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</o:shapelayout></xml><![endif]--></head><body lang=EN-US link="#0563C1" vlink="#954F72"><div class=WordSection1><p class=MsoNormal><span style='font-size:9.0pt;font-family:"Arial",sans-serif'> <img width=623 height=151 style='width:6.4895in;height:1.5729in' id="Picture_x0020_1" src="cid:image001.jpg@01D253B3.08C53900" alt="Description: Description: Description: Description: CAL/AAEM: California Chapter of the American Academy of Emergency Medicine"><o:p></o:p></span></p><p class=MsoNormal><span style='font-size:9.0pt;font-family:"Arial",sans-serif'><o:p> </o:p></span></p><div style='margin-left:15.0pt;margin-top:7.5pt;margin-right:15.0pt;margin-bottom:7.5pt' id=content><div style='border-top:solid #7F7F7F 1.0pt;border-left:none;border-bottom:solid #7F7F7F 1.0pt;border-right:none;padding:4.0pt 0in 4.0pt 0in'><p class=MsoNormal><b><span style='font-size:11.0pt;font-family:"Arial",sans-serif;color:#7F7F7F'>February 13, 2018<o:p></o:p></span></b></p></div><div style='margin-top:11.25pt;margin-bottom:11.25pt'><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'><o:p> </o:p></span></b></p><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'>Robert Pearl: Kaiser Permanente modifies ER staffing to meet patient demand, improve efficiency<o:p></o:p></span></b></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0000CC'><a href="https://www.fiercehealthcare.com/ambulatory-care/robert-pearl-kaiser-permanente-emergency-room-efficiency-staffing?mkt_tok=eyJpIjoiTnpZM05XWmpOVGhpTkdSbCIsInQiOiJteDBVNzRaaVRIVHU1aGxzVHZkUEUyRWxaWWh2SFF4NnhPRkFmUGJWVjFhcGl4U3N0QzNCWkdvYW1mMjdRT1Y4QVZMNWFORFhzN2JTQmxxZFN0Y0FrU2NDeWVidmFMYUthTkJuQXJIU2t2R1E4MDAyeUJ4T29HZ1Y5ZnJPY1wvbnEifQ%3D%3D&mrkid=905528"><span style='color:#0000CC'>Fierce Healthcare</span><span style='font-family:"Times New Roman",serif;color:#0000CC'><o:p></o:p></span></a></span></p><p class=MsoNormal style='margin-right:15.7pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>By Paige Minemyer<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Patients often face long waits for emergency care, so the Permanente Medical Group set out to improve patient flow in Kaiser Permanente emergency rooms by deploying staff members more efficiently at high-volume times.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>ERs are the busiest on nights and weekends—the least desirable shifts for clinicians—so KP took steps to adjust what its ER nurses were doing and added nontraditional ER doctors to these shifts to avoid delays, wrote Robert Pearl, M.D., a clinical professor of plastic surgery at Stanford School of Medicine and former CEO of the Permanente Medical Group, in a column for Forbes. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The triage process is often redundant and results in nurses asking many of the same questions that patients will answer a second time for admitting physicians. KP made doctors the first point of contact in the ER to move nurses more directly into patient care, especially during high-volume, low-staff times of day, which got more clinicians involved in treating patients. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>KP emergency rooms also brought nonemergency clinicians to the ER during high-volume times, Pearl wrote. The organization paired board-certified ED doctors with other physicians, such as pediatricians or family medicine practitioners, who would also be able to treat patients with minor illnesses or injuries. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>"By staffing appropriately for the acuity of patient problems, doctors can treat and discharge those with less-emergent issues faster," Pearl wrote.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Other hospitals have looked at re-engineering the triage process to make emergency care more efficient, as patients with nonemergent conditions often face long waits in the ER. A pilot program at a Chicago hospital streamlined the process so that the sickest patients were treated more quickly, reducing wait times by two hours. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>The pilot set a goal of patient admission within one hour of arrival in the ER. In addition to cutting down wait times, the updated triage pilot improved communication between clinical teams and fostered more collaboration on care. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Baptist Health South Florida adopted a "tele-triage" program to reduce overcrowding and treat patients with non-life-threatening conditions more quickly. Patients meet remote physicians in a video conference, significantly boosting the hospital's ER capacity. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Parkland Memorial Hospital took a different route to improve ER efficiency: a partnership with Toyota. The car manufacturer identified a number of inefficiencies in how the Dallas-based hospital operated its ER, including an inconsistent discharge protocol for nurses, that Parkland has adjusted.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:30.95pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:30.95pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p></div><div style='border-top:solid #7F7F7F 1.0pt;border-left:none;border-bottom:solid #7F7F7F 1.0pt;border-right:none;padding:4.0pt 0in 4.0pt 0in'><p class=MsoNormal><b><span style='font-size:11.0pt;font-family:"Arial",sans-serif;color:#7F7F7F'>February 16, 2018<o:p></o:p></span></b></p></div><div style='margin-top:11.25pt;margin-bottom:11.25pt'><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'><o:p> </o:p></span></b></p></div><p class=MsoNormal><b><span style='font-size:12.5pt;font-family:"Arial",sans-serif;color:#DF0009'>Unequal Medicare payments fuel health care consolidation trends<o:p></o:p></span></b></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0070C0'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif;color:#0000CC'><a href="http://thehill.com/blogs/congress-blog/healthcare/374043-unequal-medicare-payments-fuel-health-care-consolidation"><span style='color:#0000CC'>The Hill</span></a></span><span class=MsoHyperlink><span style='color:#0000CC'><o:p></o:p></span></span></p><p class=MsoNormal style='margin-right:15.7pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>In a recent hearing, the House Subcommittee on Oversight and Investigations examined health care consolidation, a growing trend in the health care marketplace. The hearing focused on the true costs of consolidation and the key factors increasingly driving smaller, independent care providers out of the health care system. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>One principle factor fueling marketplace consolidation is the disparity in payment across different health care sites of service, which incentivizes hospital systems to purchase small physician practices and charge more for providing care, ultimately creating higher costs for patients, employers and taxpayers. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>As consumers, we expect to pay the same price for a service regardless of where we buy it. If your car dealership charged $1,200 for changing your tires when the local mechanic only asked for $400, you’d rightly question the large discrepancy in costs. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>So why then are hospitals allowed to charge insurers, taxpayers and patients as much as triple what an independent physician practice would charge for the same health care services?<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Vertical health care consolidation—the phenomenon through which hospitals acquire and absorb physician practices—is a major contributing factor to the rising cost of health care in the United States.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>At $3.3 trillion per year and growing, America’s health care expenditures need to be closely scrutinized to determine where savings are possible without harming care or limiting patient access. There are reforms on the table that could save billions of health care dollars by improving efficiencies and leveling the playing field for all health care providers.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Medicare and other payers reimburse hospital outpatient departments (HOPD) at vastly higher rates than community-based physician practices for providing the exact same services. For the administration of chemotherapy drugs, for example, the payment to a hospital outpatient facility is more than double the rate paid to a community cancer clinic ($281 vs $136). <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Sensing an opportunity to generate more revenue, hospitals have exploited the disparity in payment by scooping up freestanding, independent practices and integrating them into larger hospital systems. According to a study commissioned by the Physicians Advocacy Institute, “the number of physician practices owned by hospitals/health systems rose 86 percent between 2012-2015, with 32,000 additional physician practices acquired.” <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>When it comes to oncology practices specifically, the rate of hospitals acquiring freestanding practices doubled from 30 percent in 2003 to 60 percent in 2015, according to a study recently published in Health Affairs. Because the payment for chemotherapy at HOPDs is 76 percent higher, on average, than at standalone cancer clinics, the fiscal windfall for hospitals is enormous.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Misaligned reimbursement rates also force patients to pay higher out-of-pocket costs for treatment at HOPDs. In its June 2013 report to Congress, the Medicare Payment Advisory Commission (MedPAC) noted that beneficiary co-payments at hospitals were nearly triple that of freestanding physicians’ offices. MedPAC estimated that equalizing payments across all providers could save Medicare beneficiaries as much as $380 million per year. Allowing the nonsensical payment disparity to continue would be irresponsible and inimical to caring for cancer patients.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>On an individual patient level, patients can experience an estimated $650 in higher out-of-pocket costs annually when care is delivered in the outpatient hospital facility, demonstrating how these disparities in payment are negatively impacting consumers.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>We are seeing steps in the right direction. Just this week, President Trump released his fiscal year 2019 budget, which calls for the expansion of site neutral payments for all hospital-owned physician practices. Under his proposal, Medicare would pay all hospital-owned physician offices located off-campus at the physician office rate, which would save an estimated $33.9 billion over ten years. <o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'>Payment parity across health care settings is the right thing to do for so many reasons. It will reduce marketplace consolidation, preserve patient choice and reduce health care spending for patients, insurers and taxpayers alike.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:15.75pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-right:15.75pt'><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal><strong><span style='font-family:"Arial",sans-serif'>Jeff Wells</span></strong><span style='font-family:"Arial",sans-serif'><br>Deputy Editor, CAL/AAEM News Service<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='margin-bottom:12.0pt'><strong><span style='font-family:"Arial",sans-serif'>Brian Potts</span></strong><b><span style='font-family:"Arial",sans-serif'> MD, MBA</span></b><span style='font-family:"Arial",sans-serif'><br>Managing Editor, CAL/AAEM News Service</span><o:p></o:p></p></div><p class=MsoNormal style='margin-bottom:12.0pt;background:#D9D9D9'><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'>Contact us at: </span><a href="mailto:calaaem.news.service1@gmail.com"><span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:#0000CC'>calaaem.news.service1@gmail.com</span></a><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'><br><br>For more articles, visit our </span><a href="http://www.calaaem.org/news_archives.php"><span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:blue'>archives</span></a><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'>. <br><br></span><a href="mailto:somcaaem@uci.edu"><span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:black;text-decoration:none'>To</span></a><a href="https://maillists.uci.edu/mailman/listinfo/calaaem"><span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:#0070C0;text-decoration:none'> </span><span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:blue'>unsubscribe</span></a><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'> from this list, visit our mail server.<br><br>Copyright (C) 2015. The California Chapter of the American Academy of Emergency Medicine (CAL/AAEM).</span> <a href="http://www.calaaem.org"><span style='font-size:7.5pt;font-family:"Verdana",sans-serif;color:#0000CC'>http://www.calaaem.org</span></a><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'>. All rights reserved.<br><br>CAL/AAEM, a nonprofit professional organization for emergency physicians, operates the CAL/AAEM News Service solely as an educational resource for physicians. Dissemination of an article by CAL/AAEM News Service does not imply endorsement, agreement, or recommendation by CAL/AAEM News Service, CAL/AAEM, or AAEM.<o:p></o:p></span></p><p class=MsoNormal style='background:#D9D9D9'><b><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'>Follow CAL/AAEM on Facebook and Twitter:<o:p></o:p></span></b></p><p class=MsoNormal style='background:#D9D9D9'><span style='font-size:7.5pt;font-family:"Verdana",sans-serif'><o:p> </o:p></span></p><p class=MsoNormal style='background:#D9D9D9'><a href="http://www.facebook.com/pages/CalAAEM/172577489479442?sk=wall&filter=12" target="_blank"><span style='color:black;text-decoration:none'><img border=0 width=28 height=28 style='width:.2916in;height:.2916in' id="Picture_x0020_6" src="cid:image002.jpg@01D253B3.08C53900" alt="cid:image002.jpg@01D253B3.08C53900"></span></a> <a href="https://twitter.com/#!/CALAAEM"><span style='color:windowtext;text-decoration:none'><img border=0 width=30 height=30 style='width:.3125in;height:.3125in' id="Picture_x0020_7" src="cid:image003.jpg@01D253B3.08C53900" alt="cid:image003.jpg@01D253B3.08C53900"></span></a> <a href="http://escholarship.org/uc/uciem_westjem"><span style='color:windowtext;text-decoration:none'><img border=0 width=112 height=30 style='width:1.1666in;height:.3125in' id="Picture_x0020_4" src="cid:image004.jpg@01D253B3.08C53900" alt="cid:image004.jpg@01D253B3.08C53900"></span></a><o:p></o:p></p></div><div id="DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2"><br />
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