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Patient Safety in an Era of Value-Based Payment: What brings you into the Emergency Department Today?

Susan Nedza MD, MBA, FACEP
Chair, ACEP Patient Safety Task Force, 2001

Everyone remembers where he or she was the morning of September 11, 2001. I was at ACEP in Dallas preparing to present the report from the first emergency medicine patient safety task force report, “Patient Safety in the Emergency Department Environment” to the Board of Directors. The task force had been convened in response to the Institute of Medicine report, To Err is Human, Building a Safer Health System. (1)  The report was important because it clearly delineated the unique challenges to patient safety within the ED environment at a time when ED crowding was rapidly increasing.

As the aircrafts crashed into the World Trade Center buildings that morning, the College rightly shifted its focus externally and embraced its role in safeguarding the nation from terrorism. In spite of its importance, no one questioned putting the report aside for the moment. In fact, it wasn’t long before the specialty successfully embraced its role in patient safety within the emergency department environment as a part of a broader quality agenda. One might argue that the entire quality enterprise in emergency medicine can trace its roots to the report and to the organizations that participated on the task force.

In an era of healthcare redesign, we face new challenges in serving as the safety net. As value based payment models become a reality and care shifts away from the hospital, it is time that we recommit to patient safety in our expanding role as rapid diagnostic and treatment center for patients enrolled in these programs. It is time to move beyond the walls of the ED and the hospital to the outside environment.

The Shift to Value-Based Payment Systems
The move to a value-based payment system in health care is not new. What is new is the heightened commitment by the Obama administration to accelerate the transition from paying for volume to paying for value. On January 26, 2015, Health and Human Services Secretary Sylvia M. Burwell announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients. HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. (2)

On April 16, 2015, President Obama signed into law H.R. 2, the “Medicare Access and CHIP Reauthorization Act of 2015” (MACRA), which reforms Medicare payment policy for physician services and adopts a series of policy changes affecting a wide range of providers and suppliers. (3) MACRA includes clear financial incentives for health care professionals to choose to participate in Alternative Payment Models (APMs) over FFS reimbursement. In addition, MACRA also includes provisions and funding to expand the focus to outcome measures as opposed to process measures.

Both of these events will accelerate the move to a value-based payment system in health care across public and private payers alike.

The Tension Between Effective and Efficient Care- Early Results from the CMS Bundled Payments for Care Initiative (BCPI)
If one considers the value equation to be Value=Quality/Cost, it becomes evident these forces are inter-related and that a tension exists between the two. If value-based payment models predominantly focus on improving efficiency solely based upon cost, one might imagine unexpected consequences and threats to effective care. We need to be vigilant about finding the point of equilibrium. 

Effectiveness vs Efficiency diagram

The Medicare innovation project, Bundled Payments for Care Initiative (BPCI) provides us an opportunity to look at what the future may hold. The CMS recently published a report regarding the early findings from the initiative4. The report includes a comparison of the results for Model 2 (Acute and non-acute care combined into one episode of care) for non-spine surgical orthopedics participants in the first year of the program to a matched set of non-participating participants. The report noted that:

  • Changes in the anchor hospitalization length of stay began before the risk period began.
  • A statistically significant difference in the decline in average LOS for surgical orthopedics excluding spine episodes (risk adjusted). For participants, LOS declined from 4.6 at the beginning of the baseline period to 4.3 days in the first quarter of Phase 2. For the non-participants, LOS was 4.7 days declined to 4.5 days. The analysis suggested that the decline in LOS was associated with an increase in short stay transfers to post-acute care providers (SNF, Inpatient Rehab Facility (IRF) or Long Term Care Hospital (LTCH)
  • The rate of admission to PAC providers declined from 66%-47%, while holding relatively steady for comparison providers (62%-60% after risk adjustment.
  • The LOS number of days in SNF went down and days in Home Health (HHA) increased when compared to the non-participants. (not statistically significant)
  • Emergency department (ED) visits (without hospitalization) for BPCI surgical orthopedic excluding spine patients within 30 days of discharge rose from 6.9% to 8.7% from baseline to the intervention period. 
  • Average ED visits fell for the comparison group patients. The difference between these two patient groups is statistically significant.

What brings you into the Emergency Department Today?
These results point to trends that may signal a rise in adverse events in the post-acute care setting or home setting potentially due to shifts to lower intensive care. As the most likely re-entry point from these settings, emergency medicine is uniquely positioned to monitor adverse events that may occur when care shifts.

Potential areas of study and data collection:

  • What is the rate of readmissions after short-stay transfers to SNF facilities when the inpatient length of stay shortens?
  • Which adverse outcomes are associated with readmission that might have been avoided with a longer inpatient stay?
  • Which adverse outcomes are procedure-related, inpatient care related or related to lapses in safety in the external environment?
  • What happens to patients who are discharged to home with or without home health instead of a post-acute care facility?
  • How many patients arrive at an emergency department other than the one where their surgery was performed? (A soon to be published study puts the number at around 20%)
  • What is the cost of transferring patients who are being covered in a value based payment model to their original facility?
  • What is the rate across procedures for return visits to the ED over 90 days post-surgery?
  • What are the most frequent ED diagnoses associated with ED re-evaluation?

The Imperative for Emergency Departments Monitoring of Potential Adverse Events and Outcomes that result from Adoption of Alternative Payment Models
As ED visits are easy to measure utilizing claims data, payers are moving beyond measuring readmission rates to embracing measurement of ED visits that don’t result in admissions within these programs as well. It will only be a short time until CMS quality metrics will be promulgated about these visits. The critical question will be how will the system value these visits as appropriate or inappropriate. Unfortunately, payers and policy makers tend to view the ED visit or the readmission as an adverse outcome as opposed to recognizing the role the ED is playing in caring for patients when defects in care or care processes occur.

It is time to shift our focus to patient safety in the external environment. Why must we embrace this change?

For patients, we are once again in the position of taking on the role of “canary in the coal mine” and utilization of our services will serve as an early warning system regarding potential patient safety and quality issues that may occur when the cost of care becomes the main driver in care redesign.

For emergency departments, it provides us with the challenge to focus not on safety within our four walls, but once again to embrace our role as safety net providers in a new way as we care for those who are high risk for potential adverse events.

For the specialty, it provides us with a research and policy challenge, as we seek to position ourselves as a critical service that provides value when we treat patients and safely return them to the community after an adverse event.

In the end, the success of moving payment models from volume to value will depend upon emergency medicine recommitting to our role in patient safety. We will best serve our communities by providing the early warning system to policy makers, insurers and hospital leadership when things don’t go as planned.

  1. Too Err is Human, Building a Safer Health System. Retrieved from http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx
  2. Better, Smarter, Healthier: In Historic Announcement, HHS Sets Clear Goals and Timeline for Shifting Medicare Reimbursements from Volume to Value. (2015, January 26). Retrieved from http://www.hhs.gov/news/press/2015pres/01/20150126a.html.
  3. H.R.2 - Medicare Access and CHIP Reauthorization Act of 2015114th Congress (2015-2016) (2015, April 16). Retrieved from https://www.congress.gov/bill/114th-congress/house-bill/2/text.
  4. CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4: Year 1 Evaluation and Monitoring Annual Report. (2015, February). Retrieved from http://innovation.cms.gov/Files/reports/BPCI-EvalRpt1.pdf 


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