient Annals of Emergency Medicine 5
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preference. Patients are often unable to reliably determine when a condition or symptom is acute or urgent enough to merit emergency care.13 To avoid placing undue burden on patients, potentially stifling their use of emergency care and possibly delaying evaluation of a true emergency, EDs should continue to be available for rapid triage and evaluation of any complaint. Typically, during their ED visit patients will be educated about the symptoms that warrant emergency evaluation after discharge and will be encouraged to revisit their longitudinal provider for further care. Finally, the current reimbursement structure in many emergency physicians’ hospital contracts includes incentive payments for the number of relative value units or highcomplexity codes generated. These metrics are used to benchmark providers within groups, shaping both individual and collective behavior.13 Success in MIPS, however, requires new physician payment incentives that augment the simple enumeration of activities performed during individual encounters with a broader consideration of the effects on quality of life, well-being, and total cost that will capture value in a more meaningful way. EMERGENCY-SPECIFIC APPROACHES TO CLINICAL PRACTICE IMPROVEMENT Fifteen percent of the MIPS score comes from clinical practice improvement activities, which fall into 7 categories: expanded practice access, population management, care coordination, beneficiary engagement, patient safety and practice assessment, achieving health equity, and integrated behavioral and mental health.17 Emergency physicians already offer expanded practice access 24 hours a day, but many ED functions with the potential to deliver high value, such as care coordination, are not covered by traditional performance standards or payment models. For example, EDs maintain facilities and staffing levels on a 24-hour basis for unanticipated surges and crises. EDs are also the only care setting in which all patients must be evaluated regardless of their ability to pay, and they serve as the safety net for gaps in the insurance, mental health, and primary care systems.13 These activities are currently subsidized by higher payments from insurers (including Medicare and Medicaid) for ED care, reflecting higher overhead costs. Incentive payments could directly reward improvement activities related to these responsibilities, decreasing reliance on cross subsidization. ED-based care coordination is time consuming and is actually discouraged by current ED throughput measures. This is unfortunate because care coordination fills important gaps in the health care system and educates 6 Annals of Emergency Medicine
patients about care-seeking options. After an ED visit, care coordination can help patients transition back to their usual source of longitudinal care; for example, by assisting with appointment scheduling from the ED. For patients who do not have an acute illness requiring hospitalization but cannot be discharged safely from the ED to independence, provision of home health services or admission to a rehabilitation facility can enable them to avoid inpatient admission when coordinated from the ED. Ensuring the connectedness of care and addressing a patient’s social determinants of health is a challenge for emergency physicians because of their time constraints, and the ED and hospital administrators should consider providing EDbased case managers, social workers, or health navigators continuously to assist with care coordination. This type of support could substantially enhance the value of care. Coordination between potentially competing hospitals is also important. For the critically ill, all EDs in a community should work with EMS and out-of-hospital systems to ensure that patients arrive at the optimal facility to treat their illness or injury, or to expedite transfer to the optimal facility when needed, regardless of patient insurance status and even if the optimal facility is in another hospital system.47 Smooth transitions are equally important for the less critically ill. Patients who need specialty follow-up care from a different hospital system should have that access coordinated during their ED visit as well, without requiring a transfer to the ED with which the specialist is affiliated. These seamless transitions require cooperation across provider types and hospital systems, where accountability should be shared across specialty providers and emergency providers in multiple hospitals within the community. USE OF HEALTH INFORMATION TECHNOLOGY TO SUPPORT INTEGRATION OF EMERGENCY CARE WITHIN THE CARE CONTINUUM Health information technology, or advancing care information, contributes a quarter of the total MIPS score.17 Although health information technology is critical to efficient and value-based care delivery in all settings and large investments have been made, 27% of primary providers still do not use electronic records, and few records are interoperable.48 Therefore, our current system falls short in coordinating care and ensuring timely communication between providers because ED visits are usually unplanned, frequently occur outside of business hours, and may (during business hours) coincide with periods when the patient’s other care providers are unavailable. Timely communication of real-time patient presentations and clinical data between Volume
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providers may reduce cost by decreasing testing and admission while creating a more patient-centered experience.49 One potential solution to this issue was introduced by Kindermann et al,50 who proposed a new notifications measure that would encourage EDs to alert primary care providers when their patients check in. (Only 29% of EDs currently do this for patients outside of their hospital systems.51) Health information exchange with fully interoperable and continuously available patient data is another promising tool for the unscheduled care setting that has been shown to reduce resource use49 and can improve patient care coordination in the ED. It has also been shown to assist with transfers of patients between EDs, during which failed interoperability of imaging systems and fee-for-service payment incentives often lead to repeated imaging studies.52,53 Stage 2 of the Medicare Electronic Health Record Incentive Program contains a measure for health information exchange that requires electronic summary-of-care documents to accompany patient transfers of care and referrals. Referral of a patient from the primary care office to the ED by telephone, including by an answering service after hours, should be considered a transfer of care and accompanied by the patient’s records. Transfer of a patient from a long-term care facility to an ED for acute care should also be accompanied by a standardized summary-ofcare document, including advanced directives and end-of-life forms, to facilitate care of the patient in the ED. By the same token, discharge from the ED is a transfer of care when followup with an authorized provider is ordered and, under current stage 2 requirements, must be accompanied by a detailed summary-of-care document sent to the primary care provider to ensure continuity of care and communication of any changes to medication lists and treatment plans at follow-up. CONCLUSION Several provisions of MIPS provide unprecedented opportunities to bring value into the emergency setting by changing incentives for patient treatment and care coordination. Value and its quality component are partially subjective and can be difficult to define, so this work must be done carefully to preserve the services that an ED provides for life- and limb-threatening conditions and as a safety net for the sick, injured, and underinsured. A range of approaches could be considered, including the development of ED-specific symptom-based quality measures, measures that share responsibility between ED and outpatient providers and across all EDs in a region, and enhanced information technology requirements that broaden the notification and summary-of-care criteria to require fully interoperable health information exchange and Volume
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bidirectional 24-hour communication between ambulatory practices and EDs. New quality measures require a large number of resources to develop and can take time to be adopted by Medicare and other payers.19,24 EDs must continue to diagnose and treat the most severe illnesses and injuries while better integrating their current efforts to rapidly diagnose illness, manage acute exacerbations of chronic conditions, facilitate hospital admissions, provide a bridge to a medical home for patients without access to a regular source of care, and serve as a foundation for local and regional disaster response, with the goals of the overall health system. Given the broad spectrum of diseases and acuity encountered in EDs, they must be prepared to dedicate space and staff to both the rapid delivery of critical care and the coordination of care for geriatric, pediatric, psychiatric, and other special populations. As the link between medical homes, accountable care organizations, and other alternative payment models, the ED of the future should coordinate patient care across medical specialties, settings, and broader communities, preserving and communicating key information through transitions in care to and from the community. Finally, emergency care increasingly needs to lead and partner with others to establish regional systems of care for entire communities (eg, regional trauma care, centers of excellence for certain conditions). If ED-centric alternative payment models were developed, they could test a vision of the ED as a fully integrated and patient-centered location for the delivery of acute, unscheduled care, and coordination of that care with the broader health system. For any such efforts to succeed, however, the ED must not simply be considered a place to be avoided at all costs, but rather as a health care solution that has the potential to play an important role in developing coordinated, high-value systems of care. Supervising editor: David J. Magid, MD, MPH Author affiliations: From the Baylor College of Medicine, Houston, TX (Medford-Davis); the Centers for Medicare & Medicaid Services Center for Medicare and Medicaid Innovation, Baltimore, MD (Medford-Davis, Carrier); the Department of Emergency Medicine, University of Maryland, Baltimore, MD (Marcozzi); the Centers for Medicare & Medicaid Services Center for Program Integrity, Baltimore, MD (Agrawal); and the Department of Emergency Medicine, Jefferson University, Philadelphia, PA and the Emergency Care Coordination Center, Assistant Secretary for Preparedness and Response, Washington, DC (Carr). Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval Annals of Emergency Medicine 7
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Value-Based Approaches for Emergency Care of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Publication dates: Received for publication April 29, 2016. Revisions received August 27, 2016, and October 4, 2016. Accepted for publication October 28, 2016. The viewpoints expressed are those of the authors and do not necessarily represent official views or policies of the Department of Health and Human Services.
REFERENCES 1. Porter ME. What is value in health care? N Engl J Med. 2010;363: 2477-2481. 2. Burwell SM. Setting value-based payment goals—HHS efforts to improve US health care. N Engl J Med. 2015;372:897-899. 3. US Department of Health & Human Services. HHS reaches goal of tying 30 percent of Medicare payments to quality ahead of schedule. March 3, 2016. Available at: http://www.hhs.gov/about/news/2016/ 03/03/hhs-reaches-goal-tying-30-percent-medicare-payments-qualityahead-schedule.html. Accessed November 21, 2016. 4. Rosenbaum S, Kindig DA, Bao J, et al. The value of the nonprofit hospital tax exemption was $24.6 billion in 2011. Health Aff (Millwood). 2015;34:1225-1233. 5. Rajkumar R, Press MJ, Conway PH. The CMS Innovation Center—a fiveyear self-assessment. N Engl J Med. 2015;372:1981-1983. 6. Song Z, Rose S, Safran DG, et al. Changes in health care spending and quality 4 years into global payment. N Engl J Med. 2014;371:1704-1714. 7. Leddy T, McGinnis T, Howe G. Value-based payments in Medicaid managed care: an overview of state approaches. 2016. Available at: http://www.chcs.org/resource/value-based-payments-in-medicaidmanaged-care-an-overview-of-state-approaches/. Accessed August 22, 2016. 8. MacKenzie EJ, Weir S, Rivara FP, et al. The value of trauma center care. J Trauma. 2010;69:1-10. 9. Khot UN, Johnson-Wood ML, Geddes JB, et al. Financial impact of reducing door-to-balloon time in ST-elevation myocardial infarction: a single hospital experience. BMC Cardiovasc Disord. 2009;9:32. 10. Nataraja S, Clement B, Herzeca J, et al. Hub of the enterprise: transforming the ED’s role in delivering agile and coordinated care. 2012. Available at: https://www.advisory.com/Research/PhysicianExecutive-Council/Studies/2012/Hub-of-the-Enterprise. Accessed November 21, 2016. 11. Rao VM, Levin DC, Parker L, et al. Trends in utilization rates of the various imaging modalities in emergency departments: nationwide Medicare data from 2000 to 2008. J Am Coll Radiol. 2011;8:706-709. 12. National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2011 emergency department summary tables. 2011. Available at: http://www.cdc.gov/nchs/data/ahcd/nhamcs_ emergency/2011_ed_web_tables.pdf. Accessed July 12, 2016. 13. Agrawal S, Conway PH. Aligning emergency care with the triple aim: opportunities and future directions after healthcare reform. Healthc (Amst). 2014;2:184-189. 14. Gonzalez Morganti K, Bauhoff S, Blanchard J, et al. The Evolving Role of Emergency Departments in the United States. Santa Monica, CA: RAND Corp; 2013.
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15. Schuur JD, Venkatesh AK. The growing role of emergency departments in hospital admissions. N Engl J Med. 2012;367:391-393. 16. Rising KL, White LF, Fernandez WG, et al. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013;62:145-150. 17. Federal Register. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) incentive under the physician fee schedule, and criteria for physician-focused payment models. 2016. Available at: https://www.federalregister.gov/ documents/2016/11/04/2016-25240/medicare-program-meritbased-incentive-payment-system-mips-and-alternative-payment-modelapm. Accessed November 21, 2016. 18. Schuur JD, Hsia RY, Burstin H, et al. Quality measurement in the emergency department: past and future. Health Aff (Millwood). 2013;32:2129-2138. 19. National Quality Forum. National voluntary consensus standards for emergency care: a consensus report. 2009. Available at: http://www. qualityforum.org/Publications/2009/09/National_Voluntary_ Consensus_Standards_for_Emergency_Care.aspx. Accessed August 22, 2016. 20. Aaronson EL, Marsh RH, Guha M, et al. Emergency department quality and safety indicators in resource-limited settings: an environmental survey. Int J Emerg Med. 2015;8:39. 21. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001:3. 22. Centers for Medicare & Medicaid Services. Measures displayed on Hospital Compare. 2015. Available at: https://www.medicare.gov/ hospitalcompare/Data/Measures-Displayed.html. Accessed September 22, 2015. 23. Carrier E, Khaldun J, Hsia RY. Association between emergency department length of stay and rates of admission to inpatient and observation services. JAMA Intern Med. 2014;174:1843-1846. 24. Griffey RT, Pines JM, Farley HL, et al. Chief complaint–based performance measures: a new focus for acute care quality measurement. Ann Emerg Med. 2015;65:387-395. 25. Graber ML, Wachter RM, Cassel CK. Bringing diagnosis into the quality and safety equations. JAMA. 2012;308:1211-1212. 26. Kanzaria HK, Mattke S, Detz AA, et al. Quality measures based on presenting signs and symptoms of patients. JAMA. 2015;313:520-522. 27. Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med J. 2001;18:430-434. 28. Pines JM, Newman D, Pilgrim R, et al. Strategies for integrating costconsciousness into acute care should focus on rewarding high-value care. Health Aff (Millwood). 2013;32:2157-2165. 29. Howard MS, Davis BA, Anderson C, et al. Patients’ perspective on choosing the emergency department for nonurgent medical care: a qualitative study exploring one reason for overcrowding. J Emerg Nurs. 2005;31:429-435. 30. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93:380-383. 31. Finnell JT, Overhage JM, Grannis S. All health care is not local: an evaluation of the distribution of emergency department care delivered in Indiana. AMIA Annu Symp Proc. 2011;2011:409-416. 32. Martinez R, Carr B. Creating integrated networks of emergency care: from vision to value. Health Aff (Millwood). 2013;32:2082-2090. 33. Newton EH, Zazzera EA, Van Moorsel G, et al. Undermeasuring overuse—an examination of national clinical performance measures. JAMA Intern Med. 2015;175:1709-1711. 34. Lee MH, Schuur JD, Zink BJ. Owning the cost of emergency medicine: beyond 2%. Ann Emerg Med. 2013;62:498-505.e493. 35. Pitts SR, Carrier ER, Rich EC, et al. Where Americans get acute care: increasingly, it’s not at their doctor’s office. Health Aff (Millwood). 2010;29:1620-1629.
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36. Pitts SR, Pines JM, Handrigan MT, et al. National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity. Ann Emerg Med. 2012;60:679-686.e673. 37. Sugarman TJ. Time to focus on improving emergency department value rather than discouraging emergency department visits. West J Emerg Med. 2013;14:617-618. 38. Rosenau AM, Augustine JJ, Jones S, et al. The growing evidence of the value of emergency care. Acad Emerg Med. 2015;22:224-226. 39. Carrier ER, Reschovsky JD, Mello MM, et al. Physicians’ fears of malpractice lawsuits are not assuaged by tort reforms. Health Aff (Millwood). 2010;29:1585-1592. 40. Kanzaria HK, Hoffman JR, Probst MA, et al. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging. Acad Emerg Med. 2015;22:390-398. 41. Sabbatini AK, Kocher KE, Basu A, et al. In-hospital outcomes and costs among patients hospitalized during a return visit to the emergency department. JAMA. 2016;315:663-671. 42. Adams JG. Ensuring the quality of quality metrics for emergency care. JAMA. 2016;315:659-660. 43. National Quality Forum. Patient-focused episodes of care. Measurement framework: evaluating efficiency across patient-focused episodes of care. 2009. Available at: http://www.qualityforum.org/ Publications/2010/01/Episodes_of_Care_Full_Report_v2.aspx. Accessed August 27, 2016. 44. Carpenter CR, Raja AS, Brown MD. Overtesting and the downstream consequences of overtreatment: implications of “preventing overdiagnosis” for emergency medicine. Acad Emerg Med. 2015;22:1484-1492. 45. Hoffman JR, Cooper RJ. Overdiagnosis of disease: a modern epidemic. Arch Intern Med. 2012;172:1123-1124.
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46. Pandharipande PV, Reisner AT, Binder WD, et al. CT in the emergency department: a real-time study of changes in physician decision making. Radiology. 2016;278:812-821. 47. Delgado MK, Yokell MA, Staudenmayer KL, et al. Factors associated with the disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by insurance status. JAMA Surg. 2014;149:422-430. 48. Office of the National Coordinator for Health Information Technology. Health care professionals participating in the CMS EHR incentive programs, Health IT Quick-Stat #44. Available at: http://dashboard. healthit.gov/quickstats/quickstats.php. Accessed July 19, 2015. 49. Lammers EJ, Adler-Milstein J, Kocher KE. Does health information exchange reduce redundant imaging? evidence from emergency departments. Med Care. 2014;52:227-234. 50. Kindermann DR, Mutter RL, Cartwright-Smith L, et al. Admit or transfer? the role of insurance in high-transfer-rate medical conditions in the emergency department. Ann Emerg Med. 2014;63:561-571. e568. 51. Office of the National Coordinator for Health Information Technology. Percent of US hospitals that routinely electronically notify patient’s primary care provider upon emergency room entry, Health IT Quick-Stat #26. Available at: http://dashboard.healthit.gov/quickstats/pages/ FIG-Hospital-Routine-Electronic-Notification.php. Accessed July 17, 2015. 52. Whiteman C, Kiefer C, D’Angelo J, et al. The use of technology to reduce radiation exposure in trauma patients transferred to a level I trauma center. W V Med J. 2014;110:14-18. 53. Liepert AE, Bledsoe J, Stevens MH, et al. Protecting trauma patients from duplicated computed tomography scans: the relevance of integrated care systems. Am J Surg. 2014;208:511-516.
Annals of Emergency Medicine 9
Value-Based Approaches for Emergency Care in a New Era Laura Medford-Davis, MD*; David Marcozzi, MD; Shantanu Agrawal, MD; Brendan G. Carr, MD; Emily Carrier, MD *Corresponding Author. E-mail: [email protected], Twitter: @MedfordDavis.
Although emergency departments (EDs) play an integral role in the delivery of acute unscheduled care, they have not been fully integrated into broader health care reform efforts. Communication and coordination with the ambulatory environment remain limited, leaving ED care disconnected from patients’ longitudinal care. In a value-based environment focused on improving quality, decreasing costs, enhancing population health, and improving the patient experience, this oversight represents a missed opportunity for emergency care. When integrated with primary and subspecialty care, emergency care might meet the needs of patients, providers, and payers more efficiently than yet realized. This article uses the Merit-Based Incentive Payment System from the Medicare Access and CHIP Reauthorization Act as a framework to outline a strategy for improving the value of emergency care, including integrating quality and resource use measures across health care delivery settings and populations, encouraging care coordination from the ED, and implementing robust health information exchange systems. [Ann Emerg Med. 2016;-:1-9.] 0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.10.031
SEE EDITORIAL, P. XX. INTRODUCTION Health care value is defined by an equation that considers health outcomes achieved per unit cost.1 Health and Human Services has already tied 30% of traditional fee-for-service Medicare payments to alternative payment models based on value and anticipates that 50% of payments will be value based by 2018.2,3 This change creates incentives for physicians to engage in illness prevention, high-quality care, and better health outcomes while reducing total costs.2-5 On April 16, 2015, the Medicare Access and CHIP Reauthorization Act of 2015 was signed into law, further amplifying value-based efforts by repealing the sustainable growth rate formula for updates to the Medicare physician fee schedule and replacing it with valuebased payment adjustments. This reimbursement trend toward value-based purchasing is not limited to Medicare because Medicaid and many commercial contracts are also adopting value-based payment schemes.6,7 These new reimbursement models will increasingly require physicians, including providers of emergency care, to demonstrate the value of their care. THE MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT OF 2015 The act provides an opportunity to develop a higher-quality emergency care system that more effectively links outpatient and inpatient services across the continuum of care. Under this new law, Medicare will adjust physician fee schedule payments Volume
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through one of 2 value-based mechanisms: the Merit-Based Incentive Payment System (MIPS) or alternative payment model participation. Although emergency departments (EDs) will encounter some patients whose longitudinal providers participate in various alternative payment models, we focus here on MIPS because initially most emergency physicians’ reimbursement will be affected by it. The MIPS ties a portion of fee-for-service payments to value and replaces 3 current Medicare programs—the Physician Quality Reporting System, the Physician Value-Based Payment Modifier, and the Medicare Electronic Health Record Incentive Program—with 1 composite physician performance measure calculated from 4 categories: quality, resource use, clinical practice improvement activities, and advancing care information (information technology) (Figure). Each of these 4 categories contributes a percentage weight adding up to 100%, but their relative weights will change. Physicians will be scored during performance periods, the first of which begins on January 1, 2017, and beginning in 2019 Medicare fee-for-service payments will either be increased or decreased for all physicians, including emergency physicians, depending on their MIPS score during the corresponding performance period. INTEGRATING EMERGENCY CARE TO INCREASE VALUE For patients with critical, time-sensitive illness or injury, our nation’s EDs offer lifesaving and limb-saving benefits Annals of Emergency Medicine 1
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factor for alternative payment models such as accountable care organizations that track quality and total costs of care. Therefore, this article outlines a strategy for improving the value of emergency care, using the 4 categories of physician performance from MIPS: quality, resource use, clinical practice improvement activities, and advancing care information (information technology).
Figure. Percentage weight of 4 MIPS categories over time.
to all age groups.8,9 The ED is recognized as a place where reliable care is available to patients when they are acutely ill, and as a constantly available hub for the health care system that provides comprehensive evaluation, diagnosis, treatment, and disposition for any patient.10 For the acutely ill, the value of emergency care is clearly understood. In contrast, for nonemergency cases the value of the ED is harder to quantify. With the rare exception of a health care system such as Kaiser Permanente, most EDs are not fully integrated into the broader health care delivery system. They do not always communicate with longitudinal care providers and focus more on ruling out or stabilizing acute threats to life than on diagnosis and coordination with long-term treatment plans. For this reason, EDs are commonly viewed as providing fragmented care that is insufficiently integrated into the longitudinal care system. Better integration of emergency care into the health care delivery system could be of great benefit to the goal of improving the quality of care while decreasing costs, in which measurement and reimbursement mechanisms are based on the value of care. Complex patient care continues to shift to the outpatient setting, and the ED, as a key interface with the community, has become an increasingly important component of the continuum of care delivery.11,12 For example, although not the most cost-effective approach, ambulatory care settings are increasingly using the ED to expedite the evaluation of patients with worsening or undifferentiated conditions.13,14 EDs have a gatekeeper role in hospital admissions: the fraction of admissions that come through the ED increased by more than 30% between the 1990s and 2000s and continues to climb because of time pressures on primary physicians that limit their ability to schedule sick visits or to directly admit their patients.15 At the same time, the ED prevents more than 50% of potential hospital readmissions by stabilizing and discharging recently hospitalized patients who present to the ED,16 an important 2 Annals of Emergency Medicine
QUALITY MEASURES THAT ENCOURAGE MEANINGFUL VALUE IN THE ED Quality measurement is a core requirement of value improvement and initially accounts for 50% of the MIPS score.17 Although other measures have been proposed, some of which are in development,18,19 current emergency care quality measures are limited to speed of throughput (door-to-disposition time or length of stay) and a small number of process-of-care measures for time-sensitive diagnoses.20 These measures address only a small proportion of the 6 quality domains endorsed by the Institute of Medicine (safe, effective, patient-centered, timely, efficient, and equitable).21 An expansion of emergency care measures should incorporate diagnostic accuracy and patient experience, and share responsibility and incentives for quality with all providers in a community. In actuality, ED quality measures that emphasize speed of throughput, which are appropriate for urgent conditions such as acute myocardial infarction, have the unintended consequence of increasing health care costs because of premature initiation of treatment and escalations in testing and admission rates.18,22,23 By rewarding faster bed turnover without measuring health outcomes, such measures are uncoupled from value and reinforce many traditional fee-for-service incentives. Certainly, they limit emergency physicians’ incentives to spend time on the activities required for value-based care such as addressing social determinants of health and coordinating care. Other quality-of-care measures applicable to longitudinal providers are based on the routine care of scheduled patients with known diagnoses. In contrast, symptombased quality measures, such as measures of diagnostic accuracy, missed diagnosis, and delayed diagnosis, would better support value in the emergency care system (Table).18,24-26 For example, how often are antibiotics initiated for an accurate diagnosis of pneumonia in the ED? These sorts of measures are more reflective of the ED’s role in making new diagnoses from symptom-based complaints rather than managing known chronic illness. Current measures of patient experience are also less germane to EDs than to other sites where care is provided. An ED, with its 24-hour access to physicians and Volume
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Table. Proposed measures to integrate the ED into the 4 Medicare Access and CHIP Reauthorization Act of 2015 domains for value-based care. Measure
Vision
Quality domain Diagnostic accuracy
Patient experience
Regional systems of care
Resource use domain Symptom-based episodes of care
Admission rates adjusted by diagnostic testing
Track whether patients receive a correct diagnosis. Measure delay from first symptomatic presentation (in any care setting, ED or ambulatory) to the correct diagnosis.
Aligned with symptom-based complaints of patients who present to the ED with undifferentiated diagnoses
Expand current patient satisfaction scores to evaluate the ED’s role in alleviation of patient anxiety. Ask patients to compare their ED experience to their best available alternative option when they sought ED care. Measure health metrics for entire communities and grade all hospitals and EDs caring for those communities on the quality achieved. Examples include: Percentage of STEMI/stroke patients treated in designated catheterization or stroke centers Percentage of trauma patients treated in a designated trauma center with a level appropriate for their severity of injury
Acknowledge patient preference for care location. Incorporate unique roles of the ED in providing continuous and safety-net care.
Develop episodes of care based on symptoms, such as chest pain or abdominal pain, that span all provider visits, diagnostic tests, and treatment costs during a period (eg, 90 days from first abdominal pain ICD code in any care setting). Measure the ratio of diagnostic studies ordered to admission rates for each symptom.
Clinical practice improvement activities domain Safety-net role Measure each ED’s percentage of uninsured and Medicaid patients treated, excluding those dismissed after medical screening examination, and compare to a community benchmark.
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Currently, some facilities may not transfer insured patients with illness acuity that exceeds their capabilities, and this competition for reimbursement is not in the patient’s best interest. Share responsibility for community health and quality metrics between multiple hospitals in a community. Encourage hospitals and EMS agencies to work together to develop appropriate transport protocols regardless of patient location or insurance status. Share responsibility for the costs of diagnostic evaluation and treatment with outpatient and inpatient physicians to avoid costshifting to the ED. Share accountability for speed and accuracy of diagnosis across the care continuum. Consider total cost of care, acknowledging that increased diagnostic testing may simultaneously increase safe discharge rates. Track variations in both admission rates and diagnostic testing rates between providers. Reward EDs providing disproportionate care to underinsured community members. Add a funding mechanism for the EMTALA mandate.
Cons Symptoms evolve over time, and at certain points in the course of disease an accurate diagnosis may not be possible. Difficult to measure “correct” diagnosis or to determine who is correct in cases of disagreement between providers; in some complex cases, there may not be a consensus. Misdiagnosis is inevitable, and we do not yet have a benchmark for the rate we would expect in a high-quality system. Does not account for differences in cost between the ED and alternative options for low-acuity visits
Amount of incentive may not be sufficient to overcome financial competition for insurance reimbursement Will need to determine the appropriate adjustment strategy to equalize nonmodifiable confounders (eg, rural location)
How to address low acuity visits May unfairly penalize providers who care for high-user patients who seek multiple opinions or make multiple visits for the same complaint
May inadvertently encourage overuse of diagnostic testing Must be adjusted by the acuity of practice setting
May encourage low-acuity care provision in the ED for underinsured patients with no other options for care Could reward ED treatment of underinsured patients who subsequently require duplicate ED care at a safety-net ED for their follow-up
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Value-Based Approaches for Emergency Care Table. Continued. Measure Care coordination (social determinants of health)
Transfer coordination
Advancing care information domain Improve bidirectional communication between usual source of care (PCP, specialist) and the ED
Health information exchange
Vision
Pros
Measure appropriate consultations to social work or case management. Track ancillary services ordered from the ED, including physical therapy, home health, durable medical equipment, transportation, and housing. Measure percentage of patients with a follow-up appointment scheduled before leaving the ED. Track new connections for patients without a PCP to a medical home. Transfer times between hospitals from the time that a transfer is first initiated until the patient departs the first ED Community-wide follow-up protocols that allow discharge of patients with minor injuries requiring nonemergency follow-up with specialty providers
Provide incentive for dedicated continuous care coordination staff to assist with nonmedical activities that allow patients to be safely discharged home. Improve completion rates of ED follow-up care. Decrease the current focus on rapid disposition to admission or discharge.
Will require EDs to invest in additional nonclinical staff to robustly meet measure Competes with current throughput measures (eg, length of stay) and physician reimbursement incentive structures
Reduce delays in patient transfer to the appropriate site of care. Avoid unnecessary ED-to-ED transfers for nonemergency care.
Some metrics (eg, ambulance availability at transfer) will be out of the hospitals’ control. Follow-up outside of the ED may not be guaranteed for uninsured or Medicaid patients.
Increase just-in-time communication from the usual source of care, who has a longterm relationship with the patient that can inform the ED provider’s decisionmaking process. Improve completion rates of ED follow-up care.
Requires development of a standardized summary-of-care document, containing all pertinent patient information such as medications, allergies, diagnoses, emergency contact, and code status Need to exclude patients without a PCP or other usual source of care from the denominator
Concurrent availability of a patient’s previous medical testing can reduce the use of laboratory and radiology testing and admission rates.
Developing an HIE is cost prohibitive in many communities. Not all visits will be aided by accessing the HIE. At times, HIE access may increase information overload.
Measure outpatient providers on the ratio of referred patients arriving to the ED with summaryof-care information received within 1 h to all patients referred to the ED. Track rates of summary-of-care documents received by longitudinal providers after an ED visit. Measure whether an HIE is available, how comprehensive the information included is (raw radiographic images preferred above solely information that a radiology test was performed), and whether the ED accessed the information during the ED visit.
Cons
STEMI, ST elevation myocardial infarction; EMS, emergency medical services; ICD, International Classification of Diseases; EMTALA, Emergency Medical Treatment and Labor Act; PCP, primary care provider; HIE, health information exchange.
diagnostics, alleviates a patient’s anxiety and physical discomfort in ways that have little or no effect on currently measured outcomes such as hospitalization or death.27 A patient may place a high value on being able to receive a full diagnostic evaluation in one location, at any time of day or night, rather than taking several sick days during weeks to obtain a series of tests ordered by a primary care provider.28,29 Current patient satisfaction measures do not ask patients how they perceive their ED care in relation to their other available options. Population health is defined as “the health outcomes of a group of individuals, including the distribution of such 4 Annals of Emergency Medicine
outcomes within the group” and considers the determinants of health and how policies and interventions affect those determinants to yield outcomes for the entire population. Currently, most EDs focus on outcomes for the individual patient,30 but population-based metrics would also be helpful to increase the value of ED care, recognizing that almost half of ED patients seek care in multiple hospitals.31 Regional systems of care (such as those for trauma, burn, stroke, and myocardial infarction) focus on geographic access to care.32 Matching population-based outcomes to a population-based measure (eg, community injury survival rate) would offer incentive to regional providers, emergency Volume
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medical services (EMS), and hospitals to improve their coordination of care, with the goal of improving health outcomes within a region. BALANCING RESOURCE USE WITH THE REALITIES OF THE ED Resource use, or the costs of all health care provided to patients, will account for 10% of the MIPS score in its first year (2019) but will increase to 30% by 2021.17 Currently, few performance measures address overuse.33 ED providers have long been criticized for excessive use of imaging and laboratory studies compared with other ambulatory care providers, particularly for patients who are ultimately found to have low-acuity diagnoses that could have been treated safely in alternative settings.34 This viewpoint overlooks important distinctions between ED care and health care delivered elsewhere. Comparisons across provider and setting types fail to recognize that emergency providers typically evaluate patients without the benefit of complete histories or longterm patient relationships and therefore require different strategies than those used by primary care providers. In addition, ED providers encounter a different spectrum of chief complaints than do other ambulatory care providers.35 Although patients with presumed low-acuity complaints tend to have more tests ordered for evaluation in the ED than in a clinic or in urgent care,36 this likely occurs because many patients self-refer to the ED when they have severe or complex symptoms.37,38 Given the short patient relationships and limited availability of patient history, ED providers also have greater concerns about the threat of malpractice litigation.37-40 The use of the ED as a diagnostic center has become a routine practice of ambulatory physicians, who refer their patients with requests for expedited evaluation, imaging, and laboratory tests.13,14 From a fiscal perspective, a primary physician might order all the same outpatient tests as an emergency physician, but they will be scheduled during several days or weeks, spreading out the costs into discrete episodes. In addition, people come to EDs for reasons other than an acute change in health. They might have inadequate preventive care, a gap in chronic disease management, or inadequate postacute care. A return ED presentation could reflect poor ED care or a failure in the inpatient or ambulatory care systems.29,41,42 Therefore, building value requires an approach to quality measures that recognizes care delivered in the ED as part of a continuum of a patient’s comprehensive care, rather than an isolated episode. This could be achieved by a measure that gauges resource use by all physicians involved Volume
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in making a patient diagnosis for a symptom; for example, from the onset of chest pain in the ambulatory or ED setting until an acute myocardial infarction diagnosis is made.43 This approach aligns emergency, ambulatory, and inpatient providers, emphasizing coordination and shared responsibility for effective patient transitions between settings, and counters the pressure that ambulatory or inpatient providers may feel to transfer expensive diagnostic testing to the ED when they are accountable for only their own individual resource use. The creation of bundled payment approaches (eg, joint replacements) also represents an important advance in aligning incentives; more bundles triggered by patient complaints that include the role of the ED in diagnosis and management should be explored. An episode might mirror the MIPS resource use care episodes recently proposed by Centers for Medicare & Medicaid Services, such as acute exacerbation of heart failure; cholecystitis; hip, femur fracture, or dislocation treatment; or asthma or chronic obstructive pulmonary disease acute exacerbation, which could be expanded to include the emergency care delivered for each condition.13,17 The use of computed tomography (CT) in the ED provides another important example of balancing resource use and value. Emergency physicians use more CT scans than clinic-based providers despite valid concerns about radiation exposure and the risk of overdiagnosis and overtreatment.44,45 Here, too, the story is more complex than simple cost analyses suggest. These decisions are driven by 3 factors, 2 of which were mentioned above. First, emergency physicians are benchmarked on making decisions quickly; waiting for a headache or abdominal pain to evolve with serial examinations may be more time consuming than performing a CT scan to rule out significant threats. Second, as noted above, patients presenting to an ED may have a higher baseline risk of serious conditions than those presenting to their primary physician. Third, and potentially most important from the value perspective, a CT scan changes the treating ED provider’s decision to admit, one of the most expensive decisions he or she makes, in 19% to 25% of cases.13,46 Payment models that rely on incentives to decrease the total cost of care and reduce hospital admissions and readmissions might inadvertently promote the use of imaging studies to support ED discharge rather than admission or observation for serial examinations. Although low-acuity conditions can be managed effectively and inexpensively by primary care providers with the benefit of established patient relationships and background knowledge, patients with such conditions continue to seek care in EDs for a number of reasons, including health literacy, primary care access, and patient Annals of Emergency Medicine 5
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preference. Patients are often unable to reliably determine when a condition or symptom is acute or urgent enough to merit emergency care.13 To avoid placing undue burden on patients, potentially stifling their use of emergency care and possibly delaying evaluation of a true emergency, EDs should continue to be available for rapid triage and evaluation of any complaint. Typically, during their ED visit patients will be educated about the symptoms that warrant emergency evaluation after discharge and will be encouraged to revisit their longitudinal provider for further care. Finally, the current reimbursement structure in many emergency physicians’ hospital contracts includes incentive payments for the number of relative value units or highcomplexity codes generated. These metrics are used to benchmark providers within groups, shaping both individual and collective behavior.13 Success in MIPS, however, requires new physician payment incentives that augment the simple enumeration of activities performed during individual encounters with a broader consideration of the effects on quality of life, well-being, and total cost that will capture value in a more meaningful way. EMERGENCY-SPECIFIC APPROACHES TO CLINICAL PRACTICE IMPROVEMENT Fifteen percent of the MIPS score comes from clinical practice improvement activities, which fall into 7 categories: expanded practice access, population management, care coordination, beneficiary engagement, patient safety and practice assessment, achieving health equity, and integrated behavioral and mental health.17 Emergency physicians already offer expanded practice access 24 hours a day, but many ED functions with the potential to deliver high value, such as care coordination, are not covered by traditional performance standards or payment models. For example, EDs maintain facilities and staffing levels on a 24-hour basis for unanticipated surges and crises. EDs are also the only care setting in which all patients must be evaluated regardless of their ability to pay, and they serve as the safety net for gaps in the insurance, mental health, and primary care systems.13 These activities are currently subsidized by higher payments from insurers (including Medicare and Medicaid) for ED care, reflecting higher overhead costs. Incentive payments could directly reward improvement activities related to these responsibilities, decreasing reliance on cross subsidization. ED-based care coordination is time consuming and is actually discouraged by current ED throughput measures. This is unfortunate because care coordination fills important gaps in the health care system and educates 6 Annals of Emergency Medicine
patients about care-seeking options. After an ED visit, care coordination can help patients transition back to their usual source of longitudinal care; for example, by assisting with appointment scheduling from the ED. For patients who do not have an acute illness requiring hospitalization but cannot be discharged safely from the ED to independence, provision of home health services or admission to a rehabilitation facility can enable them to avoid inpatient admission when coordinated from the ED. Ensuring the connectedness of care and addressing a patient’s social determinants of health is a challenge for emergency physicians because of their time constraints, and the ED and hospital administrators should consider providing EDbased case managers, social workers, or health navigators continuously to assist with care coordination. This type of support could substantially enhance the value of care. Coordination between potentially competing hospitals is also important. For the critically ill, all EDs in a community should work with EMS and out-of-hospital systems to ensure that patients arrive at the optimal facility to treat their illness or injury, or to expedite transfer to the optimal facility when needed, regardless of patient insurance status and even if the optimal facility is in another hospital system.47 Smooth transitions are equally important for the less critically ill. Patients who need specialty follow-up care from a different hospital system should have that access coordinated during their ED visit as well, without requiring a transfer to the ED with which the specialist is affiliated. These seamless transitions require cooperation across provider types and hospital systems, where accountability should be shared across specialty providers and emergency providers in multiple hospitals within the community. USE OF HEALTH INFORMATION TECHNOLOGY TO SUPPORT INTEGRATION OF EMERGENCY CARE WITHIN THE CARE CONTINUUM Health information technology, or advancing care information, contributes a quarter of the total MIPS score.17 Although health information technology is critical to efficient and value-based care delivery in all settings and large investments have been made, 27% of primary providers still do not use electronic records, and few records are interoperable.48 Therefore, our current system falls short in coordinating care and ensuring timely communication between providers because ED visits are usually unplanned, frequently occur outside of business hours, and may (during business hours) coincide with periods when the patient’s other care providers are unavailable. Timely communication of real-time patient presentations and clinical data between Volume
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providers may reduce cost by decreasing testing and admission while creating a more patient-centered experience.49 One potential solution to this issue was introduced by Kindermann et al,50 who proposed a new notifications measure that would encourage EDs to alert primary care providers when their patients check in. (Only 29% of EDs currently do this for patients outside of their hospital systems.51) Health information exchange with fully interoperable and continuously available patient data is another promising tool for the unscheduled care setting that has been shown to reduce resource use49 and can improve patient care coordination in the ED. It has also been shown to assist with transfers of patients between EDs, during which failed interoperability of imaging systems and fee-for-service payment incentives often lead to repeated imaging studies.52,53 Stage 2 of the Medicare Electronic Health Record Incentive Program contains a measure for health information exchange that requires electronic summary-of-care documents to accompany patient transfers of care and referrals. Referral of a patient from the primary care office to the ED by telephone, including by an answering service after hours, should be considered a transfer of care and accompanied by the patient’s records. Transfer of a patient from a long-term care facility to an ED for acute care should also be accompanied by a standardized summary-ofcare document, including advanced directives and end-of-life forms, to facilitate care of the patient in the ED. By the same token, discharge from the ED is a transfer of care when followup with an authorized provider is ordered and, under current stage 2 requirements, must be accompanied by a detailed summary-of-care document sent to the primary care provider to ensure continuity of care and communication of any changes to medication lists and treatment plans at follow-up. CONCLUSION Several provisions of MIPS provide unprecedented opportunities to bring value into the emergency setting by changing incentives for patient treatment and care coordination. Value and its quality component are partially subjective and can be difficult to define, so this work must be done carefully to preserve the services that an ED provides for life- and limb-threatening conditions and as a safety net for the sick, injured, and underinsured. A range of approaches could be considered, including the development of ED-specific symptom-based quality measures, measures that share responsibility between ED and outpatient providers and across all EDs in a region, and enhanced information technology requirements that broaden the notification and summary-of-care criteria to require fully interoperable health information exchange and Volume
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bidirectional 24-hour communication between ambulatory practices and EDs. New quality measures require a large number of resources to develop and can take time to be adopted by Medicare and other payers.19,24 EDs must continue to diagnose and treat the most severe illnesses and injuries while better integrating their current efforts to rapidly diagnose illness, manage acute exacerbations of chronic conditions, facilitate hospital admissions, provide a bridge to a medical home for patients without access to a regular source of care, and serve as a foundation for local and regional disaster response, with the goals of the overall health system. Given the broad spectrum of diseases and acuity encountered in EDs, they must be prepared to dedicate space and staff to both the rapid delivery of critical care and the coordination of care for geriatric, pediatric, psychiatric, and other special populations. As the link between medical homes, accountable care organizations, and other alternative payment models, the ED of the future should coordinate patient care across medical specialties, settings, and broader communities, preserving and communicating key information through transitions in care to and from the community. Finally, emergency care increasingly needs to lead and partner with others to establish regional systems of care for entire communities (eg, regional trauma care, centers of excellence for certain conditions). If ED-centric alternative payment models were developed, they could test a vision of the ED as a fully integrated and patient-centered location for the delivery of acute, unscheduled care, and coordination of that care with the broader health system. For any such efforts to succeed, however, the ED must not simply be considered a place to be avoided at all costs, but rather as a health care solution that has the potential to play an important role in developing coordinated, high-value systems of care. Supervising editor: David J. Magid, MD, MPH Author affiliations: From the Baylor College of Medicine, Houston, TX (Medford-Davis); the Centers for Medicare & Medicaid Services Center for Medicare and Medicaid Innovation, Baltimore, MD (Medford-Davis, Carrier); the Department of Emergency Medicine, University of Maryland, Baltimore, MD (Marcozzi); the Centers for Medicare & Medicaid Services Center for Program Integrity, Baltimore, MD (Agrawal); and the Department of Emergency Medicine, Jefferson University, Philadelphia, PA and the Emergency Care Coordination Center, Assistant Secretary for Preparedness and Response, Washington, DC (Carr). Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval Annals of Emergency Medicine 7
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Value-Based Approaches for Emergency Care of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Publication dates: Received for publication April 29, 2016. Revisions received August 27, 2016, and October 4, 2016. Accepted for publication October 28, 2016. The viewpoints expressed are those of the authors and do not necessarily represent official views or policies of the Department of Health and Human Services.
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