However, with this essentially being a capitation model for hospitals, they have significant incentives to decrease expenditures. How will this occur? The less care delivered, the fewer expenses hospitals incur. The GBR model regulates revenue as well, leaving fewer options to change the bottom line by increasing services. So “just follow the money.”

If hospitals decrease inpatient admissions, they will spend less on care delivery. Hospital admissions have become more focused on expense than revenue. The focus on decreasing expenses has led to fewer available beds, increased boarding, crowded emergency departments, and more nursing shortages, including an increase in absenteeism. In addition, more effort is being made to find other sources of care for patients. With the increase in case management and social services, more patients are also able to go home with prearranged services such as home health.

In the emergency department at many hospitals, there seems to be a decreased institutional emphasis on metrics such as “left without being seen.” Low-acuity visits equate to higher costs than in other settings. At times, it feels like the care we used to provide in the main emergency department has been moved out to the waiting room since many of our beds are filled with admissions.

While the initial impact of the GBR model was positive, as the “easy money” disappears, more and more pressure occurs to find new and innovative means to decrease expenditures. Unlike the current fee-for-service model, in which hospitals and providers are mostly paid for care delivered (services provided), the GBR model is intended to incentivize the delivery of more care in less expensive settings. While intended to improve quality and decrease cost, the unintended consequence may be to delay care for our patients across the spectrum.

Dr. Hirshon is professor in the departments of emergency medicine and of epidemiology and public health at the University of Maryland School of Medicine in Baltimore. Dr. Jaquis is system chief of emergency medicine at LifeBridge Health and chief of emergency medicine and attending physician at Sinai Hospital, both in Baltimore.