If the perception is that a visit to the ED represents a failure of the health care system, it sure makes it difficult for ACEP to assert that emergency physicians routinely provide valuable services to patients and insurers. Apparently, many policy makers hold this perception. It reflects the consequence of cost shifting (especially by hospitals) to cover the care of the under- and uninsured, which makes it appear that EPs are wasteful and inefficient. Health plans have aggressively promoted this mis-perception, using very distorted data. A good example is a recent study (“Many-ED Visits Could be Managed at Urgent Care Centers and Retail Clinics”) from the California Health Care Foundation , a very pro-managed care organization. Is it reasonable to compare the cost of treating strep throat in the ED versus the Urgent Care Center when the UCC turns away every patient with no money and no insurance? The attitude of the Health Plans is: “the uninsured are not our problem”, and would prefer to ignore our service to the uninsured in calculations of the value based proposition. The uninsured are not going away with Health Reform, and emergency physicians need to make sure that, in the value based purchasing calculation, no one takes for granted our mission to provide care to everyone regardless of ability to pay .
Fortunately, it’s really not all that difficult to challenge mis-perceptions about the value of ED care. The continuing growth in ED visits every year is perhaps the best testimony of the value that our patients ascribe to the care and service they receive in the emergency department. There are innumerable examples of the failure of our health care system in this country. A visit to the ED for acute appendicitis does not represent a failure of managed care, whereas a ruptured appendix that results from a patient being encouraged to wait until the morning to see their primary care physician certainly might.
With the demise of the idea of a national emergency care patient registry, it may not be easy to prove the value proposition for emergency medicine; but we don’t really need to prove our value so much as we need to substantiate it. First, we need to make sure that in comparing care in the ED to care in the office based practice; apples are compared to apples. Would all those assertions about ED patients not meeting the prudent layperson standard hold up if, for example, we could show that the incidence of peri-tonsilar abscess in patients with sore throat was three times the incidence of this complication in the PCP’s office? I think ED physicians all believe that children with fever in the ED are different than children with fever in the UCC, but try convincing a pediatrician. This will take some studies directed specifically at the value-based proposition, and that is where we should put the Emergency Medicine Foundation’s contributions to work. We heard at this year’s Council meeting about a compilation of hundreds of studies showing the value of good ED care (early antibiotic treatment in pneumonia, ED physician activation of cath labs, etc). This compilation needs to be translated into an easily digested summary with bullet points for the media and policy makers.
Although I am not a great fan of public relations, when you are faced with a perception problem, you need a well-financed, highly organized campaign. The ED has become the premier provider of diagnostic services and acute care; and in some EDs, half the patients who are discharged from the ED were sent to the ED by their PCP for evaluation and treatment. ED physicians provide four times as much charity care as any other specialty. These types of factoids need to be widely disseminated, because they change perceptions, and re-frame the value proposition. ACEP needs to provide the science, the sound bites, and perhaps the professional PR team; but this is not just a challenge for ACEP’s D.C. office, it is a challenge for every state chapter, and every emergency physician in every ED and every state. The next time you hear someone say how expensive ED services are, take the time to explain cost shifting, talk about 24/7/365, remind them about all the patients we manage to keep out of the ICU. With ACOs, bundled payments, and cost-containment, we are in a fight for the economic survival of our specialty.
Risk sharing is our third challenge. I will try to cover that in PART III.