Cost containment strategies for emergency care

It strikes me that in developing payment reform related, compensation driven cost-containment strategies aimed at constraining the cost of emergency care, policy makers, emergency physicians, and health insurers should adhere to certain principles.

The American College of Emergency Physicians should be at the forefront when it comes to establishing these principles, which I hope will be focused on protecting our patients first, and our specialty second.

The concept and practice of ‘managed care’ has raised some very reasonable concerns about the way some physicians’ commitments to the welfare of their patients has been compromised by the financial incentives inherent in compensation arrangements like capitation and risk-pools. If emergency physicians are going to be engaged, willingly or reluctantly, in cost-containment oriented incentive compensation programs; we need to make sure that the competing interests of patients, providers and insurers (including the government) are balanced properly, and morally.

I thought I would take a shot at formulating a few of these principles, and encourage readers of this blog to suggest changes and propose additions.

  1. Cost containment strategies for emergency care should focus first and foremost on cost-effective care, with the emphasis on effective.
  2. Shared-savings, pay-for-performance, capitation, risk-pools, and similar payment reform programs designed to incentivize emergency physicians to reduce the cost of providing emergency care must not result in a reduction in necessary care, an unreasonable delay in the provision of care, a significant increase in medical risk to patients, or a significant decrease in patient satisfaction with care; or shift the burden of care to those who are unwilling and/or unable to provide this care.
  3. Cost-effective care strategies should be evidence-based where possible, though common sense strategies should also be considered even if evidence in favor of such strategies is not abundant.
  4. The proportion of total reimbursement that emergency physicians derive from the successful adoption of cost-containment strategies, relative to the proportion derived from payment for services rendered, should be limited in order to ensure that these cost-containment incentives do not overwhelm service-driven and outcome-driven medical decision-making.
  5. Strategies that rely on the deferral of care in the ED should be considered as relatively high-risk, low-reward strategies when compared to others that are focused on cost-effective care and high-cost services.
  6. Cost-containment strategies for emergency care should be transparent to patients, providers, insurers, and policy-makers.

Myles Riner is an emergency physician who blogs at The Central Line, the blog of the American College of Emergency Physicians.  Reprinted with permission from the ACEP.

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  • Rob Lindeman

    There is a solution that lies anterior to ALL of these otherwise worthy ideas: focus efforts on reducing non-emergency visits. Honest estimates place the percentage of visits that simply do not belong in an ED at about %50. Forgive me for saying so, but the ACEP has tried to sell the public on the myth that 92% of ED visits are true emergencies. ED docs know better.

  • MD

    I have a solution to reduce cost for emergency care. Make a rule that if emergency physicians adhere to established criteria for ordering imaging studies, then they will not be at fault for any potential mishaps that may occur to patients. For example, to order 10000 head CTs on minor head trauma patients to find perhaps one with some significant finding is ridiculous. But ER docs have so much fear about missing that one that they over order all types of non indicated tests. I often hear ER docs say, I knew they have nothing but I am just checking. Take the fear out of medicine by reducing liability, and you will have a solution to the out of control ordering of imaging tests. Like the above poster said, if non urgent visits can be cut, then this will be another huge reduction.

  • solo fp

    Make people wait 6 hours for non emergent care, such as sinus infections, is one way that the current system penalizes users. Insurance companies charge $300 copays to each user who goes to the ER and is not admitted. Interestingly my states charges a massive $2 copay to Medicaid/welfare patients who see their assigned doctor in an outpatient visit but no copay if the Medicaid patient goes to the ER. Many Medicaid patients use the ER as their primary care clinic for free.

  • Edwin Leap

    Cost containment in emergency care is a noble idea. However, as long as EMTALA exists in its current incarnation, cost containment is going to prove nearly impossible. When patients can use the ED with no financial or social accountability, and when they can always sue for damages after being treated for free, then physicians will have to treat everyone and will practice defensively.

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