Cost Reduction Strategies for Emergency Services: Insurance Role, Practice Changes and Patients Accountability

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999–2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to “stabilize” a patient suffering from an “emergency medical condition” before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users’ characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.     

Learning the developments in EMTALA jurisprudence through the lens of John West's “case law update”

This article covers three recurring issues concerning the federal law known as the Emergency Medical Treatment and Labor Act (EMTALA) that keep popping up in John West's Case Law Update case updates, and consistently bedevil hospital risk managers. First, what exactly constitutes an “appropriate” medical screening examination; second, when is a patient actually “stabilized’ under EMTALA; and third, does the EMTALA obligation really “disappear” when a patient is admitted to the hospital? The editors wanted to analyze topics that challenge the courts to “get it right” on the law and that drive risk managers crazy. EMTALA is the “poster child” for such a topic.     

Legal billing for pathology services

Minnesota physicians recently debated whether primary care physicians can legally and ethically "mark up" or add to the fees charged by a pathologist when submitting bills for pathology services to third-party payers. This article explores the relevant federal and state laws and offers the conclusion that both federal and state law allow for such a mark-up if it reflects reasonable compensation for additional work and risk assumed by the primary care provider group.     

Court decisions side with continued treatment of medically futile cases

Confusion reigns in the care of two medically futile cases as one state's supreme court requires hospitals to ask the local state attorney's office to arbitrate conflicts between "acceptable medical treatment and the patient's wishes," and another court applies the federal Emergency Medical Treatment and Active Labor Act (EMTALA) to require a hospital to stabilize an anencephalic child's respiratory distress.     

Legal review: auto-authentication of medical records raises verification concerns

In summary, federal and state laws require hospitals and practitioners to be accountable for the accuracy and completeness of medical records. The inevitable introduction of computer systems into the process of authenticating medical records evokes novel legal issues. Any computer system that does not require the review of reports after they are transcribed raises serious concerns regarding accountability for the accuracy and completeness of those documents. While federal and state laws have recognized that a signature on a document may be made by electronic or other means, regulatory and accrediting agencies restrict the auto-authentication of medical records. Systems have been proposed that would require the practitioner to see the report and would restrict the final signature authority to the practitioner after his or her review. These systems are likely to be closely scrutinized by regulatory authorities but may ultimately receive their approval. Currently, however, any system that does not require the physician to review and affix his or her signature to each document after reviewing the document creates serious risks for the health care facility implementing that system. Whether future changes in applicable laws will allow more flexibility for such systems is by no means certain.     

Working on reform. How workers' compensation medical care is affected by health care reform.

The medical component of workers'' compensation programs-now costing over $24 billion annually-and the rest of the nation''s medical care system are linked. They share the same patients and providers. They provide similar benefits and services. And they struggle over who should pay for what. Clearly, health care reform and restructuring will have a major impact on the operation and expenditures of the workers'' compensation system. For a brief period, during the 1994 national health care reform debate, these two systems were part of the same federal policy development and legislative process. With comprehensive health care reform no longer on the horizon, states now are tackling both workers'' compensation and medical system reforms on their own. This paper reviews the major issues federal and state policy makers face as they consider reforms affecting the relationship between workers'' compensation and traditional health insurance. What is the relationship of the workers'' compensation cost crisis to that in general health care? What strategies are being considered by states involved in reforming the medical component of workers compensation? What are the major policy implications of these strategies?     

Summary of final changes to EMTALA regulations

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted in 1986. Its purpose was to ensure that all individuals receive necessary emergency services from hospitals and not be denied care (i.e., "patient dumping") because of their economic status or lack of insurance. In its application, EMTALA has reduced "patient dumping," but at great cost to hospitals and physicians as an unfunded mandate. Despite 17 years of experience with the law, providers have been uncertain as to where and when, and to whom, the EMTALA obligations apply. The law has also proven to be burdensome and has been interpreted as extending far beyond the hospital emergency room. After reviewing the law for some time, the Centers for Medicare and Medicaid Services (CMS) released its final rules redefining the scope of EMTALA, reaffirming certain guidelines and modifying or clarifying others. The new regulations attempt to restate the parameters of the law as it applies to the emergency department and the hospital, as well as to inpatients and outpatients. The new rules clarify on-call obligations for physicians, confirming guidance issued by CMS in June 2002. This article summarizes the salient features of these new regulations.     

Physician Knowledge,Assessment, and Reporting of Older Driver Fitness

ABSTRACT

Physicians have the potential to serve as an important portal for information gathering, assessment, counseling, and reporting older driver fitness, as almost all older adults require medical care and have a primary care physician. However, there are few studies that have evaluated physician knowledge about, attitudes toward, and performance of older driver fitness assessment. Two pilot studies were conducted to assess physician knowledge and attitudes and aid understanding of physician knowledge of legal reporting requirements regarding older driver medical fitness. Results suggest that although physicians believe that patients should be evaluated for safe driving, many physicians do not routinely assess fitness to drive and few feel qualified to do so. It also appears that physicians may not be adequately knowledgeable about laws about reporting unsafe drivers. Thus, occupational therapy practitioners have an opportunity to educate about driving as a complex instrumental activity of daily living.     

Legal considerations in a nuclear detonation

This article summarizes public health legal issues that need to be considered in preparing for and responding to nuclear detonation. Laws at the federal, state, territorial, local, tribal, and community levels can have a significant impact on the response to an emergency involving a nuclear detonation and the allocation of scarce resources for affected populations. An understanding of the breadth of these laws, the application of federal, state, and local law, and how each may change in an emergency, is critical to an effective response. Laws can vary from 1 geographic area to the next and may vary in an emergency, affording waivers or other extraordinary actions under federal, state, or local emergency powers. Public health legal requirements that are commonly of concern and should be examined for flexibility, reciprocity, and emergency exceptions include liability protections for providers; licensing and credentialing of providers; consent and privacy protections for patients; occupational safety and employment protections for providers; procedures for obtaining and distributing medical countermeasures and supplies; property use, condemnation, and protection; restrictions on movement of individuals in an emergency area; law enforcement; and reimbursement for care.     

ASPEN‐FELANPE Clinical Guidelines

Background: The management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to physicians, wound/stoma care specialists, dietitians, pharmacists, and other nutrition clinicians. Guidelines for optimizing nutrition status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual institutional or clinician experience. Specific nutrient requirements, appropriate route of feeding, role of immune‐enhancing formulas, and use of somatostatin analogues in the management of patients with ECF are not well defined. The purpose of this clinical guideline is to develop recommendations for the nutrition care of adult patients with ECF. Methods: A systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the ASPEN Board of Directors and by FELANPE. Questions: In adult patients with enterocutaneous fistula: (1) What factors best describe nutrition status? (2) What is the preferred route of nutrition therapy (oral diet, enteral nutrition, or parenteral nutrition)? (3) What protein and energy intake provide best clinical outcomes? (4) Is fistuloclysis associated with better outcomes than standard care? (5) Are immune‐enhancing formulas associated with better outcomes than standard formulas? (6) Does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy? (7) When is home parenteral nutrition support indicated?     

Benchmarking physician performance, part 2

Part 1 of this article (January-February 2006) reviewed ways of measuring the work of physicians through methods such as data envelopment analysis (DEA) and relative value units (RVUs). These techniques provide insights into: 1. Who are the best-performing physicians? 2. Who are the underperforming physicians? 3. How can underperforming physicians improve? 4. What are the underperformers' performance targets? 5. How do you deal with full- and part-time physicians in a university setting? Part 2 compares the performance of 16 primary care physicians in the same medical specialty using DEA efficiency scores. DEA is capable of modeling multiple criteria and automatically determines the relative weights of each performance measure. This research also provides a preliminary framework for how work measurement and DEA can be used as a basis for a medical team or physician compensation system.     

Improving attending rounds: Qualitative reflections from multidisciplinary providers

Background. Attending rounds, the time for the attending physician and the team to discuss the team’s patients, take place at teaching hospitals every day, often with little standardization. Objective. This hypothesis-generating qualitative study sought to solicit improvement recommendations for standardizing attending rounds from the perspective of a multi-disciplinary group of providers. Methods. Attending physicians, housestaff (residents and interns), medical students, nurses and pharmacists at an academic medical center participated in a quality improvement initiative between January and April 2013. Participants completed an individual or focus group interview or an e-mail survey with three open-ended questions: (1) What are poor or ineffective practices for attending rounds? (2) How would you change attending rounds structure and function? (3) What do you consider best practices for attending rounds? We undertook content analysis to summarize each clinical stakeholder group’s improvement recommendations. Results. Sixty stakeholders participated in our study including 23 attending hospitalists, 24 housestaff, 7 medical students, 2 pharmacists and 4 nurses. Key improvement recommendations included (1) performing a pre-rounds huddle, (2) planning of the visit schedule based on illness or pending discharge, (3) real-time order writing, (4) patient involvement in rounds with shared decision-making, (5) bedside nurse inclusion and (6) minimizing interruption of intern or student presentations. Conclusions. The practice improvement recommendations identified in this study will require deliberate systems changes and training to implement, and they warrant rigorous evaluation to determine their impact on the clinical and educational goals of rounds.     

Benchmarking physician performance, Part 1

The performance of 16 primary care physicians in the same medical specialty and university clinic is compared using data envelopment analysis (DEA) efficiency scores. DEA is capable of modeling multiple criteria and automatically determines the relative weights of each performance measure. In this research, the performance measures include physician work relative value units (RVUs) as an input variable and patient satisfaction and total billable charges as the two output variables. The results provide insights into: 1. Who are the best-performing physicians? 2. Who are the underperforming physicians? 3. How can underperforming physicians improve? 4. What are the underperformers' performance targets? 5. How do you deal with full- and part-time physicians in a university setting? This research also provides a preliminary framework for how work measurement and DEA analysis can be used as a basis for a medical team or physician compensation system.     

BANKRUPTCY,MEDICAL INSURANCE,AND A LAW WITH UNINTENDED CONSEQUENCES

Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986, guaranteeing a standard of medical care to anyone who entered an emergency room. This guarantee made default a more reliable substitute for medical insurance. I construct a tractable structural model of the medical insurance market and find that repealing EMTALA would increase the fraction of the population with insurance while decreasing its price. Copyright © 2013 John Wiley & Sons, Ltd.     

Privatizing health care: caveat emptor

Many Western European countries are moving toward privatization of their health care systems. The United States' health care system, since it is almost entirely privatized, is therefore worthy of study. Doing so raises several questions. How is privatization being managed in the US? How could its management be improved? What management lessons must be kept in mind if it is to be used effectively? What potential pitfalls should European countries consider as they move toward greater privatization? With operating costs, European countries must avoid the mistakes that have led to dramatic increases in annual health care costs in the US, simultaneous with reductions in access and quality. Doing so requires designing systems that promote hospital behavior consistent with a country's health objectives. With capital costs, an approach must be designed that allows policy-makers to work closely with both managers and physicians in order to make strategically sound choices about access and quality. Such an approach will require physicians to incorporate their clinical judgments into community standards of care, and to adopt a regional (rather than an institutional or personal) perspective in the determination of any incremental capital expenditures. By making regulation proactive and strategic, rather than punitive, health policymakers in Western Europe can achieve the best privatization has to offer without feeling the sting of its unintended consequences. In so doing they can help to move their health systems toward achieving the multiple and illusive goals of access, quality and reasonable cost.     

The Physician Pipeline to Rural and Underserved Areas in Pennsylvania

ABSTRACT: Context: An implicit objective of a state's investments in medical education is to promote in‐state practice of state educated physicians. Purpose: To present a tool for evaluating this objective by analyzing the “pipeline” from medical education to patient care, primary care, rural areas, and underserved areas in Pennsylvania. Methods: AMA Masterfile data (2004) including all physicians with a Pennsylvania address or who received medical education in Pennsylvania were analyzed. These data were combined with local physician supply data. Results: About 36% of Pennsylvania medical school graduates provide patient care in the Commonwealth, 16% primary care, 7% rural care, 4% rural primary care, and 0.5% primary care in a rural underserved area. Fifty‐four percent of physicians who received both undergraduate and graduate medical education in‐state are retained. Conclusions: These retention rates have developed within the context of a middle‐of‐the‐road educational pipeline policy. If Pennsylvania policy makers consider that further pipeline development is advisable, there is room to amend current policy to that end. Conditions are favorable for other states to consider similar policy amendments.     

Police Officers’ and Paramedics’ Experiences with Overdose and Their Knowledge and Opinions of Washington State’s Drug Overdose–Naloxone–Good Samaritan Law

Opioid overdoses are an important public health concern. Concerns about police involvement at overdose events may decrease calls to 911 for emergency medical care thereby increasing the chances than an overdose becomes fatal. To address this concern, Washington State passed a law that provides immunity from drug possession charges and facilitates the availability of take-home-naloxone (the opioid overdose antidote) to bystanders in 2010. To examine the knowledge and opinions regarding opioid overdoses and this new law, police (n = 251) and paramedics (n = 28) in Seattle, WA were surveyed. The majority of police (64 %) and paramedics (89 %) had been at an opioid overdose in the prior year. Few officers (16 %) or paramedics (7 %) were aware of the new law. While arrests at overdose scenes were rare, drugs or paraphernalia were confiscated at 25 % of the most recent overdoses police responded to. Three quarters of officers felt it was important they were at the scene of an overdose to protect medical personnel, and a minority, 34 %, indicated it was important they were present for the purpose of enforcing laws. Police opinions about the immunity and naloxone provisions of the law were split, and we present a summary of the reasons for their opinions. The results of this survey were utilized in public health efforts by the police department which developed a roll call training video shown to all patrol officers. Knowledge of the law was low, and opinions of it were mixed; however, police were concerned about the issue of opioid overdose and willing to implement agency-wide training.     

End-of-Life Care Issues: A Personal,Economic, Public Policy,and Public Health Crisis

Advance directive documents are free, legal, and readily available, yet too few Americans have completed one. Initiating discussions about death is challenging, but progress in medical technology, which leads to increasingly complex medical care choices, makes this imperative.Advance directives help manage decision-making during medical crises and end-of-life care. They allow personalized care according to individual values and a likely reduction in end-of-life health care costs.We argue that advance directives should be part of the public health policy agenda and health reform.IS END-OF-LIFE CARE A MATTER of personal values, economics, public policy, or a looming public health crisis? Actually, it is all of these. But when we consider the population’s demographic shift to older adults, which is associated with chronic illness and multiple comorbidities, the enormous health care costs consumed in end-of-life care, and complex ethical issues, it is time for the public health community to put this issue squarely on its agenda. Increasing the rate of completion of advance directives is a key step, and specific policy strategies can be identified to accomplish this objective.Advance directives were created by federal and state law to ensure autonomy of patients who eventually become unable to make decisions for themselves.1,2 Advance directives are free, legal, and straightforward forms that can be completed in a few minutes. Typically, advance directives address several areas regarding end-of-life care when a person becomes unable to make medical decisions for himself or herself. First, a person defines the amount and kind of care he or she might receive under various medical circumstances. Second, a person designates a health care agent to make medical decisions when the person can no longer do so. Third, advance directives may also address other end-of-life care issues including organ donation, whole body donation to medical schools, funeral and burial arrangements, legacy recordings for posterity, and—in 3 states (Oregon, Washington, and Montana)—assisted dying.     

The price of progress: prescription drugs in the health care market

Pharmacy costs are rising in excess of general and medical cost inflation, leading to calls for price and utilization controls by public and private payers. Such controls would be ineffective and counterproductive because they would attempt to reverse two profound, historic phenomena at work in the U. S. health care system. The added costs associated with breakthrough medicines represent a major structural shift from the provision of traditional medical services to the consumption of medical products; they also represent the creation of economic, social, and public health utility that we value as a society. The balkanization of medical delivery, institutionalized under traditional reimbursement strategies and galvanized by federal law, does not adequately account for or efficiently accommodate this rotation and increased utility. Federal and state laws regulating health insurance and provider risk sharing need to be revamped to encourage rather than constrain the social progress embodied in expensive, breakthrough medical technologies.     

Current medicolegal and confidentiality issues in large, multicenter research programs

The convenience of fast computers and the Internet have encouraged large collaborative research efforts by allowing transfers of data from multiple sites to a single data repository; however, standards for managing data security are needed to protect the confidentiality of participants. Through Dartmouth Medical School, in 1996-1998, the authors conducted a medicolegal analysis of federal laws, state statutes, and institutional policies in eight states and three different types of health care settings, which are part of a breast cancer surveillance consortium contributing data electronically to a centralized data repository. They learned that a variety of state and federal laws are available to protect confidentiality of professional and lay research participants. The strongest protection available is the Federal Certificate of Confidentiality, which supersedes state statutory protection, has been tested in court, and extends protection from forced disclosure (in litigation) to health care providers as well as patients. This paper describes the careful planning necessary to ensure adequate legal protection and data security, which must include a comprehensive understanding of state and federal protections applicable to medical research. Researchers must also develop rules or guidelines to ensure appropriate collection, use, and sharing of data. Finally, systems for the storage of both paper and electronic records must be as secure as possible.