Some emergency physicians may perceive hospital quality-improvement initiatives as endeavors that were conceived primarily by academic types and committees and that have relatively little effect on how the emergency department operates on a day-to-day basis. That may have been the case a few years ago, but things are changing—and fast.

Several performance-reporting and incentive programs, some in place and others in development, will affect the emergency department in the year ahead, either directly or by a trickle-down effect of hospital performance-improvement pressures. For now, the dominant one is the Physician Quality Reporting Initiative (PQRI).

PQRI Program Will Expand

The 3-year-old program created by the Centers for Medicare and Medicaid Services has begun to pay out as promised, and payments to emergency physicians this year and next are expected to increase substantially from the average $1,000 bonus for 2008 reporting, said Dr. Michael Granovsky, course director of ACEP’s National Coding and Reimbursement Conference.

“Statistically, all other things remaining equal, we should expect that payments will be larger for 2009 and 2010 because we now have 12 months at 2%,” he said, up from the 1.5% bonus structure in place in 2008. If emergency physicians maintain consistent reporting rates, he added, they can expect a bonus of roughly $1,300.

It’s not just rising incentive payments—which may not even cover the investment in systems required to report—that will drive increased participation in PQRI, Dr. Granovsky predicts. Rather, it’s the growing perception that measuring performance confers benefits for the community and fosters pride on the part of hospitals.

Since PQRI’s launch in 2007, emergency medicine has emerged as a stellar performer among the specialties in reporting rates. On the community-acquired pneumonia (CAP) measures in 2008, emergency physicians tallied a 97% reporting success rate on antibiotic administration and assessment of mental status in pneumonia, and 96% on vital signs. Emergency physicians also performed well on three other emergency medicine measures: aspirin administration for myocardial infarction, ECG for chest pain, and ECG for syncope.

One reason ACEP members might not be fully in tune with developments in the PQRI program is that incentive funds flow through the hospital or corporate entity that employs them, not directly to emergency physicians. Also, because ED billing companies handle most of the measure-performance reporting activities, emergency physicians might be unaware that a bonus payment is tied to the government initiative.

“In a sense, we’ve had the opportunity to ride that wave on the backs of the billing companies,” said Dr. Dennis Beck, chair of ACEP’s Quality and Performance Committee.

As the PQRI program expands and emergency physicians’ participation increases, ACEP has, in tandem, continued to develop additional potential measures for CMS consideration. New PQRI measures submitted to the CMS by ACEP for the 2011 period include:

• Anticoagulation for acute pulmonary embolus patients.
• Confirmation of endotracheal tube placement.
• Severe sepsis and septic shock management bundle.
• Pregnancy test for female abdominal pain patients.

All four measures have been endorsed by the National Quality Forum, said Angela Franklin, Esq., ACEP’s director of quality and health IT. “We will continue to advocate for new measures,” she added.

Dr. Beck acknowledged that emergency physicians might not agree entirely with the measures submitted for inclusion in the PQRI incentive program. But they should understand that the College is taking a proactive stance in focusing on activities emergency physicians undertake that have demonstrated quality-improvement potential and can be readily measured.

“Some members may wonder who came up with certain measures and why, but they should understand that if ACEP doesn’t engage in this area,” other entities may develop measures that aren’t a good fit for emergency medicine yet involve ED processes, Dr. Beck said. “We have to recognize that while we are active in reviewing and submitting measures, we may sometimes be criticized because our 28,000 members aren’t going to agree on everything.”

ACEP’s involvement in PQRI may soon become more important in the overall quality-improvement landscape. One indication that the program is here to stay is the CMS’s recent announcement that it will publicly report physician performance. Reporting on Core Measures is already occurring at the hospital level, as part of the Medicare Hospital Compare program (www.hospitalcompare.hhs.gov). Several of those care process measures, from pneumonia care to post-MI and heart failure treatment, involve the emergency department.

It’s a natural extension, Dr. Granovsky said, to expand performance reporting to the individual physician level because PQRI utilizes provider tax ID numbers. In fact, the CMS recently announced that for 2009 PQRI submitted data, it will post on its Web site the names of physicians who satisfactorily reported on quality measures. The posting will follow tallying of 2009 incentive payments.

It’s not clear if data on emergency physicians will be posted on an individual or group-aggregate basis, Dr. Granovsky said. Reporting to date has been conducted on a group or department basis.

Hospitalwide Initiatives Will Increasingly Involve ED

The intensifying focus on ever-rising health care costs is spurring other government initiatives that will soon affect the emergency department. In the past, the Medicare Core Measures program applied only to admitted patients. But that’s expanding for 2011 to include certain outpatient measures, such as median time to ECG, median time to fibrinolysis, and use of abdomen and thorax CT, among others, that involve ED clinical processes.

Those CT measures, and another for lumbar MRI for low back pain, reflect the CMS’s efforts to reduce medically unnecessary resource utilization. One thing is for certain: As the CMS’s hospital quality-improvement programs expand, emergency physicians will be tapped to help their facilities meet new standards. And emergency physicians’ ordering patterns will come into the picture, as hospitals are increasingly pressured to report Core Measure performance.

“Hospitals are on the hook because if they don’t report [on Core Measures], they don’t receive their annual ‘market-basket’ update of 2%. So for hospitals on thin profit margins, it’s a major issue,” Dr. Granovsky said. “That’s why almost all hospitals are now reporting.”

Resource-consumption concerns also figure in another nascent CMS initiative: looking at total costs of care per episode and at the provider level. The CMS has started evaluating total provider-associated care costs for common episodes such as MI, and other quasi-discrete diagnoses are likely to follow.

Finally, emergency physicians and other admitting providers are now charged with documenting certain medical issues that are “present on admission,” such as urinary tract infections and pressure ulcers.

Ultimately, as the CMS scrutinizes 30-day readmission rates, emergency physicians’ roles in both appropriate inpatient length of stay and protracted stays resulting from faulty processes will figure in financial penalties to hospitals. Practically speaking, any effort to make care more efficient and cut unnecessary costs is understandable and even laudable, but there’s no question that these initiatives will affect ED practice patterns, Dr. Granovsky predicted.

“Ultimately, CMS is moving toward paying us [hospitals and physicians] on outcomes, which may soon mean that we’ll get to looking at things like the 30-day outcome and costs of a pneumonia admission,” he said.