How EDs Can Adapt When Quality Initiatives Take Hold

April 2010

By Bonnie Darves
ACEP News Contributing Writer

Editor's note: This article is the first in a three-part series that will look at how quality-improvement and performance-reporting programs are affecting emergency medicine now and their impact on EDs in the months ahead.

Emergency physicians who have a patient crashing in one bay, a wailing infant in another, and an ambulance heading in likely aren't focusing on what's being debated on Capitol Hill, discussed behind the scenes at the Centers for Medicare & Medicaid Services, or hashed out in health care companies' boardrooms.

But emergency physicians must become more conversant with the forces that are slowly but surely reshaping care delivery, because those activities are already affecting their own bottom line.

CMS' nascent Physician Quality Reporting Initiative (PQRI) is picking up speed, and incentive payments have begun to flow to emergency physicians. Hospitals already under pressure to report performance on Core Measures in the inpatient setting may soon see measures that target care and use of resources within the emergency department, not just throughput. Emergency physicians, in turn, will be asked to help hospitals meet the new standards.

The push for implementation of electronic health records (EHR) in all care settings, a part of the American Recovery and Reinvestment Act (ARRA), is affecting emergency medicine, too. ARRA provides cash incentives for implementation--but the "stick" comes in 2015, when hospitals and other providers that haven't installed EHRs incur penalties. In the interim, physicians working in emergency departments, which tend to be more health information technology intensive than other hospital areas, could serve a key advisory role.

Finally, as government and other payers move toward defining and reimbursing episodes of care--and developing accompanying payment schemes--emergency physicians' practice patterns will be scrutinized. That movement, part of the trend toward "value-based purchasing" of hospital services, will increase care-cost transparency and likely shift inpatient-facility choice patterns.

ACEP Takes the Lead 

ACEP has been working actively in all of those areas in recent years to ensure that emergency medicine's voice is heard and its concerns addressed. "Quality improvement and health information technology (HIT) have become so intertwined in recent years that ACEP has assumed a major role at the national level in the initiatives that do--or will--affect members," said Angela Franklin, ACEP's director of quality and health IT. "This is a fast-evolving landscape that will continue to have an impact on emergency medicine and physicians' practice lives."

ACEP helped develop the initial emergency medicine measures included in PQRI and proposed others for 2010, and the College has been instrumental in National Quality Forum activities that target emergency care. ACEP members have interacted closely with the Joint Commission, CMS, and the U.S. Department of Health and Human Services on QI programs affecting emergency medicine, and ACEP officials frequently appear before congressional committees on issues ranging from health reform to ED crowding.

On the HIT side, ACEP is heavily involved in standards-setting initiatives such as HL-7 and the Health IT Standards Panel, as well as the Certification Commission for Health IT (CCHIT) that is evaluating and certifying specialty-specific EHR systems. The College has engaged in several national e-health initiatives aimed at integrating data from disparate sources to improve care delivery and provide emergency physicians with better access to patient data.

"This is actually just a small number of the things that College members have been doing to ensure that emergency medicine is well represented in QI and HIT," said Dr. Brian Keaton, an ACEP past president, attending physician in the department of emergency medicine at Summa Health System in Akron, Ohio. An informatics specialist who directs emergency medicine informatics for Summa, Dr. Keaton also serves on the steering group of Connecting for Health, a major public-private collaborative working to improve information sharing across entities and care settings.

"I think that emergency medicine is ideally positioned to take a central role in HIT activities, in our own hospitals and as a specialty, because in our clinical world we tend to think in terms of systems and data integration," Dr. Keaton said.

What's Driving Change 

Regardless of how health care reform plays out, the push for higher quality, more coordinated care, and more efficient use of resources is reaching into the ED.

The big drivers, of course, are escalating health care costs and concerns that Medicare will be overwhelmed financially by the baby boomer generation's increasing use of medical services.

"Even if there's no 'global' health care reform, the way emergency physicians are paid will continue to change in the next 5 years--and performance reporting will be a key factor," said Dr. Michael Granovsky, course director of ACEP's Coding and Reimbursement Conference and president of the ED billing company MRSI, in Woburn, Mass.

For example, as part of its intensifying focus on utilization, CMS already is compiling cost data at the individual-provider level for discrete care episodes or procedures. Those data, and providers' comparison to other physicians in the same specialty, now are being communicated to the individual physicians. Industry observers expect that more public reporting of the data CMS collects may soon follow.

In the current regulatory environment, it's important to keep in mind that CMS "has both the ability and the mechanism to change how physicians, including emergency physicians, are paid," Dr. Granovsky said. PQRI is just one of the initiatives intended to spur better performance. Medicare and other national demonstration projects and benchmarking efforts--which mostly target the inpatient and ambulatory arenas so far--surely will make their way into the ED.

"Many of the broad-scale QI and performance reporting endeavors underway have had minimal effect on emergency physicians, compared to primary care and other specialties," Dr. Granovsky said. "But that's changing, and emergency physicians should prepare for that."

For its part, ACEP is preparing the specialty for the fast-emerging value-based purchasing (VBP) movement by identifying avenues for input and involvement at the national level. Last spring, ACEP convened the Value-Based Emergency Care Task Force to make recommendations to the Board of Directors regarding a way forward for emergency medicine. The VBEC recommendations included targeted activities in several areas, from episodes of care to data registries, care coordination, and potential joint initiatives with federally qualified health centers.

"Our challenge is to define where emergency medicine fits and to position itself in VBP initiatives," said Dr. Dennis Beck, chair of ACEP's Quality and Performance Committee.

On the positive side of the performance-reporting picture, emergency medicine has been ahead of the curve in reporting on PQRI measures, compared with other specialties.

For three of the four pneumonia measures, reporting rates topped 96%. Although annual PQRI bonuses have been modest--about $1,000 per physician for 2008--they may increase substantially in 2010 and 2011 as the 2% bonus structure fully replaces the initial 1.5% one, and as more measures are added in emergency medicine.

In a recent PQRI development, individual emergency medicine groups and physicians can now request their individual reports directly from CMS, which should prompt increased participation. The CMS bonus schedule is being modified to speed up delivery of incentive payments to physicians, so that it will be easier for doctors to tie their performance results to recent activities.

"I think it's a journey, and we're on our way," said Dr. Beck. "The literature does show that incentives have to be timely to drive behavior change, so changes in that area will be helpful to members."

EPs Will Play a Larger Role 

In the big picture of hospital-based QI and performance measurement going forward, emergency physicians already play a major role. But they should expect to be tapped to a greater extent in the years ahead, Dr. Beck said, to help hospitals improve their overall performance in areas such as hospital-acquired conditions and 30-day readmission rates.

"We will see more leadership roles taken on by all of us who are hospital-based--emergency medicine, radiology, anesthesia, and now the hospitalists," said Dr. Beck, who is president and CEO of Beacon Medical Services in Aurora, Colo.

As hospitals engage in more incentive-based payment initiatives, emergency physicians are becoming more involved at the "C-suite" level as chief medical officers or quality committee heads, he noted. There is also visible movement toward having emergency medicine groups partner with hospitals on quality initiatives.

"Emergency medicine is actually ideally positioned to play this active role in hospital QI, because we have such a long history of dealing with hospital-based quality," Dr. Beck said.

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