Abandoning fee-for-service would affect ER care, docs say in Health Affairs -AND- Digital wait-time counters could reduce ER tensions
CAL/AAEM News Service
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Sun Dec 22 10:33:00 PST 2013
December 4, 2013
Abandoning fee-for-service would affect ER care, docs say in Health Affairs
Modern Healthcare
By Melanie Evans
As policymakers consider jettisoning the U.S. healthcare system's volume-based payment framework, a group of doctors is arguing that doing so would threaten providers' ability to deliver the expensive and unpredictable care patients need when they show up in emergency departments.
“Testing and admissions are perceived as safe harbors to reduce uncertainty and protect against medical liability, and they are well reimbursed,” Dr. Jesse Pines of George Washington University and three emergency medicine physicians write in the latest issue of Health Affairs. “There is no countervailing force to discourage overdiagnosis and overtreatment.”
Pines says the problem requires a nuanced response.
The article is one of the latest to join a crowded and heated debate over the speed and extent to which hospitals, doctors and public and private payers should adopt alternatives to healthcare's fee-for-service (pay for volume) model, which is frequently criticized as an incentive for overuse and a contributor to rising U.S. healthcare spending.
Proponents of alternatives such as bundled or capitated payments contend that strong incentives are needed to change practice patterns. Others are more reticent, arguing that many doctors lack the expertise and capital needed to make the switch.
In an interview, Pines said he fears that safety net hospitals will rethink money-losing emergency departments under capitation contracts that pay a lump sum per patient. Hospitals and doctors lose money when patients' healthcare costs exceed the lump sum.
As policymakers debate how best to control health spending, Pines urged them to consider that such payments are “potentially disastrous.”
The cost to treat patients who visited the emergency room but were not admitted to the hospital climbed 33.5% to $82 billion in 2010 compared with 2006. Spending for patients who were hospitalized after an emergency room visit increased to $202.2 billion in 2010, or 17.3%.
Those numbers are not explained by a parallel rise in the number of patients. Emergency room visits grew 7.6% and the number of hospitalized emergency room patients increased 6.5%.
“We can't reduce these costs with a blunt instrument,” Pines said. “It has to be done in a way that is evidence-based and carefully monitored.”
The authors called for the development of emergency department quality and resource-use measures that could be tied to bonus payments in addition to the volume-based payments, which would give hospitals more incentive to maintain emergency care.
Pines authored the article with Dr. David Newman of the Mount Sinai Icahn School of Medicine, Dr. Randy Pilgrim of the Schumacher Group and Dr. Jeremiah Schuur of Brigham and Women's Hospital.
In addition to suggesting a hybrid payment model, they argue that changing physician behavior is essential to reduce less expensive tests and treatments.
They suggest that doctors would benefit from timely data that shows them how their use of diagnostic imaging and other services compares with that of their peers. “For providers, cost-consciousness needs to be a clearly articulated professional and organizational priority, and feedback on variations within groups is a first step in achieving that goal,” the authors wrote.
Dr. Christopher Moriates, an assistant clinical professor at the University of California San Francisco, said he agreed that greater awareness and sensitivity to cost within healthcare would require multiple strategies.
“Cost-conscious is really the bottom, the foundational requirement,” Moriates said. “You have to be conscious.”
Woe for insurers
The problematic final push to expand insurance under the Patient Protection and Affordable Care Act could mean trouble for insurance companies, Modern Healthcare's Paul Demko reported. Moody's Investors Service issued a gloomy update for the sector as the White House continues to adjust public policy and scrambles to fix federal online insurance markets. The pool of customers that insurers anticipated would enter the exchange is up in the air after President Barack Obama reversed policy to allow a one-year reprieve for health plans that don't comply with the law's new rules, Moody's said. That could mean smaller profits for insurers.
Woe for healthcare entrepreneurs
The uncertainty around the Affordable Care Act's adoption has damped private equity investment in the healthcare sector, Modern Healthcare's Beth Kutscher reports. Deals are down significantly from last year.
December 6, 2013
Digital wait-time counters could reduce ER tensions
Fierce Healthcare
By Zack Budryk
Digital updates on emergency room wait times may reduce stress and make patients more manageable, according to an article in Slate.
London-based design firm PearsonLloyd developed an intervention for the U.K.'s National Health Service (NHS) to test the idea. A Better A&E (accident & emergency, the U.K.'s term for emergency rooms) involves the use of flowcharts posted in emergency waiting rooms with information about the steps to treatment.
The intervention also incorporates digital screens telling patients their wait times, much like those used at public transit stops, according to the article. The wait times are tailored to a patient's specific condition or injury, with options such as "major injuries," "minor injuries," "resuscitation" and "see and treat" consultations. The designers also floated the idea of an equivalent smartphone app, which would give patients the option of determining which local hospital would provide the fastest treatment.
Implementing the system drastically improved tension levels in ER waiting areas, according to PearsonLloyd Director Tom Lloyd. "We were shocked by the fact that there was a 50 percent reduction in the aggressive incidents across the two hospitals after the implementation," he told Dezeen magazine. In addition, 75 percent of patients reportedly said they felt less frustrated by wait times with the signage present, according to Slate.
The intervention, while a relief to patients, could also help protect healthcare workers from hospital violence, according to Slate. Violence against NHS employees from patients or their relatives costs the NHS about $113 million per year, the article states. The firm told Slate that the interventions have improved retention and morale among employees, and employee absences due to stress have "fall[en] significantly after the implementation of the solutions."
There may be other ways to deal with the adverse effects of ER wait times as well. Mercy Health's Anderson Hospital in Cincinnati has experienced success in reducing wait times by as much as 70 percent by speeding up treatment and altering the process for "sorting" patients, FierceHealthcare previously reported.
Bryan Sloane
Deputy Editor, CAL/AAEM News Service
Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service
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