I appreciated all the dialogue that my recent post on KevinMD’s blog, “The emergency department in an ACO world,” has generated over the past week or so – the number of comments is a great indicator that ED physicians are not just letting this topic go by. I’ve compiled the following post to address as many as I can:

Defensive medicine: I agree entirely that any discussion of the cost of medicine should pull in the defensive medicine costs. There are people much better qualified to do that than I am (Dr. Dan Sullivan MD, JD comes to mind), but I think that the cost of medical care driven by fear of litigation is consistently underestimated. I’m certain it has had an effect in my own practice. My last shift was Sunday, and I probably was overly cautious with a bronchiolitis child that might well have done well at home, and a mystery abdominal pain got a pretty aggressive (and negative) workup. How much defensive medicine effect was involved is impossible even for me to say, but like most of my colleagues I have been named once (and a jury found in my favor) and it is something I will work hard to keep from happening again.

Regarding any perceived criticisms of the ED/ED physicians: I love the emergency department and I always have. It is risky, unpredictable and difficult, and as I get older my feet hurt and my body complains after every shift (hats off to all of you who have done this a lot longer than I), but I still love giving critical care to someone who needs it. The cricothyrotomy on a young person this year who made it with his brain intact will keep me going for another few years, although I will retire happy if I never do another. I also understand that as good as the ER is at taking care of all comers (and yes EMTALA requires it), we are better at some things than others.  Regardless of our skills and commitment, our ability to take care of business the way we currently do will run into the simple fact that the cost of medicine to Medicare and Medicaid to the federal budget will not grow forever. We have been hearing the word “unsustainable” for years, and to those who think this is just one more episode of many, just call your billing company and see what your bad debt is on commercial insurance. As the cost continues to rise, more employers are passing a significant fraction of care on to the patients, who can ill afford it.  Deductibles of $2000.00 are now common, and I have seen them up to $10,000, which simply results in more medical bankruptcies and patient calls for system change.

Addressing the cost of care means becoming more efficient, and that means tackling where much of the waste is, in coordinating care for complex patients that are chronically ill. Medication reconciliation is step one there, and we need to get better at a wide range of similar activities because our patients are getting older and sicker. If that is not going to affect your practice, I am pleased for you, but it will be affecting mine. Personally, when I have 12 medications and 5 medical problem, I want all of my doctors on the same page about what the plan is for my care. Very personally, my father had a craniotomy and hematoma evacuation while taking Coumadin after being put on Levaquin. His INR was 11, and he did not sue his doctor because I get how hard it is, and my father likely didn’t connect his A-fib to his bronchitis and mention his medication history at all. Coordinated care there would have saved I don’t even know how many dollars over the years on just his case. As we see patients in the ED for the 5th, 6th, 7th time in a year, the opportunity is there for ED physicians to make a meaningful difference. To be clear, I am not suggesting that the ED physician needs to do the discharge planning and social work functions that could be so beneficial to these patients, but pointing out to your administration the need for care management, articulating the advantages of better social services support, and advocating for better outpatient support is a good way to start. Many physicians of all specialties are already doing so, and the ED has a significant place in this conversation.

Finally, an ACO is about incentives. Right now the best way for me to pay for my kids college is to make sure my ED is full of sick people. Financially, I would be better off spreading the flu around than washing my hands. Obviously, I would never let those mis-aligned incentives impact my behavior or patient care, and I do not know one ED physician anywhere that would allow any incentives to practice to a patient’s detriment (although I did know one that partially owned a motorcycle dealer!) That said, when the incentives are a problem, the uninitiated and uncertain can become concerned. For example, I would have issues buying a car from a mechanic (my father waived HIPAA on his neurosurgery, but he won’t let me tell the car story). I think the public has a reasonable concern where the incentives are misaligned. The great benefit of an ACO is that under a good clinical integration plan a good clinical decision becomes a good financial decision from all points of view. I remain concerned about how to navigate the conversation around bundled payments, but I do believe it can be worked out where clinicians are engaged and are making decisions centered on the patient’s best care. To be clear, fee for service has done well for me, but I understand why the public (employers, payers, and patients) would like to see incentives change to something that rewards health more than illness. I am going to work very hard to make sure that I am helping to enable the best possible outcome for physicians, patients, and health systems. The comments here indicate that other physicians are paying attention to this issue, and are with me on the need to navigate change with the patient’s best interest in mind.

P.S. To those taking issue with my writing style/grammar. I will attempt to improve on that one, but I majored in biology and went to medical school and spent a lot of time in the ED while my friends were learning how to write. An informal style is the result, and is unlikely to change much.  Sue me (see paragraph 2).

–Mark Crockett, MD