Regardless of one’s loyalties, anyone who has attended or seen professional football games played in the last decade knows the image of Peyton Manning breaking a huddle, surveying the field in front of him and pointing vigorously, while calling out signals to the other players on his team.

It is the image of a coach on the field. It is the image of a leader.

Who will be the leaders in the new, emerging landscape of our healthcare system? Rodak quotes Dave MacDonald, who says, “Healthcare organizations can have very complex political environments that demand comprehensive, deliberate and sound decision making. Any ‘team’ needs to have at least one person who can step in and make the tough calls.” In the evolving era of Accountable Care Organizations (ACOs), bundled payments, collaboration, physician alignment, and integration, who will become the leaders, where will they come from and what decisions will they execute?

What are the issues and where are we headed? No one can really outline the future with great clarity. However, the Supreme Court’s decision on June 28, 2012 means PPACA will go forward. The key indices and industry parameters currently developing all seem to be principally focused on value-based purchasing, ACOs, quality of care, and evidenced based care.

On the issue of evidenced based care it will presumably support and substantiate physician participation in the ACO environment. Robert Galvin, MD defines value as being quality/cost, and adds a key statement to help evaluate the signals from the noise in the current environment: “Invest in strong and clinically savvy physician leadership.”

In the recent Forbes Insights report focused on senior hospital and healthcare executives (i.e. C-Suite), two key results stand out relative to this projected state. First, 39 percent of respondents believe that at least a quarter of their revenues will be derived from value based purchasing in the next five years. Second, fully engaging their doctors was seen by C-Suite executives as the key to value based purchasing participation, as selected by one half of the respondents. In perhaps the most outspoken statement in this report, Peter J. Holden, CEO of Jordan Hospital states: “I told the doctors front and center that if you don’t learn and you don’t embrace and you don’t exert influence on what’s coming, you could be one class away from building houses.”

Regarding the evolving ACO networks, Fuchs and Schaeffer conclude health plans are the “most feasible candidate to get ACOs rolling.” This can be an ominous forecast, particularly for physicians. There are certainly similarities between the various ACO models and the original managed care model which saw such physician-unfriendly concepts as capitation, but this new, evolving era seems destined for growth. Indeed, the evolving ACO environment has grown dramatically within the last several months. Muhlestein, Croshaw, Merrill and Pena report that “the last eight months have seen considerable growth in the number of health care entities commencing Accountable Care Payment arrangements. Despite large variation in models used, this growth is evidence of the increasingly common belief that health care should be more than simply providing and billing for services. Leavitt Partners has utilized both public and private sources to track the activity of 221 Accountable Care Organizations through the end of May 2012. Although growth is concentrated in larger population centers, it has expanded to 45 different states.”

In this evolving landscape, where exactly do physicians fit? Where specifically might emergency physicians in particular leverage their key strengths to become significant contributors and players in these networks? Spoerl notes strong physician leadership as being one of the three keys to making accountable care work. In particular he comments: “Accountable care organizations require strong physician leadership to meet the challenges of quality, communication and coordination of care in new delivery models. Such leadership is also required to guide the organizations in developing equitable distribution of revenue among various primary care and specialty arrangements in ways not necessary in a traditional fee-for-service model.”

Emergency physicians are certainly familiar with the issue of primary care shortages as they experience this virtually every day. Cantlupe notes the United States has about 350,000 primary-care physicians, but about 45,000 more will be needed by 2020, according to the Association of American Medical Colleges.

Let us look at some nuts and bolts issues facing everyone in this evolving new era.

ACEP President Dr. David Seaberg said, at the recent ACEP Leadership and Advocacy Conference, that the emergency department can reduce potentially avoidable admissions and reduce readmissions. This is an upcoming CMS initiative. Emergency physicians all see patients with high levels of recidivism in their departments and can be the most critical and key decision makers on this particular subset of patients that will cost hospitals potentially millions of dollars in lost revenue if the frequency of their ED visits is not addressed.

Emergency physicians, supported by hospitals, easily available primary care, and case management resources, can be on the front lines of addressing inappropriate emergency department utilization.

Be a rapid diagnostic center. One of the hallmarks of the diagnostic skill-set of emergency physicians is their ability to quickly assess the patient’s condition and determine the next course of action, routing patients to the most appropriate next step in the healthcare system.

Get patients back to work more quickly by providing “one-stop-shopping” for tests and treatments. This can be a strategic pitch for emergency physicians to both employers and payers alike.

Reduce unnecessary testing. Emergency physicians like Dr. Joel Klein in Maryland have already taken initiative in organizations such as the Chesapeake Regional Information System for our Patients, an organization whose function is to share health information electronically across current boundaries, with the goal of improved and more efficient patient care.

Provide disaster and syndromic surveillance services. In the event of any biologic, military, or natural disaster, emergency physicians will be on the front lines, as usual.

Be part of the “medical neighborhood.” Emergency physicians have a clear opportunity to insert themselves in the newest healthcare structures, still in their infancy in both structure and evolving function, but it is necessary to insure someone else does not pre-empt the decisions and define the role of the emergency physicians.

A specific parameter that cannot be overlooked is the fact that emergency physicians exert a substantial amount of influence over the revenue stream of every hospital, every time they make the critical decision to admit their patients. Schur and Venkatesh have just reported “the number of hospital admissions increased by 15.0% from 34.3 million in 1993 to 39.5 million in 2006; admissions from the ED increased by 50.4% from 11.5 million to 17.3 million. The proportion of all inpatient stays initiated by admission from the ED increased from 33.5 to 43.8%.” Over and above the scrutiny given patient satisfaction scores attained by emergency physicians, this particular issue warrants a great deal more attention.

The veritable life blood of every hospital is affected by the clinical expertise and decision-making skills of emergency physicians. As hospitals continue to struggle with short-stay admissions and reimbursement reversals, emergency physicians are presenting creative solutions to their hospitals through observation services. New York Medicaid, a payer that has certainly never been considered particularly friendly toward emergency physicians in terms of payment rates, in April 2011 effectively designated the ED as the focal center for observation services.

It is certainly reasonable to assume and expect this recognition of the specialty to become a trend, but emergency physicians must leverage these industry moves and seize the moment.

It is estimated that 136 million patients will be seen in US emergency departments this year. The CDC Report released in May 2012 notes 79.7 percent of adults visited the ED due to lack of access to other providers, significantly more than the 66.0 percent who visited due to seriousness of the medical condition.

As noted above it will take years for the supply of primary care practitioners to catch up to the present need. Even when the remaining 50 million, currently uninsured individuals receive coverage, it will remain to be seen how effective the primary care network will be in keeping patients out of EDs, for routine, non-emergent care.

Until those issues are resolved, emergency physicians will continue to provide service to these millions of patients, another indication and confirmation of the critical role fulfilled today by emergency medicine.

Emergency medicine is the healthcare system’s go-to specialty for cases which cannot be managed elsewhere in the continuum of care, with patients routinely referred from physician offices, urgent care centers, and ambulatory surgery centers, among other places.

From patients presenting with sprained ankles and earaches, all the way through the critical trauma patients, the AAA patient superbly diagnosed by the emergency physician using bed-side ultrasound, and the chest pain patient who arrests with a STEMI, we have emergency physicians today addressing and treating these patient needs and making the appropriate calls to the appropriate specialists. Emergency physicians manage a critical revenue resource for every hospital.

As opposed to being a focus of expense in healthcare, emergency physicians today actually save insurance dollars through such programs as observation services and workers compensation programs.

What a wonderful opportunity for emergency medicine.

The quarterback, the signal caller is a role that certainly seems to fit emergency physicians, given the parameters and distinguishing characteristics presented above.

Some of the most critical decisions affecting patients and all of their downstream care are initiated by emergency physicians. ACOs and bundled payment models will usher in very different payment and reimbursement models, replacing traditional fee for service.

Some of these issues will be contingent on the political winds of change post 2012 elections, but it is reasonable to assume the current system will be changing regardless of the election outcomes. That said, emergency medicine needs to secure its role, so others do not define it for the specialty. This is a critical moment for the specialty and cannot be missed.

Refining the quarterback role will go far in ensuring emergency physicians are properly recognized and reimbursed in the models of the future. In the words of Bill Gates, “We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten. Don’t let yourself be bullied into inaction.”

This is a great time for emergency medicine, and especially a great time to define a leadership role in the emerging new era in healthcare.

John G. Holstein is Director of Development with Medical Management Professionals, a national physician coding, billing and practice management company.

References

1. Rodak, Sabrina. “Are You an Old or New Era Hospital Leader?” Becker’s Hospital Review, May 31,2012
2. Galvin, Robert. “Pay for Performance, Transparency and Value Driven Healthcare.” NY HFMA conference presentation, March 29, 2012.
3. Forbes Insights. Getting from Volume to Value in Health Care. June 2012.
4. Fuchs, Victor R.; Schaeffer, Leonard, D. “If Accountable Care Organizations Are the Answer, Who Should Create Them?” JAMA, Vol. 307, No. 21, June 6, 2012.
5. Muhlstein, David; Croshaw, Andrew; Merrill, Tom; Pena, Christian. Leavitt Partners. “Growth and Dispersion of Accountable Care Organizations: June 2012 Update.”
6. Spoerl, Bob. Putting People at the Front of Accountable Care: Insight From CHI’s Dr. Barry Hoover.” Becker’s Hospital Review, June 20, 2012.
7. Cantlupe, Joe. “Emergency Care for the ED” Healthleaders Media, May 14, 2012.
8. Schur, Jeremiah, MD, MHS; Venkatesh, Anjun, MD, MBA, The Growing Role of Emergency Departments in Hospital Admissions; The New England Journal of Medicine, Vol 367; August, 2, 2012.
9. Gindi, Renee M., Cohen, Robin A., Kirzinger, M.P.H., Centers of Disease Control, Division of Health Interview Statistics, National; Center for Health Statistics, May 2012.
10. Bill Gates. World Economic Forum. Davos. 2007.