Event recap: Next steps for integrated emergency medicine

An ambulance drives under a pedestrian bridge

Recently, the Richard Merkin Initiative on Payment Reform and Clinical Leadership hosted, “MEDTalk – Reimagining emergency medicine: How to integrate care for the acutely ill and injured.” Emergency medicine includes a range of care, from a child presenting with an earache and fever to car crash victims that require level 1 trauma care.

Dr. Art Kellermann, an emergency physician and Dean of the Hébert School of Medicine, Uniformed Services University of the Health Sciences, described the critical role the emergency department (ED) has evolved into: a treatment hub for diagnostic testing, risk stratification, primary care coordination, and a key decision-maker regarding hospital admissions. With this, policymakers, hospitals, and others have identified EDs as an important setting where valuable care is delivered and where interventions can be deployed to improve value — particularly those focused on reducing unnecessary and avoidable hospital admissions.

Dr. Jesse Pines, George Washington University emergency physician and a visiting scholar at the Center for Health Policy, moderated a panel focusing on ED health innovations that improve care quality and reduce costs and utilization. Panelists included emergency physicians from Maryland, Colorado, and Washington who discussed  a number of successful technologies, clinical pathways, and community-based models of care. Each organization has seen dramatic improvements and cost savings and each is planning additional initiatives to further expand measures that will improve value. Although local circumstances such as patient population needs and public policy drive many of the reforms, Dr. Nathan Schilcher indicated that physician engagement and support was critical to transform practices and offer better patient care.

The second panel, moderated by Dr. Mark McClellan, senior fellow and director of the Health Care Innovation and Value Initiative, centered on payment and other policy reforms to support integration and transformation in the acute care setting. The panelists agreed early on that financial alignment among payers, providers, and health entities is essential to ensure connectivity and coordination between EDs, specialists, governments, and authorities.

As team-based care models continue to become the norm among providers, alternative payment models should be used to reimburse physicians as well as for hospitals to reward specialists, primary care clinicians, and emergency physicians for working together. These innovations need to give providers the incentives and tools they need to provide cost-conscious care and to create systems to manage patients before, during, and after acute care episodes.

Dr. Jesse Pines concluded the MEDTalk by recommending that government, payers, providers and hospital entities take numerous actions. Broadly these included:

  • Engage acute care providers in developing clinical pathways and protocols to more efficiently utilize all team-members, improve outcomes, and decrease workload.
  • Develop systems to manage demand for acute care and post-acute care through telemedicine, telephone, or other asynchronous forms of communication to help manage high-cost frequent users.
  • Involve patients using patient-centered tools or value-based insurance design arrangements such that patients share in the savings that result in choosing the most appropriate and lower cost facilities and providers.
  • Engage emergency physician coalitions in delivery reform to coordinate efforts and disseminate information, to consider the entire continuum of care (i.e., prevention, management, and acute exacerbations), and to work systematically with data to evaluate the improvements in the intervention.
  • Expand quality measure development such as patient access and safety; whether the right care was delivered, how well coordinated it was, and the outcomes of care delivered for specific conditions; and measures of resource utilization that are actionable by providers. Many of the current ED measures use time as a denominator, which is not necessarily correlated with the desired triple aim transformation. 
  • Develop acute care payment model pilots through the Center for Medicare and Medicaid Innovation (CMMI) and private payer initiatives to reward providers for the value they provide through the new services and delivery efficiencies.
  • Partner with providers and facilities to ensure interoperability of health information across facilities, vital to a provider’s ability to deliver cost-conscious care.