Three of the most severely ill or injured emergency medicine patients, as described by the American Medical Association in the 2014 CPT manual, are (inclusive of their level of service designation):²

99284: Emergency department visit for a patient with flank pain and hematuria.

99285: Emergency department visit for a patient exhibiting active, upper gastrointestinal bleeding.

99291: First hour of critical care of a 45-year-old who sustained a liver laceration, cerebral hematoma, flailed chest, and pulmonary contusion after being struck by an automobile.

In today’s evolving and very dynamic health care environment there are several determiners of value as it applies to emergency medicine. The industry’s three major sources of financial value metrics are the Centers for Medicare & Medicaid Services (CMS), insurers, and the hospital c-suite. Regarding CMS and insurers, we’ll focus on value as measured in payment rates. Regarding the c-suite, we will present a different set of metrics for review.

The current Medicare 2014 national reimbursement rates for the three levels of care noted above are:

Medicare 2014 Rates

99284: $118

99285: $174

99291: $225

Medicaid Traditional

99284: $96

99285: $148

99291: $207

Stark reality hits home here regarding the financial “value” placed on some of the most severely ill or injured patients seen every day in our emergency departments, starting with the Medicare program. In today’s commercial world, people are paying, on average, $200–300 for their new mobile phones; $300 for a 30–39” television, and anywhere from $150–260 for a dinner outside the home for a family of four. The average daily corporate travel per diem rate is currently $293.³ As the retailization of health care continues to evolve, it would seem payers have a way to go to more equitably reimburse emergency physicians, particularly for treatment of our most severely ill and injured patients. More specifically, Medicare reimburses $75 less for a critical care patient than the current price paid by thousands of people every day for their latest phone and $68 less than the current average corporate per diem rate. It gets far worse when scrutinizing our other governmental program, traditional Medicaid. By way of comparison and inclusion, Walmart is diving into the primary care arena at $4/patient visit, driving the economic value of care even lower.⁴

What are the value metrics used by the hospital c-suite today? These also likely play a role in payer determinations of value in establishing their proffered reimbursement rates. As itemized by Ellison, these metrics are:⁵

1. Average time spent in the ED before patients were admitted to the hospital as an inpatient: 274 minutes.
2. Average time spent in the ED after the physician decided to admit them as an inpatient but before leaving the ED for their inpatient room: 98 minutes.
3. Average time patients spent in the ED before being sent home: 134 minutes.
4. Average time patients spent in the ED before being by a health care professional: 26 minutes.
5. Average time patients who came to the ED with broken bones had to wait before receiving pain medication: 57 minutes.
6. Percentage of patients who came to the ED with stroke symptoms who received brain scan results within 45 minutes of arrival: 57 percent.

Why are these particular metrics isolated, and what is behind monitoring these types of metrics? Eggbeer and Bowers make two very relevant and cogent points regarding two of the major determiners of value in today’s health care marketplace, namely the hospitals and insurers.⁶ First, “an estimated 20 percent of health system networks offer either their own insurance product or a co-branded product. An American Hospital Association survey of 100 hospitals last year found that 38 of the hospitals already owned health plans, while an additional 21 were planning to offer a health product in the next three to five years.” In this marketplace hospitals are beginning to forge relationships with payers, and therefore blurring traditional provider/insurer lines of demarcation.

Medicare reimburses $75 less for a critical care patient than the current price paid by thousands of people every day for their latest phone.

The second major point made by these same authors is, “a health plan is fundamentally a risk-selection business, wherein cost control and financial stability are core values. In the emerging consumer market of public and private exchanges, quality, cost, service, and convenience are the major value drivers.” Emergency medicine practices, save for independent, freestanding EDs and their practices, all are housed within hospitals and these hospitals are increasingly viewing every aspect of care and the providers associated with that care from a commercialized and retail-oriented lens. Mellin and Funk go so far as to include physician profiling as one of their six key metrics in population health management.⁷ Measures of clinical efficiency are coming more frequently to the forefront as the health care landscape continues to take shape. There is a clear message for emergency medicine in Musssallem’s words, “we need to show up with evidence.”⁸