Where does emergency medicine fit in the emerging and evolving new health care world? Who will define how emergency medicine fits into this world? Does it matter?

The first question is perhaps the most difficult as the world is changing so rapidly. The current era is arguably the most extensive because the health care world was last shaped with the advent of managed care. In that prior era, emergency medicine certainly took its share of hits, which were to a great extent reimbursement and revenue based with claims denials, inappropriate bundling of services, etc. But the overall structure and function of the specialty remained intact.

The current evolving world mandates the specialty takes a firm stand on its presence, but also very importantly on the central role and value it brings to the table. The evolving world of ACOs is the new world. Becker’s Hospital Review reported in February that there are 428 ACOs in 49 states and that the “physician group sponsored” ACOs is fast gaining ground on the “hospital-sponsored ACOs.”

As emergency physicians, you are at the forefront of the entire spectrum of patient care, making daily decisions for your patients that ramify throughout the health care world. An emergency physician’s decision to admit a patient is one of the most significant triggers impacting the bottom line revenue of every hospital. These decisions impact the constantly shifting balance of outpatient and inpatient services that is critical for the survival of every hospital.

As emergency physicians, you fulfill a central role in the entire system. Despite fulfilling this central role, defining how emergency medicine fits into this emerging new world is fast becoming one where others are moving toward defining the metrics and indices of cost and quality by which emergency medicine will be measured. Emergency medicine has an audience of three. Understanding the audiences will lead to fortifying the specialty’s role and function in the system. These are as follows:

Know Your Audience

Medicare-CMS

Private Payers

Hospital C-Suite

For Medicare/CMS, the issue will typically be focused on the reimbursement for the various levels of care and the justification of these levels as evidenced by physician documentation supporting them. So far, the quality related indices from CMS are the Maintenance of Certification (MOC), Physician Quality Reporting System (PQRS) and the upcoming Value Based Modifier (VBM). Remember the PQRS system started out as a “pay for reporting” system and has evolved into today’s “pay for performance” system.

As recently as March, CMS broadened its view, as evidenced by its release of information on emergency department wait times with the following introductory note: “Long waiting times in hospital emergency departments can increase risks for patients, especially those who have serious illnesses. Waiting times at different hospitals can vary widely, depending on the number of patients seen, emergency department staffing, efficiency, admitting procedures, or the availability of inpatient beds.”

The landscape is changing as the metrics are mounting by which emergency medicine is and will be measured, with some impacting your revenue today (i.e. especially PQRS), and potentially more metrics on the way; ultimately the bottom line will be about cost. It is likewise very wise for emergency physicians to ready themselves for reporting indices to the other two audiences, namely the private payer industry and hospital administration. Regarding the private payer audience, an interesting comment was made recently in similarly noting the rhetoric about quality is not the issue of importance. Rather, said managed care consultant Ron Howrigon at the 2013 ACEP Reimbursement Conference in February, it’s about cost savings – measures such as lower incidence of CT scans and reduced admissions.

The message is clear that others are developing their metrics and measures, and it’s ultimately about cost, but where is emergency medicine in establishing these metrics by which you will likely be measured? A strong notice of the hospital audience chiming in occurred when the New York Health and Hospitals Corporation announced earlier this year in a press release that it will award up to $59 million in bonus payments to physicians for hitting their defined quality and efficiency targets. Where does the Hospital C-Suite stand fit into this equation? A glimpse of this was described recently by Sinai Health System CEO Alan Channing, when he included the following measures in his list of “How to Keep the Hospital Happy” measures.

• Build business
• Keep referral sources happy
• Good communications
• Simplify management issues
• High HCAPS scores
• Consistent and high quality scores
• Rapid through-put
• Minimize hospital’s financial participation
• Support the hospital’s mission, vision and values

This list represents the circumstances under which the emergency department group gets and/or keeps the contract. Does it matter? Absolutely, because the C-Suite is mandating the metrics that literally define how your services will be measured. Meet the metrics and you have a job; miss the mark and you could be history. It doesn’t get any more important than that; it means survival.

The picture emerging here is one where the audience emergency medicine plays to is fast moving toward establishing the metrics by which the quality and value of emergency care will be measured. The most significant issue here is the specialty needs to be defining the metrics by which you will be measured, not the audience!

So what are or could the emergency medicine-specific measures/

metrics be today? More importantly what are they as defined by the specialty? A preliminary list might include the following:

• Various Turnaround Times
• Door-to-doctor times
• Door-to-balloon times for MI
• Door-to-needle times for CVA
• Percent of patients admitted
• Patterns and percentages of readmissions over time
• Percent of patients leaving prior to medical evaluation (LWBS)
• Ancillary charges per encounter-Lab/X-ray/CT/MRI/Nuclear Medicine/Ultrasound
• RVUs/ hour of coverage
• Patients/hour/practitioner
• Patients admitted to ED observation
• Patients admitted to inpatient status after ED observation
• Patients discharged home after ED observation
• Patient satisfaction (“experience”) scores
• Feedback and rating from in-house departments
• Feedback and rating from sub-specialty colleagues
• Effective communication and care coordination with primary care physicians.
• Incidence of ambulance diverts.

This is by no means an exhaustive list and is not meant to be. The list will evolve, but the most important issue is that you have direct input into the measures and indices by which you will be evaluated. The message is clear. CMS, private payers and your hospital administration C-Suite colleagues are all moving toward defining these measures. It is time for you to call the signals by defining the measures specific to your specialty; the time is now, especially before someone else does it for you.

John G. Holstein is a director at Medical Management Professionals.