Asking the Wrong Question About ER Care

Recently, Drs. Lee, Schuur, and Zink published an article in Annals of Emergency Medicine that detailed three different approaches to estimating the percentage of total national health care costs that were expended for emergency department care.  The statement in this article that most health care journalists have picked up on is related to the authors’ assertion that spending on ER care could amount to as much as 10% of national health care budget.  This clashes significantly with ACEP’s assertion that these costs represent just 2% of overall health care outlays.  However, the key takeaway from this article is that we really don’t have accurate models and reliable data to be able to determine with any certainty just how much money is spent on ER care in our country.  I even have doubts about the accuracy of the $2.6 trillion denominator (total costs for all care) used in calculating this percentage.  In any case, the authors assert that “rather than minimize the issue of cost, we should recognize the economic and strategic importance of the ED within the health care system and demonstrate that costs are commensurate with value.”   I am not sure how it will be possible to demonstrate the true value of emergency department care if we can not accurately determine the true cost of this care; but I agree with the authors that the question of how much is spent on ER care is not nearly as important as the question of how to maximize the value of this spending.

The urge to under-represent the financial impact of ER care on our health care budgets is directly proportional to the over-exaggeration of this financial impact by health plans, government health care programs, legislators and policy makers.   I have often wondered why, with so much wasted spending in health care, there is a disproportional focus on ER care spending.  In a prior post, I pointed to this pie graph that shows that eliminating so-called ‘unnecessary ER care’ is but a small portion of the potential savings we might be able to achieve in overall health care spending.  No doubt that ER care is involved in several other pieces of this pie, but the brunt of the pressure being applied to ER care providers (particularly emergency medicine physicians and hospitals) is related to avoidable ER visits, unnecessary diagnostic testing, and the high costs and charges (mostly hospital related) that come into play in ER care. 

The most recent journalistic assaults on ER care  in the WA Post and NY Times often cite other news articles about the high cost of health care throughout the system like this one in Time Magazine, and fall closely on the heals of complaints by CMS about the inappropriate up-coding of ER physician claims, and by patients about outrageous hospital charges.  Unfortunately, many of the studies quoted in these news articles, including the one that prompted this blog, rely on data in the Medical Expenditures Panel Survey, which I previously criticized as terribly flawed survey drivel.  As a result of this assault, ACEP, the American Hospital Association, and physicians and hospital administrators in your local hospital, find themselves on the defensive; and are searching (if not frantically, at least deliberately) for ways to highlight the value proposition for emergency care services.  Although it is possible that if most ER patients had to pay for their ER care out of pocket, these patients would avoid the ER like the plague: the fact is that the number of ER visits in this country continue to grow by the millions every year.  You would think that with this many patients and families ‘voting with their feet’, journalists and policy makers and even researchers would temper their inclination to point the fickle finger (sorry) at ER care with some recognition of the importance of these services, and the perception of the value and necessity that so many of our citizens place on high quality, readily available ER services.  Unfortunately, the good PR that is all too often generated by the incredibly effective, even heroic, ER care response to tragedies like the Boston Marathon bombing seem to fade in the public consciousness as quick as the next news cycle. 

I agree with the authors of the Annals article, cited at the beginning of this post, that rather than trying to refute the allegation that ER care is too expensive, ACEP and the AHA need to focus on why ER care is so valuable to our communities.  As emergency physicians, we need to find ways to get more and better ER care at lower costs, and prove to policy makers, legislators and health plans that investing in quality ER care and the maintenance of the emergency care safety net is both a sound investment, and a critical one.   ACEP is certainly making an effort here, both on the PR front and in programs like those of ACEP’s Cost Effective Care Task Force and Delphi Panel, which I have the honor of participating in.   We undoubtedly need more and better data on the costs and outcomes of ER care, but we cannot wait for ACEP leadership to turn the PR tide, or for elaborate databases to materialize and academicians to find the answers:  these issues must be addressed by working emergency physicians and emergency department directors in each and every ER in the country.   The best ways to highlight and enhance value are nearly always home-grown.

Share/Bookmark

Grace under fire.

Acts of terrorism in the homeland tend to bring out the best and the worst in us; which makes it all that more important to try to find the right role model to emulate in responding to these major insults to our collective national consciousness.  You might think that we should first look to our political leaders, but you have to be selective.  Hardly anything politicians say gets me inspired or riled up anymore:  I have come to accept that much of the time most politicians are grandstanding when there is a microphone in their face, or pandering to their ‘base’ (especially if their district has been skillfully gerrymandered).  This time, however, NY State Senator Greg Ball, in an interview on CNN, managed to turn my stomach with his statement in support of torturing the Boston Marathon bomber ‘if it could save the life of innocent Americans’.  Never mind that the perpetrator is still intubated, or that torture has not been proven to deliver particularly reliable intel, or that this man deserves to be convicted for terrorism as well as murder via WMD:  to hear this Senator, or Sean Hannity, or any of the other advocates of torture rant about applying this savage art to a patient in a hospital with a tube in his trachea was just too disgusting.  They have become what they hate.

As a physician, and a humanist, to me the idea of torturing even the most heinous criminal in the hope that this might save lives just seems to cross the line into depravity.  I suppose there are instances where even a humanist could justify torture:  the ticking time bomb with hundreds or thousands of lives at stake is the exception that perhaps illustrates that in some circumstances we must break the rules.  The problem is: who decides when the circumstances justify breaking the rules, and where is the line crossed?   On hearing these calls for the use of torture, and the ticking time bomb justification, the first thing that came to mind was whether torture would be justified to save the life of a kidnap victim.  How about a bus-load of kidnapped children?  Would it be ok to use torture if the suspect was not a US citizen?  What if he just had a green card?  How about if he was 16 instead of 19 years old?  Talk about a slippery slope.

In contrast, I also saw an interview with one of the victims of the Boston bombing, Adrianne Haslet, a 32 year old dance instructor who lost her lower leg in this terrorist attack.  If anyone had a right to be vitriolic, to rail against her attacker, to inveigh torture and worse, she did.  Instead, she was inspiring, determined to make the most of her life going forward, vowing to run her first marathon, in Boston, on her yet to be purchased prosthesis.  ‘Inspiring’ just is not an adequate term here: she was and is amazing (you must see the video of her interview – here).  Adrianne’s employers set up a foundation to help her cover her medical expenses and the cost of a prosthesis, and I urge you to contribute.  The contrast between her comments and Senator Ball’s comments was so stark that it left me wondering if it might be possible to get the two of them together in the hope that the Senator might learn something about grace under fire and how to set a good example.    I hope no one ever asks Adrianne if she would have been ok with having these terrorists tortured if it might have saved her leg, but my guess is that for her it would be a difficult question to answer.  Perhaps she will decide that in addition to returning to dance, she might consider going into politics, and show us all how that job should be done.  Clearly, we need some better role models.

Share/Bookmark

Coverage Denied: not indicated under Choosing Wisely rules

 When the American College of Emergency Physicians (ACEP) decided not to join the Choosing Wisely campaign, I was among those who expressed disappointment with this decision, in part because I have long been a proponent of efforts to encourage more cost-effective care in the ED.   In fact I had already independently done a significant amount of work in the development of such strategies.  I recognized that there were legitimate concerns about participation in this campaign, but felt that overall ACEP had an obligation to become ‘part of the solution’ to the unsustainable growth in health care expenditures in our Country.  When ACEP’s Board reversed itself on Choosing Wisely, I thought this was a thoughtful and appropriate decision, and still do.  That being said, I do have concerns about the language that most of the medical specialty societies participating in Choosing Wisely are using in their cost-effective care recommendations.  Using a ‘do this’, or ‘don’t do that’ format is too prescriptive, and more importantly, this format lends itself to misuse by third party payers as justification for denial of coverage.

The CW campaign states that the effort is “focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary”.  This is a valid patient-centric approach that relies on shared medical decision-making “to help make wise decisions about the most appropriate care based on a patients’ individual situation”.  It also implies that these recommendations are just that: recommendations, not absolute dogma.  Mr. John Held, from the ABIM Foundation, has indicated that these lists “do not all need to be in the do this or don’t do that format, however most of them are.  It should also be noted they are not “never do” events, and are backed by evidence and guidelines when such tests or procedures should be used.”   Clearly, ABIM recognizes the possibility that third party payers could use these lists and the evidence behind them to deny coverage and payment.  By claiming that CW does not intend for these recommendations be considered ‘never-do events’, and that they are based on guidelines; it appears that ABIM hopes to deter the linkage of these lists to payment denials. Unfortunately, the inflexible language used in most of these CW recommendations makes it that much easier for payers to do just that.

I still strongly support the effort, but I am very concerned that the dogmatic ‘do this, don’t do that’ language used in these recommendations will effectively hand over the keys to medical decision making to government and third party payers.  The typical approach used in these Choosing Wisely recommendations looks like this one, from the American College of Physicians:  ‘Don’t obtain imaging studies in patients with non-specific low back pain.” I would have preferred language like:  “Imaging studies are not generally indicated in patients with non-specific low back pain.”   The latter leaves more room for clinical decision-making, the former invites payers to deny coverage first, and dispute the decision later, especially when the test is negative.  Even though ACP does go on to define non-specific low back pain as: “pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination”, it is sometimes difficult to attribute low back pain to a specific disease or spinal abnormality without imaging, especially in patients who are elderly, or are demented, or have other seemingly unrelated conditions, like diabetes. 

Some physicians may feel that using this alternative, more elastic language is hedging, and that using the more directive language might give physicians liability ‘cover’ when they decide not to order a test, or might provide physicians with stronger moral suasion in promoting a cost-effective care approach with patients or family.   There may be some validity to these arguments, but I am not persuaded.  I don’t believe that dogmatic mandates for care provide any significant protection from malpractice liability.  Getting sued for malpractice is a function of poor outcomes, bad luck, and negligence, and a good plaintiff’s attorney can spin these situations their way no matter how the recommendation, guideline, or mandate is worded.  I do believe that shared decision-making is a good thing, but that physicians generally do not need to rely on inflexible mandates to help patients arrive at the best decision:  guidelines will suffice.  What I do not want to see is physicians having to say: “since CW says ‘don’t do that test’ your insurance plan is not likely to pay for it”.   In my mind, that is not persuasion, it is coercion.

I also believe that physicians would be more willing to adopt a recommendation that advises them of best evidence rather than one that delivers a medical edict.  For the CW Campaign to succeed, it is not necessary to completely eliminate any use of these tests and treatments when indications for them are questionable.  A significant reduction in their use would go a long way towards solving the current health care financing crisis.  Furthermore, the development of these lists is predicated on best evidence, not on scientific certainty.  How many Level A guidelines that have been adopted in one decade are abandoned the next?  Using  ‘do this, don’t do that’ language turns a recommendation into a directive; and leaves less room for the uncertainties in the art of medicine, or the nuances in the application of exceptions to the rule or the clinical decision tools that are built into many of the strategies in the CW lists.  These clinical decision tools are never absolute:  they inevitably rely on clinical judgment. 

Using less dogmatic language in the Choosing Wisely recommendations may not dissuade payers from attempting to use these lists to deny coverage or exert undue influence on these decisions; but it will allow physicians and specialty societies more leeway to object to these denials, and keep these payers from beating us, and our patients, over the head with our own ‘best evidence’.   The CW Campaign may wish to reconsider its use of overly prescriptive language, especially as payers and employers begin to use these lists to justify denial of coverage when the decisions made by physicians and their patients appear to run contrary to CW recommendations.  I believe CW will soon be incorporated not just into pre-authorization criteria for elective tests and procedures, but also into benefit design, and eventually into retrospective medical necessity determinations.    Don’t be surprised to see code-modifiers developed to indicate when a test is performed at the insistence of the patient, leading to higher co-insurance payments or retrospective denials applied by payers or employers.  Perhaps my concerns are overblown, but there are already pretty clear indications that this is exactly what employer funded, commercial, and government insurance plans intend to do.

Share/Bookmark

The newest fashion in ER scrub suits.

Recently I heard Dr. Sanjay Gupta give a talk at the Marin Speaker’s Series.  He covered a lot of ground (he is CNN’s most traveled correspondent), and one of the issues he discussed was altruism.  He cited a study linking altruism to neural activation of a pleasure center in the brain.  This study substantiated his belief that altruism was a fundamental attribute of human nature, something he has seen consistently and repeatedly on every continent.   This observation segued into the role of altruism in the practice of medicine, and this in turn led me to consider the particular role of altruism in the practice of emergency medicine. Although I am not inclined to believe that altruism is a universal human trait, I do think altruistic tendencies play a role in the personal choices we make and the walks of life we tend to follow.  Medicine is obviously just one of many professions that offer opportunities to exercise the altruistic muscle; and unfortunately opportunities to satisfy our baser instincts as well.  Certainly, emergency physicians (EPs) do not have a corner on the altruism market, but there is no question in my mind that altruism plays a major role in the practice of emergency medicine.

Webster defines altruism as: (1) unselfish regard for or devotion to the welfare of others, and (2) behavior by an animal that is not beneficial to or may be harmful to itself but that benefits others of its species.   This is distinguished from devotion to loved ones or friends;  it is devotion to the welfare of people you may not know, or ever expect to see again.  Altruism is unselfish in that it is not done in the expectation of a return on the investment.  In fact, there may be considerable sacrifice involved.  Yes, yes, I know that emergency physicians make a pretty good living; and perhaps I and many other EPs would never have considered EM or any other medical specialty if the compensation end of it wasn’t reasonably attractive.  Considering ‘Doctors Without Borders’ ducking bullets in the Sudan, physicians who volunteer their services for several weeks every year in the poorest towns in Guatemala, or even the docs who practice primary care in under-served and under-insured rural America:  how can I possibly justify highlighting emergency physicians in a discussion of medical altruism?  Believe me, I have nothing but respect and admiration for the aforementioned volunteers and committed practitioners, and I have no doubt that the general public shares those sentiments.  I just wish that, when the practice of emergency medicine came up in general conversation, people would go beyond thinking ‘Wow, that must be stressful’ or ‘You must see a lot of gunshot victims’ to recognize the full implications of ‘they are the safety net for a beleaguered health care system’ and ‘they care for everyone regardless of health insurance or ability to pay’.

Now I readily admit that physicians have lost their altruism luster in the last few years.  Emergency medicine is no different.  Some ER groups overcharge, and aggressively rely on the out-of-network / balance bill play to pad revenues.  EPs do tend to over-test, are in too much of a rush at the bedside, and prescribe when they should be giving reassurance, advice, and encouragement.   Emergency care is expensive; and though shifting costs to make up for uncompensated care losses may be a necessary evil, it is still a kind of unauthorized and sometimes regressive form of taxation.  Nonetheless, I still believe that the thing that attracts many of the best and brightest new medical school graduates to Emergency Medicine Residency programs is the same altruistic inclination that keeps older EPs coming back to do another Friday night shift in the ER.

Some physicians volunteer, many don’t.  Some physicians provide a significant amount of charity care, others hardly any.  Some physicians are very selective about the patients they are willing to treat, while quite a few open their office or operative schedules to whomever comes their way.  However, EVERY emergency physician, no matter where they practice, treats EVERY patient who comes to the ER, and provides care to a substantial number of patients that most physicians prefer to avoid altogether:  the dangerously combative sociopath, the disorderly drunk, the abusive addict, the neglected, demented, odoriferous, impacted, foul-mouthed, and incredibly foolish.  Emergency physicians as a group provide more charity care than any other specialty, to patients they rarely get to know, and 60 percent of the time they do it on nights, weekends and holidays.  EPs are among the first to be exposed to contagious diseases in an epidemic, and will be among the first to treat those who are contaminated with lethal radioactive materials or toxins in a terrorist attack.   The stress of managing severe trauma or dealing with parents devastated by sudden infant death syndrome is not the only thing that contributes to burn-out for emergency physicians:  it is the taxing, and under-appreciated, day in and day out role of the overwhelmed safety net provider trying to plug the gaps in a failing health care system fraught with unrealistic expectations, threats of malpractice suits, and the constant exposure to barely controlled chaos that makes ER practice so challenging.  It wasn’t that long ago when EPs were recognized by legislators and policy makers as the ‘white hat’ doctors.  Now, EPs are seen as overutilizers of expensive resources, whose efforts to reduce ER wait times and improve patient satisfaction in the ED are derided because these things ‘encourage Medicaid patients to use the ER inappropriately’.  Inexplicably to most emergency physicians, and despite significant advancements in the practice, the shine on the apple of emergency medicine is fading.

Fortunately, millions of patients continue to value the ER as an important health care resource; but a society that fails to acknowledge or appreciate altruism is destined to extinguish that behavior over time, regardless of how well the neurotransmitters work.

Share/Bookmark

Bedside Ultrasound in the ED

For many emergency physicians (EPs) the performance and interpretation of ultrasound examinations on patients in the ED has become an incredibly valuable and often life-saving tool, but until recently most health plans and government payers have balked at paying EPs for these services.   Even though the F.A.S.T. ultrasound exam has become a widely used diagnostic modality in the evaluation of major trauma patients in the ED, and ultrasound training has now been incorporated into the curriculum of nearly every emergency medicine residency training program in the country; health insurance plans have routinely been denying payment to emergency physicians who perform U/S exams in the ED.  The primary methodology for denying these payments has been for payers to bundle these services into the Evaluation and Management codes submitted by EPs in claims, relying on claims editing software, usually purchased by these payers from McKesson.  McKesson’s ClaimCheck, and the newer version, ClaimsXten, included claims edits that automatically denied payment for the two CPT codes (93308 and 76705) used in the evaluation of trauma patients by emergency physicians, using the excuse that the interpretation and reports provided by the EPs were actually ‘reviews’ of test results rather than actual reported interpretations of these diagnostic ultrasounds.  By failing to pay for these services, health insurers may actually have deterred some emergency physicians from learning to perform and use ultrasound, and thus delayed or impeded important diagnoses and needed care, or steered EPs to use more expensive CTs and other imaging studies.

As more and more EPs began to be trained to perform ultrasounds and began to actively use U/S in their practice (something that is very commonplace in Europe), the Reimbursement Committee (RC) of the American College of Emergency Physicians began to receive requests from the Ultrasound Section of the College, and from numerous providers and EM Residency directors, to try to address these inappropriate payment denials.  Previously, payers had expressed some legitimate concerns about paying EPs for ultrasounds:  receiving occasional claims from both EPs and from radiologists for the interpretation and report of the same test, believing that the EP’s I&R was often included in a simple note in the medical record rather than standing alone in the record as an ‘official’ report, and believing that these U/S tests were sometimes being coded by the EP as if the physician owned the equipment (which would be paid at a higher rate) rather than the hospital.  The RC’s view was that these were legitimate concerns, but did not warrant the automatic denial of all payments in claims edit software.   At the request of the RC, and with financial support from the Emergency Medicine Action Fund, ACEP hired the legal firm of WhatleyKallas to approach McKesson and request that the Company expunge the edits that resulted in the automatic bundling and denial of payment for the two codes used in the evaluation of major trauma patients.

Previously, Deborah Winegard, an attorney at WhatleyKallas, had managed to convince McKesson to remove one of these two edits on behalf of cardiologists, who were experiencing much the same payment problem when they performed certain U/S exams of the heart.   Not surprisingly,  however, McKesson and the health plans that had purchased these edit software bundles, pushed back on ACEP, insisting that the college demonstrate that the documentation of these interpretation and reports by EPs first meet CPT standards.  ACEP responded by again refocusing the issue on the fact that bunding these codes into the E&M service was not consistent with CPT coding rules, and that EPs were charging for the performance and interpretation of these U/Ss, not for reviewing interpretations provided by other physicians.  Since McKesson marketed their edit programs as being consistent with AMA CPT, the edits in their coding Knowledge Base should in fact follow these rules.  ACEP, through WhatleyKallas, insisted that if EPs were not documenting these interpretation and reports properly, the issue should be addressed through the payer auditing process, and through educating physicians about CPT documentation requirements.  Eventually, McKesson, though their Medical Director, Dr. Moeller, wrote ACEP a letter indicating that the edits in question would be removed, but also noting that it was really up to the health plans to decide whether or not to continue bundling these trauma U/S codes into the E&M service for emergency physician claims, as “customizations of the default logic – both adding and removing edits, occurs entirely at a health plan’s discretion.”   Dr. Moeller also noted that “several (plan) Medical Directors identified health plan policies that are intended to reimburse only the ‘official’ interpretation, or chart copy, of an imaging study, including image documentation. Other Directors expressed additional concerns: duplicate ‘over-read’ interpretations also reported by radiologists; ER physicians reporting 76705 without a Mod -26 (Professional component only); chart notes without a formal chart report; interpretations without image documentation; and confusion with examinations done by radiologist for non-traumatic indications.”

Removal of these edits by McKesson is a good step in the right direction, but it is really just the first step.  Emergency physicians need to document their I&Rs of U/Ss in the appropriate way (and include one or more actual U/S images in their report), and ACEP will need to continue to educate health plans and government payers about the value of these EP services to our patients and to the payers themselves.  Major trauma is not the only indication for rapid bedside U/S in the ED.  U/S to rule out cardiac standstill in arrest, identify pleural effusions, foreign body penetration of the eyeball, complete obstruction in ureteral stones, hemoperitoneum in ruptured ectopic, placement of central lines, and leaking abdominal aortic aneurysm, to name just a few, are also becoming part and parcel of the diagnostic armamentarium of the emergency physician.  These scans, and the underlying premise of appropriate reimbursement in CPT, will come next on the agenda for ACEP’s Reimbursement Committee, EMAF, and WhatleyKallas.

Share/Bookmark

Obamacare in the Emergency Department

Many emergency physicians have expressed support for the provisions in Obamacare that expand Medicaid coverage; though they usually acknowledge that coverage does not necessarily mean access to care.  Certainly, moral considerations account for much of this support, but in addition, emergency physicians tend to believe that providing Medicaid coverage to many of the currently uninsured will benefit them as well, by reducing the financial burden that comes with providing care to everyone, including many patients who have no insurance coverage and can not afford to pay for this care.

There is no question that providing health insurance to those who are currently uninsured is a positive development for our Country; though a substantial number of our citizens and legislators have great concerns about how ObamaCare expands health insurance coverage to a substantial portion of the 45 million Americans who currently have no health insurance.  Nonetheless, this has to be considered one of the President’s most significant accomplishments in his first term.   However, moving the uninsured into Medicaid may not improve the financial picture for most emergency physicians, since in most States Medicaid reimbursement rates do not come close to covering the cost of providing this care.   It seems logical that providing at least some payment for the care of the uninsured should significantly mitigate the losses associated with caring for those financially indigent patients who currently have no coverage and no ability to pay; but a closer look at the likely financial and utilization consequences of expanding Medicaid on the economics of emergency medicine practice shows a considerably different picture.

If you examine the typical independent emergency medicine group practice, or for that matter, the practice of emergency physicians employed by hospitals, what you will find is that the revenues derived from treating Medicaid patients cover less than half of what it costs to pay for EP coverage and practice expenses like billing and malpractice insurance.  This is true even if non-physician practitioners like Physician Assistants and Nurse Practitioners account for a substantial proportion of the hours of provider coverage in the ED.   Thus, the typical EM group practice, or the hospital paying for EM provider coverage in the ED, loses money on every Medicaid patient they see.  Granted, some payment is better than no or negligible payment.  The problem is, as more of the uninsured are covered by ObamaCare under an expanded Medicaid program, the more these newly insured patients will use ED services, especially considering the shortage of primary care providers available to see these new Medicaid patients.  As the president of the National Center for Policy Analysis, John Goodman, put it:  “people with insurance consume twice as much health care as the uninsured, all other things equal. The trouble is that the new health insurance law has no provision for increasing the number of health care providers. As a result, when people try to increase their use of physician services, many will be disappointed and a large number are likely to turn to the emergency room when they cannot get their needs met at doctors’ offices:

• Whereas the uninsured make almost two physician visits per year, the number is more than 3.5 for the privately insured and almost 7.5 for Medicaid patients.
• On the average, we estimate the typical newly insured patient will attempt 3.6 additional physician visits.
• If, say, only one-third of these turn to the emergency room because of inadequate primary care supply, that would equal between 39 million and 41 million additional emergency room visits every year.”

Of course, Obamacare also provides new coverage to many of the currently uninsured through exchanges; but as noted above, the newly covered Medicaid patients will flood EDs in much greater numbers.  These Medicaid patients might even push the remaining uninsured out of limited clinic appointment slots and right into the ED. In order to provide care for all these new Medicaid users of the ED, EM groups (or hospitals) will have to significantly increase the hours of provider coverage in the ED.  Unfortunately, because of the way EDs are staffed, the uneven distribution of patients who present to the ED, and the need to meet surge demands; a 10% increase in ED patients often requires a 15% or 20% increase in provider coverage.  Even if most of this increase is provided by NPPs, the end result could well be that the new Medicaid revenues derived from Medicaid patients who were previously uninsured ‘charity’ users of the ED, and the additional revenue derived from the Medicaid patients who become new users of ED services, will fail to cover the cost of staffing up to meet this new demand.  You can’t make up losses incurred when you lose money on every transaction by doing more transactions, even if you lose a bit less money on some of these transactions than you would otherwise.

This situation is likely to be made worse when State Medicaid programs ramp up efforts to curtail payments to hospitals and EM providers in response to the increased numbers of Medicaid patients flooding EDs around the country.  Denials of payment for so-called ‘inappropriate ED visits’, down-coding of claims to ‘triage rates’, and other methods to defray these costs further undermine the revenues needed to support increased provider staffing of the ED.   I believe that for many already overwhelmed emergency physicians practicing in community hospitals across the country, ObamaCare will be at best a break-even proposition, and at worst a financial kick in the cojones.

Share/Bookmark

A la carte vs prix fixe medical care

The push for payment reform in US health care is getting a great deal of support from every corner, and this will impact compensation for emergency physicians just as it will for nearly every specialty.  Nearly everyone believes that our fee-for-service reimbursement system results in too much care for too little benefit.  The perception that preventative and primary health care services are undercompensated, and procedural services to rescue failing health are overcompensated, seems to be widely accepted as one of the major reasons why our health system is too expensive and ineffective in producing better health as an outcome.   Personally, I think characterizing FFS as the real villain in this drama is a bit overblown.  For-profit health insurance plans, pharmaceutical companies, medical equipment manufacturers; industry lobbyists and advertisers, Wall Street’s short-term-goal driven stock holders, and lack of political leadership all play a significant role.  However, I think FFS as we currently know it is dying, and capitated multi-specialty medical groups focused on disease prevention are gradually going to push out other, less cost-efficient provider systems.  Mostly, physicians in these groups will be salaried.  So where does that leave emergency physicians?

There are a lot more emergency physicians who are employed these days, by hospitals, by EP medical groups, and by HMOs and the like, and there are pluses and minuses to this.  I am convinced that paying these physicians a straight salary or even a straight hourly may not provide enough incentive for providers to practice cost-effective care, maintain productivity, or invest in the operation of their ED.  I don’t have good data on this, but I suspect that EPs who are paid strictly on an RVU productivity incentive model do not have cost-effective care high on their agenda.   I believe that over time, compensation for EPs will be driven by payment reform to reflect the new value based care model, using incentives to encourage EPs to achieve these goals.  Unfortunately, incenting physicians to do the right thing, cost-effectively, and efficiently, is not a simple matter.  All other things being equal, physicians who work hard deserve to be paid better than those that don’t.  Likewise for physicians who do technically or mentally demanding and difficult work, who have better outcomes, who communicate well with patients and staff, and who trained longer and harder.  Fee-for-service may encourage some or even most physicians to do too much for too little benefit; but it also generally pays physicians who work harder and are more efficient, more skilled, and more compelling in the marketplace better than physicians who aren’t.  There are unfortunately far too many exceptions.

The practice of emergency medicine does not lend itself well to bundled payments, capitation, or other payment reform population based models that use risk-sharing and outcomes targeting as the primary incentive in achieving quality, cost-effective care.  EPs have control over their slice of the acute care continuum, the care provided in the ED; but unlike most other clinical physicians, their ability to affect ongoing patient care, or what happens before the patient gets to the ED, and after the patient leaves, is limited.  EPs can provide some preventative health care services, and can certainly impact in-ED and post-ED outcomes through coordination of care; but it is difficult to see how, on a case by case basis, it would be possible to determine what portion of the bundled payment for acute MI or hip-fracture should go to paying the EP, who may do a whole lot for some of these patients, or not as much for others.  Even considering a population of patients, how does one fairly determine the portion of a capitation payment or premium dollar that should be allocated to emergency physician services?  If a multispecialty medical group employing emergency physicians fails to manage its capitated patient population well, and provide effective preventative care and good chronic illness care; the group will have less profit to distribute to its primary care providers, but its emergency physicians are likely to have to work harder, and see more of these managed care patients in the ED.   Should reimbursement for repair of a laceration, or managing the victim of an MVA or GSW, be adjusted based on the financial success of a capitated multi-specialty medical group?

The value based payment goal for EM is to encourage cost-effective care with excellent outcomes and high patient satisfaction, and the doctrine of fair compensation requires pay that reflects performance, productivity, work-ethic, and skills.  What kind of compensation system effectively addresses these requirements?  Rather than abandon fee-for-service payment for EPs altogether, I think we may need to remodel it.  The advantage of RVU-based fee-for-service reimbursement is that it does reflect effort and productivity, yet it does not factor in value and outcomes.  First, I would start by revising RVUs for emergency care, which tends to pay more for doing more tests and treatments, and to a degree incentivizes over-testing and over-treatment.  Some aspects of care, like laceration repair, are not subject to physician discretion; others, like IV rehydration, are.  Perhaps RVUs should be based not so much on what you do, but on what kind of patient you care for, in a quasi-bundled EP-specific fashion.  This would allow for some adjustment in advance for those services that are discretionary and those that are not, for acuity, for complexity, and for other aspects of care that require more or less skill and (yes, I said it) time; without encouraging unnecessary services.  Secondly, I would establish some ER group risk pools for emergency care services, to encourage good outcomes, reduce unnecessary testing, factor in patient satisfaction, and reduce variability in care.  Risk pool allocation could vary based on individual provider contributions to achieving the risk pool targets.  Finally, I would adjust the portion of the population’s slice of the policy premium allocated to the ER group to factor in ED patient volume and complexity.

I know this sounds complicated, but the KISS principle and fairness are often less than compatible when it comes to practices as varied and unpredictable as emergency medicine.   Also, most of these adjustments to FFS would come under the auspices of employment agreements or contractual relationships between payers and providers.  Thus, it may be possible to bypass the painstaking RVU process to get to these remodeled FFS payment provisions.  In any case, I would prefer to see EPs develop these models and become true participants in the value based proposition, than to be sidelined and managed as a cost-center.

Share/Bookmark

Bones with Tricorder, the Ultimate Field Triage Tool

Recently, the California EMS Commission began to consider expanding the paramedic scope of practice in selected California counties to include ‘Community Paramedicine’ services, “an expansion of paramedic roles to support community primary care and public health delivery in both rural and urban communities”.  This program is being promoted by private EMS ambulance and transport companies looking to expand the services that paramedics provide, and it is modeled after similar programs being considered in other states, and in Canada and Australia.   Under the program proposed for California, paramedics could be engaged to reduce hospital re-admissions, identify unsafe home environments, improve patient compliance with medical regimens, reduce delays in receiving primary care, and meet the need for alternatives to ER care for those that do not require transport to an ER.   In this way, the program hopes to contribute to achieving ‘maximum value from every resource within the health care delivery system’ in order to ‘improve individual and community health, reduce unnecessary hospitalizations and Emergency Department visits, and reduce healthcare costs’.

These certainly are laudable goals, but behind this effort to expand the scope of paramedic services is the expectation that these programs will generate greater profits for ambulance service companies, and these companies believe that health plans will endorse and support this idea in order to reduce their own costs, and enhance their own financial bottom line.  One of the most interesting arguments put forward in support of these programs is that they may be part of the solution to the primary care physician shortage, and of course to ER over-crowding.   In fact, some of these ideas and proposed new roles for paramedics may have some merit.  Certainly, paramedics could be trained to assess dangers in the home, or to provide in-home evaluation of post-discharge compliance with medication regimens and follow-up care appointments, or immunize home-bound patients in an epidemic; and perhaps they could do this at lower costs than physical therapists and home-health nurses.  Things become a bit murky, however, when paramedics are expected to evaluate patients in the field and decide that some of these patients can be treated in the field and released, or diverted from the ER to an urgent care center, retail clinic, or the patient’s primary care provider.  It is possible, but doubtful, that Medicaid or Medicare programs would pay enough for these services to make it worthwhile for commercial EMS Companies.  Even if these payers would pay (‘Medicare has decreed that the EMS fee schedule is a ‘transport benefit, not a treatment benefit’), it is unlikely that many commercial urgent care centers or retail clinics would be willing to accept Medicaid or uninsured patients triaged and transported from the field to their doors by ambulance, cabulance, or medi-van.

Commercial health plans, on the other hand, might buy into this concept because their costs for ER care can easily cover payment of a fee to paramedics for treat and release, or diversion to an urgent care center or retail clinic.  Here’s the rub:  in most communities across the country, retail clinics and UCCs are unlikely to be willing to accept and treat all comers triaged away from the ER by paramedics.  Thus, paramedics are going to have to determine not only which of their patients are medically eligible for diversion from the ER, but also which of these patients are financially eligible for diversion to the retail clinic, UCC, or medical office.  In other words, this differentiation would entail the intrusive and arguably unethical EMS wallet biopsy.

There are additional factors that should, and hopefully will, be seriously considered, tentatively pilot tested, and thoroughly studied, before Community Paramedicine Programs are widely adopted.   There is no doubt that most paramedics can be trained to utilize limited treat and release protocols safely, and without undue liability risk.  The key here is LIMITED, but these Community Paramedicine programs would be build on a significant expansion of current paramedic scope of practice, not simply a little flexibility in, and adjustment to, state EMS regulations.   Who will train these paramedics to administer these expanded diagnostic and treatment services?  What would this training entail?  What kind of physician supervision will be required, and will it be readily available?  Will telemedicine help cover this supervision issue, and who will pay for the equipment and physician coverage?  What about diversion on the cusp of the clinic or UCC’s usual business hours, or the impact on EMS response times?

Treat and release in the field by paramedics is something that is allowed by more than a few EMS Agencies (though commercial ambulance services are loathe to give up the transport revenue), and studies have demonstrated that it can be done safely and effectively, but current T&L protocols are carefully constrained as to which patients can be treated and released, and under what circumstances.  Advising patients to decline transport or sign an AMA form is fraught with liability, and the question of paramedics being able to obtain informed consent in the field remains an uncertain issue.  Though there has been a tremendous amount of press coverage and political hoopla about the excessive cost of treating patients in the ER who ‘don’t need to be there’; there is evidence that diverting such patients away from the ER doesn’t really save health plans or consumers as much money as everyone seems to believe, especially after considering the cost of caring for these patients in alternative venues.   There may not be enough potential savings to make it worthwhile for the payers to pay ambulance companies for these services, unless we are talking about diversion of higher cost, higher acuity patients, where the risks to patients being diverted from the ED really begin to escalate.   I am admittedly a bit concerned that pre-hospital diversion of commercially insured patients with significant medical issues away from the ER could endanger the financial viability of hospitals or ER groups, most of which rely on commercial patients for at least 50-60% of their revenues. I can only hope that diverting these higher acuity patients would raise serious objections from every quarter.

Paramedics have published a host of articles and blogs supporting the expansion of their scope of practice and adoption of Community Paramedicine programs, claiming that “EMS can ‘fix’ the US healthcare system”.  They might be a bit less gung-ho if they understood that economic triage could be required.  Like emergency physicians and nurses, paramedics take pride in being egalitarian providers.  Perhaps, considering the cost of ER services, political agitation for more cost-effective care, and limited access to primary care providers; the time for Community Paramedicine has come: but pardon me for being just a bit skeptical.  The opportunity to reshuffle the revenues and reduce the costs associated with emergency care can far too easily drive corporate providers and well-intentioned policy makers to ignore or down-play ethical considerations and the best interests of the patients at risk.

Share/Bookmark

Health Plans Have All the Leverage

One of the hard lessons I have learned in negotiating health plan contracts for physician groups is that if you can’t find a way to apply leverage in the negotiation, there is no negotiation.  Leverage is the key to success in most negotiations.  With leverage you can get a better deal, without it you are just another commodity.  Physicians can obtain leverage in many ways:  more training, excellent reputation, strength in numbers, careful use of consultants, financial backing, strategic planning, good public relations, and yes, even good bedside manner.  There is a certain cost to obtaining leverage, and expending leverage can be productive, or wasteful, depending on the physician’s skill as a negotiator.  EVERY relationship involves negotiation, and every physician must learn the art of negotiation. Unfortunately, many physicians have lost all leverage in their relationships with third-party payers; and they are left with a ‘take it or leave it’ option, if they are lucky, or a ‘take it or leave’ option if the plan has been able to achieve near dominance in the market.

The right of a physician to withhold services, or provide services selectively, depending on whether they are able to negotiate reasonable terms and reimbursement rates from these third-party payers, has been steadily eroding.  Perhaps the most obvious sign of this loss of the right to selectively provide services is the demise of out-of-network (OON) leverage:  that is, the ability of physicians to decline to participate in health plan networks.  If you cannot walk out of a negotiation, there is no negotiation.  Physicians who primarily or exclusively practice in hospitals have probably lost the most ground here, in part because of coercive contracting and the EMTALA mandate to provide emergency care to all, regardless of insurance status; but also because many hospitals have also lost leverage in negotiations with health plans.  Such hospitals tend to lean on their hospital based physicians to share the pain in these lopsided networking relationships with health plans.  This is particularly true in communities and states where commercial health plans have completely sewn up the market for health insurance.  In states like Alabama, where Blue Cross Blue Shield of AL has about 87% of the commercial health insurance market; plans can use their monopoly and monopsony power to all but dictate price to every potential enrollee and rates to every provider.  There are no real negotiations, and the situation really is a ‘take it or leave’ proposition.  I have seen contracts between plans and providers in these grossly under-regulated monopsony conditions where the reimbursement rates were ‘specified’ with the following phrase:  “Corporation’s purpose and intent shall be to maintain a Fee Schedule in which the amounts are neither excessively high nor excessively low”, and “The decision to adjust the Fee Schedule will be made solely by the Corporation”.   Hospital based physicians faced with such terms can either accommodate to a markedly reduced income, or leave the state.

The right to decline to participate in a plan network is often the only significant leverage that physicians have in negotiations with plans for fair in-network rates.  Even those physicians and physician groups that have the option to go ‘out-of-network’, and receive their usual and customary charge for these services rather than a deeply discounted payment as an in-network provider, are struggling to maintain this leverage.  Legislators, bombarded with consumer complaints about large balance bills, have limited or even eliminated the ability of physicians to bill patients for the difference between what the plan will pay as a benefit of OON care, and what the provider charges.  These complaints have been instigated by a progressive decline in OON benefits, resulting in larger balance bills.  Unless these legislators include a reasonable minimum OON benefit standard in legislation to prohibit balance billing, these laws effectively chop physicians off at the knees, eliminating any leverage they may have to negotiate fair rates for in-network services.  Insurance regulators that ignore health plan monopolies further erode provider leverage, depressing payments to providers at the expense of profits for plans.  This eventually undermines access to care, as indicated by a recent survey of 13,575 physicians conducted by The Physician Foundation, which “found that over the next one to three years, more than 50 percent of physicians will cut back on patients seen, work part-time, switch to concierge medicine, retire, or take other steps likely to reduce patient access”.  Unfortunately, few insurance regulators seem interested in enforcing rules against such monopolies.

One legislative approach to level the playing field and restore some clout to physicians in plan contract negotiations is to require plans to pay the OON benefit to OON providers directly, rather than send a check to the enrollee, as was recently done in Florida.  Another is mandatory recognition of assignment of benefits, which plans often ignore.  Physician shortages, especially in primary care, may also restore some leverage for these physicians, but health plans are already pushing back by increasing coinsurance payments and co-pays for enrollees that go OON for their care, renting physician networks to other plans, suing physicians for ‘excessive’ OON charges, and penalizing (sometimes ousting) in-network physicians for referring enrollees to OON facilities and providers.  This may sound like a tug of war equilibrium, but most physicians, especially hospital based specialists, feel like David facing Goliath.

Some would say that the concept of third-party payment (i.e. health insurance) itself is to blame for the demise of OON leverage and loss of value for physician services.  Others might point to the increasing role of government health care coverage, with reimbursement tied to shrinking budgets, as the culprit.  Regardless of the cause, physician margins, the difference between revenues and the cost of practice (call it take-home pay) are shrinking, and despite the growth of Independent Practice Associations, large group practices, affiliations with hospitals, Wall Street financing of large physician practices, and all the other efforts to enhance physician leverage:  health plans, with huge piles of cash to invest in political campaigns and large legal firms on retainer, are winning this war.  Consumers, unfortunately, are caught in the middle.

Share/Bookmark

Whoa! That AHIP Survey is TOTALLY BOGUS.

I use to hear the phrase ‘totally bogus’ all the time in the ‘80s, and when America’s Health Insurance Plans released a ‘Survey of Charges Billed by Out-of-Network Providers’; I knew I had come across the perfect example of a totally bogus piece of deliberately misleading health insurance industry propaganda.  According to the survey summary:  “for consumers who choose to seek care out-of-network, our latest survey shows that the charges billed by some out-of network providers can exceed several hundred or several thousand percent of what Medicare would reimburse for the same service in the same area”.  The summary goes on to say that “Protecting consumers from runaway charges billed by some out-of-network physicians is an important policy issue at a time of major economic challenges and a national debate surrounding the affordability of health care”, and that this “illustrates the value of provider networks and a pressing problem faced by consumers who want affordable, meaningful access to out-of-network providers”.  This problem is, of course, balance billing, which ‘detracts from the ability of health plans to offer affordable access to out-of-network providers’.

Allow me to translate for you.  This survey is a sly bit of propaganda aimed not at consumers, but at health plan regulators and policy makers.  It is intended to shift the blame for large balance bills for OON services away from health plans that have recently begun to severely reduce covered benefits for OON services, and towards OON providers who charge ‘exorbitant fees’.  It is intended to stir up ill will towards physicians who decline to participate in plan networks, and promote the nation-wide prohibition of balance billing to ‘protect consumers from these runaway charges’.   It is intended to mask the profit-motivated abandonment by plans of paying benefits for an OON provider’s services that cover 100% of most physicians usual and customary charges, and justify the adoption by plans of OON benefits that are less than 30%, or 40%, of most physicians’ fees.  Ultimately, this propaganda effort is designed to eliminate any leverage that physicians might have to get fair contracting rates for in-network service, force more physicians to join these networks against their better judgment, and discourage enrollees from using OON providers.  So how is this survey intended to work its magic?  To begin with, the survey was plugged in the NY Times.

Like most propaganda, there is a small grain of truth imbedded in the froth of hype and misinformation:  some physicians’ charges really are excessive.  What makes this survey so misleading, and dangerous, is that it uses anecdotal evidence and extreme examples to tarnish the image of all physicians.  If consumers, regulators, and legislators don’t read the fine print or ignore the corrupted methodology of the study;  they will be left with the impression that this is how ALL physicians set their fees for OON services.  Conducted for AHIP by the firm Dyckman & Associates, this study relies on many of the same methodologic slight of hand techniques that health plans have used to challenge the right of physicians to balance bill in any number of states.  I have personally seen this use of extreme and unverified examples of physician charges in just this way in California, when the DMHC held hearings on their proposal to prohibit balance billing of HMO claims.

Look closely at this firm’s explanation of their survey methodology.  First, plans were asked to provide the three highest billed charges in 2011 and their corresponding zip codes from non-participating providers for each of the 24 CPT procedure codes within the 30 most populous states.  “In analyzing the response data, Dyckman took measures to try and exclude any claims that could possibly have been billed or reported in error. For example, Dyckman excluded claims where the reported out-of-network charge was more than 2,000 percent of the Medicare fee and at least 50 percent (1.5 times) greater than the next highest reported charge-to-Medicare fee ratio in the same locality for the procedure code.”   There is no explanation for why this approach or these numbers were used, or why they believed that setting the limit at 2000% would eliminate claims that ‘could possibly have been reported in error’ and 1500% wouldn’t.   Let us imagine how this might work:  say five plans each reported three examples of the highest reported charges (out of many tens of thousands of claims) for a particular service from OON providers in a locality.  Say the average charge for this service was $300, or 300% (three times) the Medicare rate of $100.  Assume Dyckman got the following charge data from these 5 plans:

$750; $775; $790; $850 $890; $890; $1,000; $1,100; $1,125; $1,285; $1,290; $1,350; $1,380; $1410; $2,180

Since $2,180 was more than 2000% (twenty times) of the Medicare rate of $100, and more than 1.5 times higher than the next highest reported charge, the $2,180 charge would have been eliminated as representing a probable error.  The report would then indicate that the ‘highest charge’ for this service in this locale was $1,410 or more than 14 times the Medicare rate.  But remember, these were fifteen claims with the highest charges out of what might have been tens of thousands of claims submitted by providers for this service.  What if every one of these extreme charges the plans reported on were claims errors?  Did Dyckman review the actual physician bills from which these charges were abstracted, or just accept whatever the plans reported as their highest charges from physicians?  Did they ever call any of these physicians to check to see if these reported charges were correct, or were merely clerical errors?  Doubtful in either case.

Even more bizarre, the survey then goes on to state that “the maximum reported charge billed by a non-participating provider as a percent of the Medicare fee in the same locality was 9,465 percent, based on a billed charge received by a health plan from an out-of-network provider of $9,471 for subsequent hospital care. The applicable Medicare fee for that service in the same locality was $100. Therefore, the billed charge was nearly 95 times the corresponding Medicare fee.”  Wait!  I thought that they were going to exclude “claims where the reported out-of-network charge was more than 2,000 percent of the Medicare fee” as representing a probable error, yet here they are talking about a fee that was more than 9,000 percent of the Medicare rate.   Does this mean if they had a report from a plan of a charge for $8,000, and all the remaining reported charges were for less than $2000, that the $9,471 charge was retained as a non-excluded charge? Frankly, the methodology for this survey is TOTALLY BOGUS.  Let’s look at a portion of this survey related to extreme physician charges in New York:

According to this table, at least one physician charged $12,000 for a service that Medicare reimburses at $187.38 in this state, or 6,404% of Medicare.  According to FAIR Health (which the survey uses at one point as a reference), the charges for a 99285 emergency department visit in NY City in their usual and customary charge database, which contains hundreds of thousands of validated claims, fall in the following range:

50^th percentile : $586               70^th percentile : $595               90^th percentile : $670

This means that the average physician charge for this (sometimes life saving) service is about $586, and that nine out of ten physicians charge less than $670 for this service.  Isn’t it just as reasonable to assume that the $12,000 charge was an error, rather than an example of an accurate physician claim for this same service in the ER?  Physicians submit and plans process hundreds of millions of claims a year, and clerical errors on both sides are unfortunately rather commonplace.

For removal of a gallbladder using a laparoscope, the average NY City surgeon charges $6,000.  I suppose there could be a surgeon there who charges $44,000, and certainly $6,000 is nothing to sneeze at when compared to what Medicare pays (Medicare, by the way, was initially established to be a charity care program for the elderly, most of who were very poor); but doesn’t it really make more sense to predicate health care policy and fair payment legislation on validated data showing what most physicians charge, and not on what some health plans allege that some physician might have (erroneously) charged?

When then NY AG Mario Cuomo first sued a bunch of health plans for underpaying consumers hundreds of millions of dollars for OON claims by manipulating the Ingenix database of physician usual and customary charges, the difference between what the plans should have paid and what they actually paid as a benefit for OON services was probably less than $1 in $10.  Unfortunately, Cuomo’s settlement did not require these plans to continue to use the 70^th or 80^th percentile of a validated database of usual and customary charges as the standard for OON benefits nationally. Consequently, health plans are now shifting the standard for their OON benefits to 125% or 140% of Medicare.  Thus, these plans are reducing OON benefits by more than half, and putting the burden for paying the unpaid balance on the backs of their enrollees.  Multiply this by the hundreds of thousands of OON claims underpaid by these plans every year, and it makes the insurance industry fraud that got Mr. Cuomo all fired up look like a petty misdemeanor.

Remember that the health insurance industry was hoping to use this survey to get insurance regulators and health care policymakers to ignore what the plans are doing, and instead focus their ire on physicians.  It is time for physicians to push back, and we can start by calling for a retraction of this ridiculous, totally bogus survey.

Share/Bookmark