Emergency physicians are judged by a different criteria than many other types of physicians, which significantly impacts their incentives to develop a value-based, long-term plan for their patients. In a paper published in Annals of Emergency Medicine, Dr. Laura Medford-Davis, assistant professor in the Department of Emergency Medicine at Baylor College of Medicine, examines the varying incentives for physicians and how these need to change in order to advance emergency department care.
“Emergency department physicians have typically been incentivized based on a fee-for-service model, which provides reimbursement based on how many patients are treated, as opposed to a value-based approach, which would be more encouraging to developing a long-term treatment and follow-up plan for patients,” said Medford-Davis.
In order to succeed in changing the incentives structure for emergency care physicians, the emergency department itself needs to be viewed as a healthcare solution that can play a key role in developing coordinated care at a high value, not a place to be avoided.
In the paper, Medford-Davis outlines a strategy for improving the value of emergency care using the Merit-Based Incentive Payment System (MIPS) from the Medicare Access and CHIP Reauthorization Act, a value-based mechanism that ties a portion of fee-for-service payments to value using a composite physician performance measure. The physician performance measure consists of four categories, including quality, resource use, clinical practice improvement activities and advancing care information, all of which add up to 100 percent.
“Emergency care has been disconnected from a patients’ overall, long-term care,” said Medford-Davis. “When a patient presents at an emergency department, the physicians typically have no access to their previous medical history and records, but if we can integrate emergency care with primary and specialty care, emergency care has the potential to meet the needs of patients, providers and payers more than we realize, decreasing costs and improving quality of care.”
Looking at the four MIPS categories, Medford-Davis first outlines how to address quality, noting that emergency department quality is largely measured by speed of throughput and care for a small number of time-sensitive diagnoses.
“Emphasizing speed of throughput has the unintended consequences of increasing healthcare costs and fragmenting procedures from value, thereby limiting the time available for value-based care activities, like coordinating care or identifying social determinants of health,” explained Medford-Davis. ”To incentivize emergency medical services and hospitals to improve their coordination of care and the outcomes in an area, it would be valuable to correlate population-based outcomes with population-based measures.”
Because emergency medicine care providers often lack a full medical history when a patient is admitted, they are required to employ different strategies than primary care providers when it comes to resource use. Medford-Davis presents several strategies that can help improve resource use and value by gauging resource use by all physicians involved in making a diagnosis, which aligns emergency, ambulatory and inpatient providers to encourage coordination of care and shared responsibility. Other methods include creating bundled payment approaches and the use of computed tomography (CT) scans.
“Emergency care providers make decisions based on three factors, which significantly impact resource use,” says Medford-Davis. “They are judged on making decisions quickly, their patients likely have a higher baseline risk of serious conditions, and a CT scan can change the treating physician’s decision to admit the patient, which is one of the most expensive decisions they make.”
To alleviate this issue of resource use, Medford-Davis says new physician payment incentives must be established to more broadly consider the effects on quality of life, well-being and total cost.
To enhance approaches to clinical practice improvement in the emergency setting, Medford-Davis proposes incorporating emergency department-based case managers, social workers or health navigators to assist with care coordination and alleviate some of the time constraints faced by emergency physicians, thereby substantially improving the value of care. Medford-Davis also stresses the importance of the seamless transition of patients from the emergency department to another hospital or institution, should they require care elsewhere.
Finally, because many visits to emergency departments are unplanned and outside of primary care provider hours, emergency departments face a challenge with communication of patient records.
“Timely communication of patient clinical data between providers can help reduce costs by decreasing testing and admission while simultaneously creating a more patient-centered experience,” said Medford-Davis. “Reliably available patient data and exchange of health information is a promising tool for unscheduled care and coordination, and encouraging emergency departments to alert the patient’s primary care provider at check-in can advance the use of health information technology in the emergency environment.”
“MIPS is the first step in changing the incentives structure, and it can serve as a framework for new opportunities to generate greater value in the emergency setting. I hope to see the shift continue to gain momentum, but until the strict fee-for-service method is viewed as obsolete, change will be difficult,” said Medford-Davis.