A few months ago, I announced that I was teaming up with the Geriatric Emergency Department Collaborative (GEDC), as well as West Health and The John A Hartford Foundation, to work on a series of blogs that delve into the concept of value-based care in emergency medicine.
The first blog in the series, posted in May, provided an overview of value-based care and highlighted some of the initial work being done within emergency medicine to improve the quality of care delivered and lower costs. We particularly focused on the advent of geriatric emergency departments (GEDs), which incorporate specially trained staff and assess older patients in a more comprehensive way. In 2018, ACEP launched the Geriatric Emergency Department Accreditation program which established criteria for three levels of GED accreditation. There are now over 340 GEDs in the US, along with a growing presence internationally.
Now that you have a general overview of value-based care, let’s dive deeper and discuss some of the challenges we face moving in this direction and what we collectively need to do to advance this movement.
As avid readers of Regs and Eggs well know, there are no alternative payment models (APMs) that you as emergency physicians can directly participate in, and ACEP created an emergency medicine APM called the Acute Unscheduled Care Model (AUCM) to fill that gap. Unfortunately, the AUCM, or even elements of the AUCM, have yet to be fully embraced. Why is that? Also, why haven’t existing APMs, like accountable care organizations (ACO) initiatives, really tried to engage you and your emergency physician colleagues to help lower overall costs and improve quality?
As someone who worked at the U.S. Department of Health and Human Services (HHS) for eight years and was involved in the development of many of the initial APMs launched by and within the Centers for Medicare & Medicaid Services (CMS), I can say that one major barrier to promoting value-based care in emergency medicine is the perception of an emergency department (ED) visit. I also can say with confidence that one of the main goals of each CMS APM is to eliminate unnecessary ED visits, and if a patient participating in the APM winds up in the ED, that is considered a failure. In fact, when the founding chair of the GEDA Board of Governors, Dr. Kevin Biese, had an opportunity to meet with the former Deputy Secretary of the Department of Health and Human Services (HHS), Eric Hargan, to discuss the merits of Geriatric EDs, five minutes into the conversation the Deputy Secretary looked sideways at Kevin and said “Haven’t you heard that we don’t want anyone to go the ED?”-- to which Dr. Biese replied, “How is that working for you?”
While reducing unnecessary ED visits is a worthwhile objective, it should not be the end goal. As Dr. Biese astutely pointed out to the former HHS Deputy Secretary, there are roughly 150 million ED visits a year— it is impossible to avoid them all. Rather than considering an ED visit a failure, we need to change the perception and convince policymakers and other stakeholders to instead to view it as an opportunity. As you all well know, emergency physicians are the gatekeepers to hospitals. You all decide whether a patient should be admitted to the hospital, placed in observation, or safely discharged. Roughly 60 percent of all Medicare hospital admissions come through the ED.₁ There are also great financial implications from these decisions. An average Medicare admit costs $14,900 more than a discharge.₂ Health care systems truly cannot get a handle on health care costs without engaging the ED.
As Peter Parker (a.k.a., Spiderman) is told, with great power comes great responsibility. I would argue that emergency physicians have both great power to influence patient care and a great responsibility to make the best disposition decision on behalf of their patients. But even with great power and great responsibility, you all lack the financial incentives, the tools, and the resources to channel that power and responsibility to improve health care quality and reduce costs. In all, there is an inherent disconnect between the role that you play in our health care system and your overall ability to engage in value-based care.
So, like I said before, let’s use ED visits as an opportunity to lower costs and improve quality by engaging emergency physicians. And how do we shift that narrative from an ED visit being a failure to instead being an opportunity?
As emergency physicians, you can do so by showcasing the efforts you take to successfully transition patients home. Policymakers in turn should realize the potential for cost savings if patients are safely discharged home rather than admitted. If given the financial incentives, tools, and resources that go along with being part of an APM, you can connect or reconnect patients with their primary care providers and ensure appropriate follow-up care once they are discharged. That way, patients who come to the ED (again, we can’t avoid every ED visit) don’t wind up right back in the ED once they are discharged and/or later admitted to the hospital.
In order for you to successfully transition complex patients home, working with multidisciplinary coordinated care teams while a patient is in the ED is key. The use of multidisciplinary coordinated care teams is a cornerstone of GEDs and can be replicated to care for any complex patient population.
Multidisciplinary coordinated care teams work in a GED through identifying underlying geriatric syndromes (like falls, polypharmacy, delirium and dementia) as well as social vulnerabilities (like food insecurity or elder mistreatment) through enhanced screening processes and then intervening upon the findings of the screenings while communicating with the patient’s primary care physician.
Multidisciplinary team members (such as transitional care nurses, social workers, physical therapists, pharmacists, etc.) help provide enhanced care and community connections for the most vulnerable older adults, as well as focus on transitions of care. Team members can reach out to the local Agency on Aging, services like Meals on Wheels, physical therapy providers and home health agencies, or can help facilitate direct to Skilled Nursing Facility or hospital-at-home transfers when an in-patient admission is not required.
Most GEDs have standardized work flows and process maps for incorporating multidisciplinary teams into ED care. These work flows make transitional care nurses and social workers proactive rather than reactive and dependent upon the provider to know to activate a multidisciplinary team to respond to the unique needs of the patient.
The impacts of the use of multidisciplinary, coordinated care teams and specifically transitional care nurses, although nascent, is compelling:
- Up to 16.5% reduced risk of hospital admission₃
- Up to 17.3% reduced risk of readmission₄
- $3,202 savings per Medicare beneficiary after 60 days₅
The use of multidisciplinary, coordinated care teams in GEDs has shown to reduce the risk of hospital admissions, readmission, and reduce costs. If you are looking to make the first steps towards value-based care, building multidisciplinary, coordinated care teams and tracking outcomes, like avoided admissions, are great places to start.
Thus, to sum up, I would like to make this blog a call to action both for you as emergency physicians and for policymakers. It’s time to truly realize the potential of emergency physicians to influence health care quality and cost and engage them in APMs and to change the perception of an ED visit as a failure into an opportunity to change the patient’s care and cost trajectory.
Before concluding, I want to give you a preview of what we’ll focus on in the remaining blogs in this series. In our next blog, we will describe some best practices for integrating value-based care into contracts with health plans. As we have stated, not many emergency physicians are engaged in value-based care initiatives, but some of you—especially those of you in multi-specialty practices—are doing it already! And those emergency physicians can share insights into how they were able to negotiate value-based contracts and what their experience has been trying to meet the overall goals and objectives included in those contracts. Next, we’ll discuss some potential ways to engage in value-based care outside the four walls of the ED, including describing some treatment modalities, such as telehealth, that have been utilized and some initiatives that have already been tested. Finally, we may write one additional blog that will wrap up all that we’ve discussed and assess the future landscape for value-based care in emergency medicine.
We hope to publish the remaining blogs in the blog series over the next several months. In the meantime, rest assured, you will still get your weekly filling of regs and eggs on other regulatory issues affecting you and your patients!
Until next week, this is Jeffrey saying, enjoy reading regs with your eggs!
- Gonzalez Morganti, Kristy, Sebastian Bauhoff, Janice C. Blanchard, Mahshid Abir, Neema Iyer, Alexandria Smith, Joseph Vesely, Edward N. Okeke, and Arthur L. Kellermann, The Evolving Role of Emergency Departments in the United States. Santa Monica, CA: RAND Corporation, 2013. https://www.rand.org/pubs/research_reports/RR280.html. Also available in print form.
- Moore BJ (IBM Watson Health), Liang L (AHRQ). Medicare Advantage Versus the Traditional Medicare Program: Costs of Inpatient Stays, 2009–2017. HCUP Statistical Brief #262. August 2020. Agency for Healthcare Research and Quality, Rockville, MD. hcup-us.ahrq.gov/reports/statbriefs/sb262-Medicare-Advantage-Costs-2009-2017.pdf.
- Hwang, U., Dresden, S.M., Rosenberg, M.S., Garrido, M.M., Loo, G., Sze, J., Gravenor, S., Courtney, D.M., Kang, R., Zhu, C.W., Vargas-Torres, C., Grudzen, C.R., Richardson, L.D. and (2018), Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use. J Am Geriatr Soc, 66: 459-466. https://doi.org/10.1111/jgs.15235
- Dresden SM, Hwang U, Garrido MM, Sze J, Kang R, Vargas-Torres C, Courtney DM, Loo G, Rosenberg M, Richardson L. Geriatric Emergency Department Innovations: The Impact of Transitional Care Nurses on 30-day Readmissions for Older Adults. Acad Emerg Med. 2020 Jan;27(1):43-53. doi: 10.1111/acem.13880. Epub 2019 Dec 1. PMID: 31663245.
- Hwang U, Dresden SM, Vargas-Torres C, et al. Association of a Geriatric Emergency Department Innovation Program With Cost Outcomes Among Medicare Beneficiaries. JAMA Netw Open. 2021;4(3):e2037334. doi:10.1001/jamanetworkopen.2020.37334