Can emergency medicine become the epicenter of positive change, innovation, and solutions for today’s C-suite? The answer is a resounding yes. This is an incredibly exciting time for the specialty. If yes, then how?

First, the practice needs to be as efficient and financially successful as possible. This requires constant and persistent vigilance over all practice metrics. As reported by Wall Street Journal reporter Stephanie Armour, patient volumes continue to rise across the United States.⁶ Additionally, as the Medicaid rollout continues, virtually every practice is seeing a shift in its payer mix. Monitoring the acuity, clinical, and payer mixes of practices is imperative today because very minor shifts can have substantial impacts. There can be subtle shifts today, especially in these days of Medicaid expansion. The former self-pay patient now insured via Medicaid generates new revenue. However, leakage from the former commercial patient mix into Medicaid may cause substantial revenue loss. (See “Role Reversal: Chasing the Insured for Payment” in the July 2015 issue of ACEP Now for more on this challenging situation.)

The former self-pay patient now insured via Medicaid generates new revenue. However, leakage from the former commercial patient mix into Medicaid may cause substantial revenue loss.

Along with these changes, efficient staffing—meaning the matching of physicians, advanced practice providers, and scribes, where appropriate—becomes increasingly important. The monitoring of the clinical mix will also become more important as ICD-10 rolls out later this year.

Ultimately, the development, refinement, and definition of emergency medicine’s value statement are at stake here. Components of the evolving value statement include:

• The ED as the center for acute undifferentiated care.
• The ED as the rapid, high-quality diagnostic center.
• Asplin et al suggest this may also require changing the approach to intermediate and complex patient conditions.⁷
• The ED as a key hospital center for identification of frequent users, hot spotters, and mental health patients.
• Emergency physicians as master diagnosticians.
• Emergency physicians as master play-callers in care coordination to subspecialists.
• Emergency medicine as a major source of hospital admissions.
• Observation in the ED to reduce unnecessary admissions and readmissions.
• Benchmarking through the use of already established resources such as the Emergency Department Benchmarking Alliance. It is not necessary to re-create the wheel; these resources are invaluable.
• Usage of ACEP’s Clinical Emergency Data Registry (CEDR) when available and complete.
• Usage of such resources as the NNT where applicable. Using evidenced-based protocols and treatments is paramount today. Judd Hollander, MD, FACEP, a deputy editor for the Annals of Emergency Medicine, stated, “We don’t need more data, we need more evidence.”⁸ Putera et al note, “The time of [pivotal clinical trials] publication to meaningful uptake of class IA [acute coronary syndrome] therapies into clinical practice took a median of 16 years. This significant time lag indicates systemic barriers to the translation of therapeutics into routine clinical practice.”⁹
• Mastering patient flow, especially as the clinical mix continues to change.
• Continual refinement of such indices as:
  • Door-to-doctor times;
  • Door-to-balloon times;
  • ED time after admission decision;
  • ED time before pain medications; and
  • CT scans per provider, which can be monitored via your billing service to ensure intradepartmental consistency.
• Mastering of patient threshold management, which is measureable.¹⁰ As James J. Augustine, MD, FACEP, vice president of the Emergency Department Benchmarking Alliance, points out, EDs typically stratify into cohorts with thresholds of 20,000 patient visits.
• Consistently high patient-satisfaction scores.
• Assessment, evaluation, and decisions on emergency medicine’s contribution to patient care, including the post-ED visit, as well as discharge planning for wellness, post-visit care, and return to the ED if required.
• Telemedicine’s role in emergency medicine.

As emergency physician and AIM Specialty Health chief medical officer Susan Nedza, MD, MBA, FACEP, so eloquently stated, “No one manages uncertainty better than emergency physicians.”¹¹ Emergency medicine’s image is important outside the specialty, namely with hospital administration, payers, and, in some cases, patients. There are challenges and issues to boldly face and solve; it is imperative this be done sooner rather than later, when one or more of these parties will mandate it for the specialty. The time for introspection and reinvention of the breadth of EM services is now.