In Pennsylvania, as across the U.S. as a whole, emergency medicine constitutes an essential strut in the support of a health care system that is increasingly overtaxed and underfunded. Nationally, in 2010 there were 129.8 million emergency department visits, or 42.8 visits per 100 persons, of which 13.3 percent resulted in hospital admission, according to Centers for Disease Control and Prevention data. Of the more than 110 million patients who were seen in the ED and not admitted to the hospital, the majority not only had health insurance, but also had a health care provider that they would identify as a source of primary care. For many of these insured patients, ease of access, relative speed of care (compared to primary care office visits), and patient perceptions of quality in a hospital-based resource-rich environment are principal drivers of ED utilization. For uninsured patients, the ED often represents their only available venue in which to receive health care. Yet, emergency medicine accounts for only 2 percent to 4 percent of the nation’s total health expenditures, according to AHRQ data.

By virtue of statutory regulations that require type A emergency departments to provide unscheduled care 24 hours a day, 365 days a year, EDs represent an irreplaceable part of the health care safety net for all patient categories. Further, due to the obligation to remain constantly staffed and available, the marginal cost (the cost of seeing the next case) of ED care is often less than that incurred in other venues. While hospital (facility or “technical”) component fees typically drive up the cost of emergency care, professional fee billing by emergency physicians is generally in line with that of office-based providers for similar levels of evaluation and management (E/M) services. Moreover, it must be recognized that the E/M services provided in an ED quite often serve to obviate “unnecessary” hospital admissions; in such circumstances, the care provided in the ED, often characterized as “expensive,” nonetheless represents considerable cost savings when compared to the expense of hospital inpatient care.

Medicaid enrollees of all age groups use EDs as a source of episodic care. There is evidence that Medicaid beneficiaries may use the ED more frequently than non-Medicaid patients. However, recent study has demonstrated that most Medicaid usage of EDs is appropriate, and related to more serious or urgent complaints.

Under the provisions of the Patient Protection and Affordable Care Act (ACA), Medicaid enrollment for all age groups is expected to increase by 16 million over the next decade. Included in this expansion would be a rise in the number of Pennsylvania CHIP beneficiaries, currently reported as 187,634 statewide as of April 2013, according to Pennsylvania Insurance Department data.

The Capital BC CHIP process improvement study, based on the questions posed to PaACEP, rests on several assumptions: 1) that some undefined percentage of current CHIP beneficiary ED visits would be better served if seen in some other venue; and 2) that some subset of these ED visits may be categorized as “unnecessary.”

With respect to the “other venue” assumption, there is a further assumption that such other venues in fact exist for CHIP beneficiaries in a meaningful and consistently accessible fashion. This argument from Access, while dependent on the structure and dimensions of the Capital BC network and therefore beyond the province of PaACEP to either know or judge, is nonetheless a critical determinant in the treatment venue selected by CHIP beneficiaries. Clearly, PaACEP is in no position to determine Captial BC CHIP program structure and resource allocation; however, to the extent that current structures and resource allocation may be subject to analysis and process improvement, PaACEP will endeavor to outline barriers to care and potential solutions based on the medical literature.
As to the existence of “unnecessary” ED visits and their scope, the embedded assumption is that the medical necessity of the encounter can be determined prospectively, i.e., prior to the actual clinical assessment of the patient. Retrospectively, there are certainly ED encounters in which no serious medical problem is found, but the linkage of this fact to the concept that such encounters should have been handled differently is at best vexatious if not impossible, since it was only the real-time clinical encounter that allowed this determination to be made. The difference between a pediatric rash due to bug bites from that of the cutaneous manifestations of meningococcemia serves to illustrate this point.
Attempts to sort ED patients by “emergent” versus “non-emergent” criteria prospectively have proven problematic. While use of the so-called “Billings Algorithm”, developed at New York University retrospectively identified ED patients categorized as “Non Emergent”, “Emergent, Primary Care Treatable”, and “Emergent ED Care Needed, Preventable/Avoidable”, the authors were careful to point out that their findings of relatively high incidences of these patient categories “…do not necessarily mean that ED utilization patterns…are inappropriate.” They go on to note that, “much of what may seem like misuse of emergency services may actually be a reasonable response to an underdeveloped primary care delivery system that is failing to meet patients’ needs.” More recently a study at NYU, where the Billings Algorithm was developed, showed that the use of these criteria in function of discharge diagnosis failed to meaningfully sort out emergent from non-emergent ED visits. These authors conclude: “Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits.”

In published comments on her study’s results, Dr. Raven went on to note: “If a triage nurse were to redirect patients away from the ER based on non-emergency complaints, 93 percent of the redirected ER visits would not have had primary-care treatable diagnoses. The results call into question reimbursement policies that deny or limit payments based on discharge diagnosis. The majority of Medicaid patients, who stand to be disproportionately affected by such policies, visit the emergency department with urgent or more serious problems.”

Finally, the National Hospital Ambulatory Medical Care Survey data from the Center for Disease Control indicate that for all ED visits, only 8 percent were characterized as “nonurgent.” This report will be further cited in the section below covering the response to questions relating to triage.

Emergency physicians are subject to two important statutes that circumscribe their scope of action: EMTALA and prudent layperson standards. EMTALA, the Emergency Medicine Treatment and Active Labor Act, is a provision of the Consolidated Budget Reconciliation Act (COBRA) which mandates that any patient presenting to an ED be subjected to a medical screening examination to determine the presence of a medical emergency. The scope of this screening examination is variable in function of the presenting complaint, but must extend to the utilization of all usual resources, including subspecialty consultation that might customarily be brought to bear on a similar complaint. Thus, all patients presenting to the ED must be seen by a healthcare provider and “screened” to determine whether a medical emergency condition exists. Failure to do so carries stiff federal penalties for both hospitals and providers themselves that are not covered by medical malpractice insurance. At the completion of the screening examination, if no emergent condition is found, the patient may be discharged to another venue for treatment; however, in practical terms, once the screening has been completed it is unconscionable for a health care provider not to personally undertake whatever requisite treatment the minor condition requires, including provisions for follow up care. Thus, presentation to an ED generally mandates a “full” ED visit, limited only by the nature and medical necessity of the presenting problem. And a number of such visits may be viewed as “unnecessary” retrospectively, but only retrospectively.

Prudent layperson statutes require third party payers to reimburse emergency medicine encounters based on the nature of the presenting complaint, rather than on the final diagnosis established after the encounter. Thus, gastroesophageal reflux causing chest pain but requiring a work up to exclude coronary artery disease cannot be denied for payment. Recent attempts by the Washington state Medicaid program to limit reimbursement to a set of discharge diagnoses were found to be unenforceable and incompatible with the provisions of prudent layperson standards. Interpretation of the potential seriousness of their symptoms is obviously subject to significant interpersonal variability in any cohort of prudent laypeople, but case law has generally tended to show a liberal interpretation of patients’ abilities to identify potential emergent medical conditions and to cast a wide net over the concept of prudence. In the pediatric population served by CHIP there are further barriers to the determination of potential emergent medical conditions ranging from inexperience in childcare, to general lack of medical sophistication on the part of parents, to variable levels of parental anxiety, to lack of access to medical resources in cases where reassurance alone might be sufficient. In this context, a number of resultant ED visits may be viewed as “unnecessary” retrospectively, but only retrospectively.

Thus, prudent layperson statutes contribute substantially to determining who comes to an ED, and EMTALA mandates that they all be seen.

An important illustration of the quandary shared by insurers and emergency physicians is provided by a study of the incidence of application of evidence-based treatment of patients in a specialized Pediatric Emergency Department (PED). In this study, while evidence-based treatment decisions were made in a reassuringly high percentage of cases, more than one-third of all cases presenting to the PED required no therapeutic intervention. The decision not to treat was, of course, itself also evidence-based and could only be arrived at through thorough clinical assessment and appropriate application of evidence-based rules. Which, if any, of the one-third of all cases that did not require treatment might, by some lights, be defined as “unnecessary,” and how could this be if the clinical encounter itself were “necessary” to make this determination?

Thus, prospective definition and determination of “unnecessary” ED visits tends to prove illusory for insurers, and for emergency physicians is rendered moot by the provisions of EMTALA. Retrospective determinations of “unnecessary” are fraught with complexity and potential for error at best, and, at least from a patient perspective, at worst are outright fictions.

In response to the communication from Capital BC to PaACEP (email from Leona Wickenheiser to PaACEP Executive Director David Blunk, March 26, 2013) we will endeavor to provide answers to the questions posed to the chapter.

Questions

1. Knowing that once a patient enters the ED seeking care the patient cannot be turned away:

• What percentage of ED cases seen are considered emergencies?
• What percentage of cases should have gone to urgent care centers?
• What percentage could have waited to see the PCP?

PaACEP has no internal statistical database to draw on to answer these questions with any real-world validity.

Certainly, based on Capital BC references to the highest volume ED visits, most cases falling under these general categories would be considered emergencies:
“Injuries/fractures/contusions” typically require diagnostic imaging to be accurately differentiated and the clinical distinction among them has some emergent importance. The requisite clinical assessment to determine need and extent of imaging, and the imaging studies themselves tend to be either unavailable or only sluggishly so in venues other than an urgent care center or a full service ED

“Abdominal pain” comprises a broad spectrum of potential etiologies that can only be precisely parsed through a comprehensive evaluation by a skilled clinician, and given the scope of such an assessment, generally the resource-rich environment of an emergency department is the most appropriate setting for these evaluations.

“Pharyngitis/strep” may be initially evaluated in almost any medical facility, but the typical rapid onset of symptoms coupled with uncertainty of potential adverse short-term evolution and lack of access to other venues accounts for many, if not most ED visits for this complaint. Certainly, more complex or severe cases or those with airway-threatening complications are appropriate only for the full-service setting of an ED. And, in gauging relative costs of ED versus alternative setting care, as pointed out by Smulowitz et al, “even without taking into account the additional cost of treating some of the lower-severity conditions in an alternative setting, it would require diverting more than 80 patients with pharyngitis to save the money equivalent to a single avoided hospitalization.”

“Respiratory infections” again constitute an array of potential diagnoses, many of which require the in-depth ancillary testing available only in an ED. From a patient perspective, understandable uncertainty of underlying causes and potential for adverse evolution are often drivers of the decision to seek care in an ED. Here again, retrospective application of a discharge diagnosis of “URI” or “bronchitis”, will fail in a substantial number of cases to differentiate between true “emergency” presentations versus those that might be considered “nonemergency” visits.

“Vomiting,” while most often of benign cause in the pediatric population, is a source of serious concern for parents and carries an immediacy of evaluation and management. Many cases seen in the ED have already received phone counseling or prescriptions from a primary care provider, or have been the subject of “watchful waiting” or home remedies prior to coming to the ED. The differentiation of benign causes such as viral gastroenteritis from more serious underlying conditions such as intussusception can often only be made after a thorough clinical evaluation coupled with more or less extensive ancillary testing.

“Bronchitis” should rightfully be included in the above “respiratory infections.”

“UTIs” are relatively common and require at least some ancillary testing for diagnosis. Here again, the need for testing and relative lack of other available venues are likely the principal drivers in seeking care in an ED.

As to the question of what percentage could have waited to see the PCP, this is obviously indeterminate in a prospective fashion. Many cases seen in the ED are in fact referred by the PCP due either to lack of scheduling flexibility, diagnostic uncertainty, need for ancillary testing, or in some cases simply as a use of the “Easy” button to avoid non-routine unscheduled office visits.

With regard to Urgent Care Center utilization, many cases are already being seen in this setting when such facilities are available and thus never become ED cases in the first place. Other, more complex, cases are seen in the ED following evaluation in such centers and referred on for higher level evaluation and management. Still others correspond to patient choice based on perception of quality of care where use of an ED instead of an Urgent Care Center is considered preferable. Thus there is no precise answer to the question as posed.

In general, as pointed out by Smulowitz’ study, “…although seemingly ‘low hanging fruit,’ diverting minor injuries or illnesses to other settings would not be expected to result in substantial cost savings, even with diverting up to 50 percent of visits, The cost of these visits is responsible for a small proportion of the 2 percent to 4 percent of total health expenditures accounted for by the ED.”

Finally, there is no objective answer to the question of what percentage of ED cases seen are considered emergencies. The previously cited recent work by Smulowitz et al categorizes 10-16 percent of ED cases as “emergencies,” that is, almost always requiring hospital admission. However, these “emergencies” would still account for only 20-25 percent of all admissions; thus, the vast majority of patients admitted through the ED would come from a category that the authors characterize as “Intermediate/complex conditions” whose evaluation and management generally require the resources of a full service ED to determine both the severity and most appropriate disposition for the presenting complaint. While some number of ED presentations might have been handled as non-emergencies in other venues, there is no statistical tool that has the power to deal with the inherent complexities of the question itself. And, as noted, attempts at retrospective analysis based on discharge diagnosis lack sufficient correspondence with clinical outcomes and actual need for emergency care to be practically utilizable as an assessment of “emergent” versus “nonemergent” cases. As noted by Dr. Maria Raven, principal author of the JAMA article cited above, “Currently, there is no possible way to determine the outcome of the visit in advance, and our study has shown that it’s not good policy to do so after the fact. Insurance companies should not treat these two patients differently. Patients should never be burdened with the task of diagnosing themselves out of fear that their potential emergency isn’t covered by insurance.” Further, as alluded to in the introduction, under EMTALA provisions all patients at the time of presentation are “emergencies” until proven otherwise by hands-on evaluation, and after the fact no statistics are kept, other than in cited research studies, on those that might otherwise have sought care elsewhere.

2. During triage, does staff use criteria to determine severity levels? If so what criteria are used?

The Triage process is definitionally a tool to determine the order in which patients should be seen. Note that “the order in which patients should be seen” is the only legitimate function of Triage; it is never a question of “whether this patient should be seen’. Under EMTALA, all patients presenting to the ED must have a screening examination to determine whether an emergency medical condition exists.

Various classification systems are used to assess the level of severity of the presenting problem.

Severity of Medicaid cases in the ED
Nonelderly Medicaid patients are using emergency departments at higher rates than nonelderly privately insured patients, often for serious medical problems that require emergency care. Triage acuity was determined by staff on the patient’s arrival in the ED and is measured as the amount of time within which a patient needs medical attention. Numbers of visits in 2008 are reflected per 100 enrollees.

Triage acuity of visit Medicaid Private insurance
Emergent (0-14 minutes) 5.6 3.6
Urgent (15-60 minutes) 18.1 9.6
Semi-urgent (1-2 hours) 10.4 5.5
Nonurgent (2-24 hours) 4.5 1.6
No triage/unknown 7.2 3.7

Reference: “Dispelling Myths About Emergency Department Use: Majority of Medicaid Visits are for Urgent or More Serious Symptoms,” Center for Studying Health System Change, Research Brief, No.23, July 2012

The Center for Disease Control’s publication “National Hospital Ambulatory Medical Care Survey: Fact Sheet, Emergency Department” includes data covering Triage status for all ED visits for 2009. The breakdown by category is as follows:

• Immediate: 2 percent
• Emergent: 10 percent
• Urgent: 42 percent
• Semiurgent: 35 percent
• Nonurgent: 8 percent
• No Triage: 3 percent

Thus, in this comprehensive survey, only 8 percent of all ED cases were characterized as “nonurgent” at the time of triage. The database was comprised of 21 percent of patients aged under 15 years old and another 16 percent aged 15 to 24 years. Medicaid or CHIP beneficiaries accounted for 29 percent of all patients in the survey. And while the report provides no definitions of the Triage categories, it is plain that the vast majority of ED presentations fell into a status that renders their categorization as potentially “unnecessary” as problematic at best, and at worst meaningless. Of further note is that the “Common reasons for visit” and “Common diagnoses” reported in the CDC database, while not limited to a pediatric population, show general concordance with those cited by Capital BC CHIP.

In many institutions, patients assessed as likely to remain “ambulatory” and “treat-and-release” are triaged to a “Fast Track” area, while those with higher acuity, e.g., with abnormal vital signs at Triage, or those with potentially high severity presenting complaints are directed immediately to an acute care bed. Only in truly exceptional cases would the Triage process itself result in the transfer of a minor problem to some lesser venue of care without the benefit of the full screening and stabilization evaluation mandated under EMTALA.

3. If Emergency Care is not needed, do you know if a lesser code is used to bill the visit?

All patients evaluated in an Emergency Department are subject to CPT codes appropriate for Place of Service (POS) 23. The range of CPT Evaluation and Management (E/M) codes extends from 99281 through 99285, and to Critical Care Services (99291-92), and Observation Services, in function of the intensity of the E/M service provided. Compliant coding requires that the patient record contain sufficient clinical information to sustain the particular level of service coded. “Lesser codes” would correspond to 99281 and 99282 coding which constitute less than 5 percent of all ED visits on average, however these codes make no determination and contain no implication relating to the phrasing “if Emergency Care is not needed”.

4. Do you think any of the following issues contribute to the patient rationale for/play a role in ED visits?

• Access to PCP and urgent care centers
• Patient perception in severity of illness
• Ethnicity/cultural issues

A number of these questions have been addressed in the Introduction and in previous answers.

In an important study (National Study of Barriers to Timely Primary Care and Emergency Department Utilization Among Medicaid Beneficiaries, Cheung PT, et al; Annals of Emergency Medicine: Vol. 60, No.1, 4-10, March 2012) the authors identified the increasing prevalence of barriers to timely primary care and their contribution to increasing ED utilization. In an analysis of 230,258 adult patients who participated in the 1999 to 2009 National Health Interview Survey, frequently identified barriers included: “Couldn’t get through on telephone” (4.0 percent), “Couldn’t get an appointment soon enough” (7.2 percent), “Waiting too long in physician’s office” (7.6 percent), “Not open when you could go” (3.8 percent), “No transportation” (7.6 percent). Identified barriers to care were consistently and more frequently found among Medicaid beneficiaries than among non-Medicaid patients.

The issue of “no transportation” may apply specifically to some urgent care centers more remotely located in comparison to urban ED’s which are often sited on public transportation lines.

Clearly, many ED visits result from lack of timely access which is especially prevalent on nights and weekends. In fact, other studies have shown that the ED is not only the venue of choice at such times, but often the only available site of care for all patients regardless of age, income level or insurance status. To quote the recent RAND study (“The Evolving Role of Emergency Departments in the United States”, Morganti et al, RAND Health, 2013): “Data from the Community Tracking Study indicate that most ambulatory patients do not use EDs for the sake of convenience. Rather, they seek care in EDs because they perceive no viable alternative exists, or because a health care provider sent them there.”
Primary care access is obviously related to the continuing (and worsening) shortage of primary care physicians in general, their limited “after hours” availability, and their unwillingness to participate in Medicaid programs in the first place.

On the subject of patient perception of severity of illness, there is plainly significant and largely unquantifiable variability in function of general educational level, degree of medical sophistication, and personal behavioral components.

As to “ethnicity/cultural issues”, while these may be operant to some degree, their potential role is difficult to analyze due to numerous possible confounding influences and are, in any event, likely of secondary importance compared to the principal barriers otherwise identified. A recent study (Hong R et al, The emergency department for routine healthcare: Race/ethnicity, socioeconomic status, and perceptual factors, Journal of Emergency Medicine, Vol 32, No 2, February 2007) found that after controlling for insurance status, income, employment status and education, neither race nor ethnicity remained a strong predictor of routine ED use. The authors note, “Race/ethnicity-based disparities in routine ED use were due to the confounding effects of socioeconomic status.”

5. What percentage of non-emergent patients use the ED as a matter of convenience/”first stop” to address their health needs?

This answer harks back to the factors cited in previous questions. In a major study by the New England Healthcare Institute (“A Matter of Urgency: Reducing Emergency Department Overuse”; A NEHI Research Brief, March 2010) the authors note that “ED overuse spans the entire population, irrespective of insurance status or age.” Elsewhere, Weber’s analysis (Weber EJ et al, Are the uninsured responsible for the increase in emergency department visits in the United States? Annals of Emergency Medicine, 2008 Aug: 52 (2): 108-115) demonstrated that the increasing rates of ED utilization have resulted from disproportionate increased visits by the insured, and that even having a usual source of care other than the ED made such patients actually more likely to utilize the ED as a point of care.

Again, the answer to this question is impeded by the fact that it is front-loaded with the ill-defined term “non-emergent” coupled to a request for a percentage answer that would itself be contingent on some agreed upon definition of that term.

6. Do you keep statistics related to:

• Diagnosis
• Time of day, day of week
• Any other factors for ED visits
• Review of the findings

PaACEP does not serve as a warehouse for such statistical information. All hospitals and individual ED practices collect such data elements, and there would be significant variability expected among institutions within the Capital BC CHIP catchment area.
In a published report, “Potentially unnecessary emergency room visits in upstate New York”, Excellus BC/BS defined potentially “unnecessary” visits as those that either “didn’t need care within 12 hours, or that did need care within 12 hours, but could have been treated in a primary care setting.” Of these cases, only 45 percent were seen during typical working hours of 9 a.m. to 5 p.m. while 46 percent were seen between 5 p.m. and 6 a.m. The highest percentages of potentially unnecessary visits were seen on Sunday (44.6 percent of cases that day) and Monday (44.5 percent). The large diagnostic categories (not limited to a CHIP population) were visits for back disorders, acute upper respiratory infections, ear infections and sore throats.

7. What barriers do you think are of significant importance to target to reduce unnecessary ED visits?

Refer to question 4.

In summary, the issue of the adequacy of resources within the primary care network remains the principal determinant, assuming there is agreement as to the definition of “unnecessary.”

8. What types of actions/interventions can be developed to reduce unnecessary ED visits?

In sustaining and perhaps augmenting the primary care network essential to the optimum functioning of the Capital BC CHIP program, perhaps no development offers more direct benefit than the Primary Care Incentive Program (PCIP) included in the provisions of the Patient Protection and Affordable Care Act (PPACA). By reimbursing primary care providers to Medicaid beneficiaries at Medicare rates, PCIP should provide strong financial incentives to see patients, expand their operational hours, and develop programs to improve access.

PaACEP is unaware of current operational standards of the Capital BC CHIP Program or what new initiatives might be in the process of development. That being said, by way of potentially useful interventions, we would cite the following:

• Expansion of the Capital BC CHIP primary care network: To what extent insufficiencies in the number of primary care providers contributes currently to potentially unnecessary ED visits is uncertain. However, the predictable expansion of CHIP enrollees through provisions of PPACA would seem to mandate a concomitant increase in the number of available providers.
• Increased hours of operation by primary care providers: Many parents of CHIP beneficiaries have regular full time jobs that make it difficult for them to bring their children in or benefit from phone consultations during working hours. In the Excellus NY database, expanding availability of primary care providers until 9 p.m. would have accounted for two thirds (67 percent) of those hours when patients sought ED care. Additionally, more robust weekend coverage would catch at least some ED visits; in the Excellus report, 43.3 percent of ED visits on Saturday were potentially unnecessary and 44.6 percent of those on Sunday.
• Enhanced availability for phone consultations: A significant number of ED visits might be resolved by thoughtful professional reassurance of the parents. After hour ED visits in the Excellus report showed 22 percent occurring between 5 p.m. and 8:59 p.m., 13 percent between 9 p.m. and 11:59 p.m., 11 percent between 12:00 a.m., and 9 percent between 6 a.m. and 8:59 a.m.
• Open access scheduling: This tactic involves setting aside designated provider hours for unscheduled office visits.
• Coordination of ED and Primary Care Services: Continuity of care for CHIP subscribers requires adequate communication between the ED and PCP. Notification of the PCP by the ED provider doubtless occurs in all serious cases. For more minor ED presentations, the presence of an enterprise-wide electronic health record would be expected to provide a shared patient information database, including recent ED encounters. Absent such a shared EHR, it is incumbent on Emergency Physicians to make the PCP aware of the CHIP patient visit either through transmitted copies of the discharge instructions or the medical record itself.
• More appropriate utilization of specialized services for frequent ED users: Some portion of “unnecessary” ED visits may relate to children and adolescents with mental health or substance abuse issues. The limited availability of follow up care in these categories may result in over utilization of the ED and improved coordination and increased availability of these services represent a potential opportunity for improvement.
• Increased availability of “retail clinics”; Walgreens, Walmart and other corporate enterprises have instituted walk-in services staffed by mid-level providers (Nurse Practitioners) to address a limited spectrum of clinical presentations. Capital BC should monitor this development with respect to both cost and quality of care parameters.
• Potential contribution of Telemedicine: This modality is coming into use in some ED’s and has potential to expand to other provider venues. Capital BC should encourage promulgation of this addition to the potential spectrum of patient care, and assure that existing contracts with its providers allow for appropriate reimbursement
• Improved coordination of care for children with chronic diseases: A number of ED visits result from children with chronic conditions whose management requires ED care only in the context of unusual or unexpected circumstances. Improved coordination of outpatient care options for these patients would eliminate potentially unnecessary ED visits.

9. Do you think it would be valuable to collaborate on this initiative with Capital Blue Cross and Primary Care Practitioners to further investigate/test interventions to reduce unnecessary ED visits?

Yes, potentially, although both funding and human resource allocation for such a product would require significant planning and coordination.

10. Do you know of any physician champions to assist in this initiative?

To be determined.

Finally it is noteworthy to cite the principal summary findings of the recent RAND Health report on the role of emergency medicine:

“Our study indicates that (1) EDs have become an important source of admissions for American hospitals; (2) EDs are being used with increasing frequency to conduct complex diagnostic workups of patients with worrisome symptoms; (3) Despite recent efforts to strengthen primary care, the principal reason patients visit EDs for non-emergent outpatient care is lack of timely options elsewhere; and (4) EDs may be playing a constructive role in preventing some hospital admissions, particularly those involving patients with an ambulatory care sensitive condition. Policymakers, third party payers, and the public should be aware of the various ways EDs meet the health care needs of the communities they serve and support the efforts of ED providers to more effectively integrate ED operations into both inpatient and outpatient care.”

Dr. Stunz is Co-Chair of the PaACEP Emergency Medicine Practice and Medical Economics Committee.