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One of the most important aspects of any emergency department (ED) is risk management. Unfortunately, with tort reform hot on everyone’s mind, many people associate risk management strictly with hospitals and physicians doing everything they can to “CYA” – translation, avoid malpractice lawsuits. But that couldn’t be further from the truth. With the passing of the healthcare reform bill, risk management will continue to play a critical role in supporting our nation’s physicians and the clinical decisions they need to make to ensure patients receive the best possible care.
The newly-insured are going to soon flood today’s already overcrowded EDs, and pressure on each individual physician is only going to continue to mount. For many ED clinicians, the day starts out with a worried look out onto a crowded waiting room – so many patients to see, with more to come. Whether they want to admit it or not, the fear that runs constantly through every physician’s mind is, “What if, in the chaos that surrounds me, I miss something?” Every physician will take every possible opportunity to ensure that they don’t. But of the dozens of patients in that waiting room, a handful of them likely have high-risk conditions, and no matter how skilled you are, the trouble is identifying them where you least expect it. Enter the support of risk management.
I was traveling through Europe during the last week of the healthcare debate, leading up to the House of Representative’s vote to pass the Senate’s version of healthcare reform. I found it quite interesting that both the European press and the “word on the street” seemed to indicate that most Europeans believed that the U.S. was “finally” going to catch up to them – that America was finally going to provide universal healthcare to all of the people in the U.S. You should have seen the surprise on those faces after I informed them that even the most optimistic estimates would still leave over 10 million people without health insurance (to put it in a European context…more than the entire population of Greece, or Belgium, or Austria). It was obvious that the average European impression of American-style health reform was a movement towards their norm. They failed to understand that this was less about healthcare, and much more about politics and winning elections.
When President Obama set out to pass healthcare reform legislation, he stated two specific reasons why this was so important: universal access to health insurance and cost control. In fact, he often spoke of how the spiraling costs of healthcare in the US threatened the very viability of our economy. The President said that we could not sit idly by and watch healthcare costs grow to consume 20 percent of our GDP. It was the reason why companies like GM could not compete against their foreign counterparts. Well, when you look at the Congressional Budget Office’s (CBO) projected outcomes of the legislation and the subsequent reconciliation bill that were just signed into law, there will still be 12 to 14 million Americans without health insurance 10 years from now, and the growth in healthcare expenditures will reach more than 20 percent of the GDP in 2020.
I’m very torn about healthcare reform. As a business owner smack dab at the epicenter of the effects of healthcare reform, it’s a very timely boon to our business. As a taxpayer, although I think a lot of the reforms are necessary, I’m very skeptical about how we go about implementing and paying for it. And in many ways, I think so much more could have been done.
Good for business, but good for patients?
For Picis, healthcare reform and its companion legislation, the ARRA HITECH stimulus money, are going to spur tremendous growth opportunities. Today, the 32 million people that will soon be insured will end up going to the hospital emergency room for care under the EMTALA law (where hospitals aren’t allowed to turn away ER patients). The only problem is the hospital ends up footing the bill, putting pressure on their margins and reducing their ability to invest capital in IT and other systems. After covering 4 million more lives here in Massachusetts, we actually saw ER visits go up by 7 percent. Why? We didn’t add any more primary care doctors, and these newly insured patients swelled the offices of the existing general practitioner population to the point where 56 percent are no longer taking new patients. So where do these patient go? You guessed it – back to the ER, but for an entirely different reason. They’re not going to the hospital to get the only free care they can get – they’ve now got insurance – they’re going because they can’t find a doctor to see them in the ambulatory setting.
The transition of patient care and documentation from one provider to another has always been a challenge for the healthcare industry — disconnected hospital systems can lead to a game of “telephone” with important patient data (on paper or verbally,) which is both inefficient and risky. I have been involved for years in connecting systems together, and the complex interfaces that have been used to do this in the past have been a headache — plus, they have not achieved the seamless “plug and play” that we have seen from other industries. Nobody worries about what brand of mouse or keyboard they purchase anymore, they plug it in and it works. When will we see this kind of Valhalla for medical systems?
Soon, hopefully. Government organizations are now getting involved in setting standards for healthcare systems to work together. I have never seen so much progress and I couldn’t be more excited about it. A lot of this effort is around something called a CCD, or continuity of care document. There are different forms and different names, but they all boil down to a document that summarizes an episode of care, with structured data around things like medications, allergies and a problems list, which can be consumed and used in any system that touches the patient. There is a central “library” that these documents are submitted to, and then can be “checked out” at any time so that the most accurate information is always available to the physician.
One of the most important issues this year for emergency medicine physicians — audits — seems to be slipping by without a lot of notice. How is cost containment going to impact emergency physicians? Well, it could put us “up on a RAC,” for starters.
Recovery Audit Contractor (RAC) programs that examine physician documentation for signs that an admission was not justified have “corrected” $1.03 billion in “improper payments” by Medicare in Florida, California and New York. In other words, if you (the physician) have not documented how sick the patient is and how long you intend to treat them, your hospital could be denied the admission, have to pay fines and a third-party auditor could be reimbursed a percentage for finding the problem.
