Let’s set the stage with a couple of industry quotes.

“We’re sorry, but we have no idea how we perform on the procedure you are having. We can’t tell you if our physicians use the best treatments—the treatments shown in the literature to be the best … but trust us, we have some great physicians, and we deliver great care. We just can’t prove it.”¹

“Putting a single, predictable price tag on a medical procedure allows a hospital to position these services as ‘branded products’ and to compete on cost and quality. The common element is the necessity to leverage both cost and quality data to craft an evidence-based economic and clinical value story that the organization can share with payers and employers.”²

The above quotes capture the essence of the hospital C-suite’s dilemma today: persistently driving toward greater value while dealing with the pervasive and pressing issue of first defining and then actually measuring quality and cost, the two major components of their value statement.

So what is emergency medicine doing to become the primary driver and answer for today’s hospital executives? Whether an employed, contracted, or an academic practice, emergency medicine can become the epicenter of answers for disruptive innovation and positive change in every hospital.

There needs to be a concerted effort by the specialty to tighten up its own house first. According to Kanzaria et al, “over 82 percent of respondents believe too many diagnostic tests are ordered in their own emergency departments.”

Before tackling the issue of emergency medicine becoming the answer to this C-suite dilemma, it is first important to note how emergency medicine will not only not become an answer but alternatively can persist as a center of problems for hospital executives. There needs to be a concerted effort by the specialty to tighten up its own house first. According to Kanzaria et al, “over 82 percent of respondents believe too many diagnostic tests are ordered in their own emergency departments.”³ Some degree of intraphysician variability is acceptable. However, it is imperative that we reduce wide variation in patient treatments and diagnostics. W. Richard Bukata, MD, medical director for The Center for Medical Education, Inc., discusses practice variability specifically regarding computed tomography scans and plain X-rays.⁴ Stephen Klasko, MD, MBA, president and CEO of Thomas Jefferson University in Philadelphia, provides valuable perspective here: “Doesn’t it stink that Nick Foles has a better idea of whether a screen pass will work in a given situation than I do of knowing whether a cancer drug will work?”⁵ This is prime time for evidence-based medicine.

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.

Mr. Holstein is director of business development at Zotec Partners in Bala Cynwyd, Pennsylvania. Dr. Sama is president of Progressive Emergency Physicians and former president of ACEP.

References

1. Byrnes J. Measure quality to create value. HFM. March 2015.
2. Sackman JE, Buseman CM. Payment reform: a primer for taking on risk. HFM. March 2015.
3. Kanzaria HK, Hoffman JR, Probst MA, et al. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging. Acad Emerg Med. 2015;22:390-398.
4. Bukata R. Is the plain X-ray dead? LinkedIn Web site. Accessed Aug. 10, 2015.
5. Marchese J. How Jefferson’s Stephen Klasko intends to fix our screwed-up health-care system. Philadelphia. Dec. 14, 2015.
6. Armour S. US emergency room visits keep climbing. The Wall Street Journal. May 4, 2015.
7. Asplin B, Pilgrim R, Pines J. Right-sizing your ED amid health reform. Course lecture presented at: EDPMA Solutions Summit. May 2015.
8. Hollander J. Innovations In technology. Course lecture presented at: EDPMA Solutions Summit. April 2015.
9. Putera M, Roark R, Lopes RD, et al. Translation of acute coronary syndrome therapies: from evidence to routine clinical practice. Am Heart J. 2015;169:266-273.
10. Augustine J. How do you measure up? ED benchmarking and hospital perception. Course lecture presented at: ACEP Reimbursement & Coding Conference. January 2015.
11. Nedza S. Commercial payers, ACOs, and future ED reimbursement. Course lecture presented at: ACEP Reimbursement & Coding Conference. January 2015.