The Future of Emergency Medicine Part II

David Meyers, MD, FACEP

The last newsletter contained a synopsis of the presenters prior to the break at the December 4th, 2013 “The Future of Emergency Medicine” conference sponsored by the journal Health Affairs.  Please see the May issue of the QIPS newsletter to get up to speed with “The Future of Emergency Medicine Part I” where leaders in emergency medicine such as Art Kellerman MD, FACEP and Jeremiah Schuur MD, MHS, FACEP gave their predictions on the future of emergency medicine.

Sara Rosenbaum, a health policy expert from George Washington University (GWU) began the session with an overview of the impact of EMTALA. Issues on the horizon include failure-to-screen vs poor medicine, futility, the obligations of specialty hospitals, and the application of the law to inpatients.

Maria Raven, MD, MPH, FACEP, an emergency medicine physician from University of California, San Francisco, discussed her New York City study characteristics of ED “frequent flyers”, especially Medicare and Medicaid patients, dispelling often incorrect beliefs about a small number of patients who account for high ED usage and costs. These patients have high rates of chronic disease, mental illness and social needs such as homelessness and lack of support systems. They also have high rates of primary care utilization. Predictive modeling works to identify individuals who would become frequent ED users. In the future, this population can be managed effectively by applying administrative data and multi-disciplinary teams to reduce their reliance on the ED, reduce their burden of disease and address the psychosocial needs which contribute to better health.

Jesse Pines, MD, MBA FACEP, from GWU’s Department of Emergency Medicine and Health Policy talked about cost reduction strategies for acute care from the perspectives of policy-makers and clinicians which assure high quality of care. Current focus is on ED flow and length-of-stay, penalties for missing an important condition, and patient satisfaction. In the future, prevention of illness/injury, better out-patient illness management, seat belt use, vaccines, etc. will have a big impact on costs. Care in the appropriate setting gets a lot of attention, but such delivery system changes have not been clearly demonstrated to reduce costs and improve health. Similarly, the patient-centered medical home may be effective but the full impact remains to be seen. Use of clinical decision support tools and rules to avoid unnecessary testing can help as can better end-of-life care and coordination of care. Disposition decision-making needs to be studied to determine how to make the best disposition. This will require taking full advantage of community resources. Payment reform away from the fee-for-service model may work, but it will be disruptive.  The key will be finding the balance for appropriate use of resources, i.e., the Goldilocks principle - not too much, not too little, but just right.

Several other speakers addressed the future of EMS systems, mass casualty event management, trauma systems and more.  I encourage you to visit the Health Affairs web site to listen to the presentations and read the articles in the journal for full details of the studies on which these presentations were based.


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