Cooperating for better care.

emergency department

Tag Archives

The value of shared clinician-patient decision-making in the ED


“There is tremendous potential for driving value-based care in the emergency department through shared decision-making,” wrote Edward Melnick, M.D., assistant professor of emergency medicine at the Yale School of Medicine, and Erik Hess, M.D., associate professor of emergency medicine and research chair for the Department of Emergency Medicine at the Mayo Clinic, in a Health Affairs blog post: “As we continue to build incentives for value-based care into our healthcare system, we should not leave the ED out.”

The post reported on the value of decision-aids to encourage shared decision-making during a randomized control trial at six EDs across the U.S.  The pilot program used a decision aid, “Chest Pain Choice,” developed by Dr. Hess and his research team. Chest pain, a frequent cause of patient visits to the ER, often leads to unnecessary admissions. So Dr. Hess’s team wanted to know what would happen if clinicians took the time to inform patients of their options.

The results, they write, were increased patient engagement and a reduced number of  what turned out to be unnecessary hospital admissions for cardiac testing. Doctors Hess and Melnick see this as a “multibillion-dollar opportunity” to reduce waste in the healthcare system. The findings were so promising that the researchers are developing decision aids to discuss CAT scans for people with minor head trauma.

To read more, please hit this link.

Emergency department nurse lists what she wishes she had known


Arielle Pardes, R.N., writing  in Cosmopolitan magazine, elaborates on 10 things that she wished she had known before becoming an emergency department nurse.

To read her article, please hit this link.

ER physicians, wanting more more money, denounce Cigna ad



Some real emergency department physicians are angry about Cigna’s recent “TV doctors” ad campaign that uses humor to encourage Americans to get annual checkups. The real physicians want more money from insurers.

Cigna spent  $9 million on the campaign, which featured well-known actors, such as Patrick Dempsey and Alan Alda, making fun of their roles on medical shows. The American College of Emergency Physicians (ACEP) said that the money “would be better spent on patients” by increasing money to be paid to  emergency medical care.

The median annual emergency physician salary this year is $264,949,   with a range usually between $225,805-$310,341. U.S, physicians remain by far the highest paid in the world.

The ER physicians complain that insurers, by narrowing networks and raising deductibles and premiums,  are “exploiting” federal law that requires emergency departments to treat all patients, regardless of ability to pay. ACEP President Rebecca Parker, M.D., said.  “Emergency physicians are there for their patients 24 hours a day, every day of the year. We can’t say the same for the insurance industry.”

In May, the organization sued the Department of Health and Human Services over federal rules that  the group asserted would lead to insufficient payments  to  physicians to provide out-of-network emergency care. It has also done  research that indicates that insured patients delay care because of high out-of-pocket costs and subsequently end up in the ER.

To read a FierceHealthcare piece on this controversy, please hit this link.

Alternative payment models for emergency departments


As more healthcare facilities move away from a fee-for-service model, they may find it difficult to apply alternative payment models to the emergency department, frequently a safety net for patients who may be uninsured or unable  for other reasons to pay for care.

The ED also presents challenges because emergency care isn’t set up to follow patients after discharge, which makes it difficult for organizations to obtain a full grasp on care costs, according to new study published in the American Journal of Managed Care. Furthermore, ED doctors may order many  tests to rule out life-threatening conditions for patients, and so payment reform may lead to misdiagnoses as care patterns change, study authors note.

Emergency room  operations present big challenges to healthcare-payment reform. So  the  authors of a new study in the American Journal of  Managed Care examine how payment models under the Department of Health and Human Services’ four-category framework could work. They suggest that hospitals could, in FierceHealthcare’s paraphrasing:

  • “Connect the fee-for-service model to quality benchmarks. In this model, according to the study, EDs would still operate under a fee-for-service system, but they could earn additional payments by achieving certain goals, like improving patient satisfaction or better care coordination. Being paid directly for coordination of care can lead to better outcomes and lower costs, according to the study.”
  • “Build a new payment model based on fee-for-service. One way this could work is for providers to establish frequent-use programs, which cut costs by personalizing plans for patients with more complex medical, psychological and social needs. EDs could also offer bundled payments for more episodic conditions, which may reduce both costs and unnecessary readmissions.”
  • “Create a population-based payment system….  ED providers would be payed a fixed sum based on local population, previous emergency care use or projected costs across a certain window of time. Basing payments around population gives incentives to providers to address inefficient care and to prevent unneeded ER visits for acute care….”

To read the study, please hit this link.

To read the FierceHealthcare article on the study, please hit this link.

Calif. hospital to close after outpatient conversion plan fails


Saddleback Memorial, in wealthy San Clemente, Calif.,   will close May 31 because of falling inpatient volumes, in a sign of the rapidly accelerating national move to outpatient treatment for  the sort of patients who used to be expected to spend at least several days in the hospital.

Hospital officials said that there are often fewer than 10 inpatients at the hospital, and  inpatient surgeries have dropped to less than one a day.

In August 2014, MemorialCare, the parent system, announced plans to convert the 73-bed hospital into an outpatient medical campus and worked with state lawmakers to allow a satellite emergency department at the outpatient campus in San Clemente. However, the legislation failed in January.  Then the San Clemente City Council rezoned the San Clemente campus property to require hospital services.

“Without legislation to allow a satellite emergency department, and given this new restrictive rezoning that requires hospital services, the vision to convert the campus into a modern ambulatory care center cannot now be achieved,” hospital officials said.

Physicians, hospitals face ProPublica pressure


Yelp, the consumer review site and mobile app,  is expanding its pages with quality-assessment data  about physicians and hospitals from the nonprofit investigative-journalism group ProPublica.

The Sacramento Bee reports that ProPublica “will provide quarterly updates on health services at 4,600 hospitals, 15,000 nursing homes and 6,300 dialysis clinics in the United States, using data it has compiled from the federal Centers for Medicare and Medicaid Services. The information will include emergency department wait times, patient survival rates, incurred fines and physician communication ratings.”

Many in the medical community have complained that the profiles  can give an incomplete picture of hospital and physician performance.

Brian Jensen, regional vice president of the Hospital Council of Northern and Central California, told The Sacramento Bee that the profiles may not capture a complete picture of health services, even with the added quality metrics.

“I would caution that oftentimes, because of the complexities of health care and how it’s measured and all of the different services, it might not always transfer as easily to an application like Yelp as, say, your favorite Chinese restaurant. But consumers should have as much of a say as possible.”

However much physicians and hospital officials  dislike these review services, their numbers will increase.


New ambulatory vs. critical-care confusions


A look at the usefulness and reality of new federal quality and safety benchmarks this year, which are not leaving everyone happy.

Consider that, as Hospitals & Health Networks reports, a “major shift is taking place in Medicare’s Physician Quality Reporting System program, while the National Quality Forum is examining a group of relatively unpopular patient-safety measures for possible revision.”

”{S}ome physicians — including specialists who work in ambulatory care — continue to be concerned that they will have a difficult time finding measures that realistically can be met.

”Some of the worry is driven by changes to the measures that can be used in PQRS reporting. Emergency department physicians face a limited number of choices that can be applied to their specialty. ”

H&HN said that Catherine Polera, chief medical officer for the emergency medicine division of Sheridan Healthcare, noted that ”the Centers for Medicare & Medicaid Services removed some of the core measures that may have worked in an emergency department setting and replaced them with ambulatory care measures. The new measures ‘relate more to primary care than they do critical care.’

”Although primary-care measures have some application to the ED, ‘we see more trauma, we see more chest pain patients, more abdominal pain patients, and I’m not seeing those related measures,’ she says.”

‘”Determining the implications for a hospital is a little more complicated,” Akin Demehin, senior associate director of policy for the American Hospital Association (AHA), told H&HN {which is part of the AHA}. “‘It mainly boils down to whether a physician bills for the procedure or whether the hospital bills for the physician. Whoever submits the bill, generally speaking, is going to be responsible for the reporting.”’



The rise of the specialty emergency department


This Modern Healthcare article discusses the rise of the specialty emergency department, specializing in, particularly, geriatric cases as Baby Boomers head into old age

The magazine notes that ED visits, ”which are the starting point for about half of all hospital admissions, are continuing to grow, despite the dramatic decline in the uninsured rate brought about by the Affordable Care Act‘s insurance and Medicaid expansions.”

”In part that’s because the number of newly insured patients is growing faster than the number of primary-care physicians available to treat them.”
”Patients, meanwhile, have come to view the ED as a sort of high-tech, 24/7 urgent-care center.”

E.D. docs must think like primary-care physicians


Charles Reese, M.D., president of the ED Benchmarking Alliance, writes of the future of the emergency department:

“We like our specialty, in part, because it is so episodic. What you see is what you get, and the bottom line problem for that day is what we like to solve. But the new world will require a broader vision. We will need to pay more attention to what was going on before the patient came to us and, even more important, what will happen next. We need to see ourselves more as part of a system, and our plan must reflect the larger care plan and problem set of the patient as a whole. We need to think more (good grief) like a primary care provider!

“The danger for emergency physicians lies in a failure to adapt. Rather than being the poster child for ‘cost containment’ and inappropriate utilization, emergency medicine needs to show how we can add real value in the new healthcare paradigm.”


Contact Info

(617) 230-4965

Wellesley, Mass