a b s t r a c t

While there has been considerable effort devoted to developing Alternative Payment Models (APMs) for primary care physicians and for episodes of care beginning with inpatient admissions, there has been relatively little at- tention by payers to developing APMs for specialty ambulatory care, and no efforts to develop APMs that explic- itly focus on emergency care. In order to ensure that emergency care is appropriately integrated and valued in future payment models, emergency physicians (EPs) must engage with the stakeholders within the broader health care system. In this article, we describe a framework for the development of APMs for emergency medicine and present four examples of APMs that may be applicable in emergency medicine. A better understanding of how APMs can work in emergency medicine will help EPs develop new APMs that improve the cost and quality of care, and leverage the value that emergency care brings to the system.

(C) 2017

Introduction

There are growing indications that a fundamental shift in the way health care is paid for is underway, and that “the shift will be swift” [1]. In January 2015, the U.S. Department of Health and Human Services announced that 50% of all Medicare spending would flow through alter- native payment models (APMs) by 2018 [2], creating a renewed sense of urgency in payment reform efforts. Shortly thereafter the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed, which creates powerful incentives for physicians to participate in APMs. Although there are discussions about replacing the Affordable Care Act, there is a broad agreement that existing payment mechanisms in health care are not promoting high-value, cost-conscious care. APMs can take a wide variety of forms in practice, but at their core, APMs are systems that incorporate value and Total cost of care into the payment mechanisms of health care.

While there has been considerable effort devoted to developing APMs for primary care physicians and for episodes of care beginning with inpatient admissions, along with some attention to specialty am- bulatory care, there have been no major efforts to develop APMs that explicitly focus on emergency care [3]. Indeed, many APMs directly or

* Corresponding author at: Dept. of Emergency Medicine, Pen Bay Medical Center, 6 Glen Cove Drive, Rockport, ME 04856, United States.

E-mail address: [email protected] (N.J. Harish).

indirectly focus on reducing ED utilization. The narrow focus on reduc- ing ED utilization misses important opportunities to collaborate with EPs to reduce the total costs of care. In addition, APMs have not tradi- tionally enrolled patients who do not have access to a primary care prac- tice, although these are patients whose uncoordinated care represents a big opportunity for improving value and reducing costs.

In order to ensure that emergency care is appropriately integrated and valued in future payment models, EPs must engage with the stake- holders within the broader health care system in order to develop new APMs that improve the cost and quality of care, and leverage the value that emergency care brings to the system. Specifically, EPs should take active roles in their health system ACOs, ensuring that emergency care is factored into payment mechanisms being developed. On a larger scale, EPs should coordinate representation on federal advisory commit- tees such as the Payment Model Technical Advisory Committee (PTAC) that advises the Secretary of Health and Human Services on physician payment models.

In this article, we will describe a framework for the development of APMs for emergency medicine [4-6].

Barriers to delivery of high value care in fee for service

Many of the problems with the quality, safety, and efficiency of health care are caused by problems in the current structure of the fee- for-service (FFS) payment system. Although many people believe the

http://dx.doi.org/10.1016/j.ajem.2017.03.025

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surge capacity “>N.J. Harish et al. / American Journal of Emergency Medicine 35 (2017) 906–909 907

Table 1

APM #1: Additional payment for high-value services.

Goal Enable EPs to spend additional time to develop a discharge plan for a patient and/or to hire additional staff (e.g., a case manager) to make post-discharge appointments for testing or treatment in order to enable more ED patients to be discharged rather than admitted to the hospital. This could be applied broadly, or more narrowly to patients meeting specific criteria, such as a complex chronic disease or complex social situation.

assume a relationship between the patient and provider that is main- tained during that extended period of time. Emergency medicine, in contrast, is a specialty designed to deliver short-term care. Therefore, the accountability elements of APMs for emergency care must recognize that EPs often have only a single interaction with the patient. They gen- erally have no control over what happens to the patient before the epi- sode of care. Currently, they also have limited control over what happens after the encounter, although there are efforts to improve post-ED continuity of care.

Change from FFS payment

EPs could be given the ability to bill for a new CPT code for discharge planning services provided in the ED.

Mandate to see all-comers

Example A new code for “Greater than 15 min spent on discharge planning and direct patient education,” or “follow-up appointment scheduled.”

Most physicians have the ability to assess whether they will have ad- equate resources to address patients’ needs before they decide to treat

Ensuring adequacy of payments

Accountability for spending and quality

Payment amounts would be determined based on both the cost to deliver services and the expected savings from reduced hospital admissions. Higher payment amounts would be paid for patients with greater needs.

The EP would be accountable for achieving

risk-adjusted Hospital admission rates that are at or below pre-defined target levels based on admission rates that are known to be achievable with adequate resources. The payment amount for the new service code would be reduced if hospital admission rates are significantly higher than the target levels. Quality would be evaluated by measuring the rates of overall return visits to the ED and the rate of return visits with a high-acuity diagnosis such as myocardial infarction, and reducing payment amounts if ED return visit rates increase. Quality and outcomes would also be monitored using follow-up patient well-being scores.

them. However, EDs (EDs) are required by federal law (the Emergency medical treatment and Labor Act, or EMTALA) to evaluate all patients who seek care regardless of their need and without regard to their abil- ity to pay. Consequently, it is essential that APMs for emergency medi- cine ensure that payments are sufficient to adequately address the wide array of patient needs that EPs must address.

Mandate to maintain surge capacity and Disaster preparedness

The FFS system does not provide explicit financial support to physi- cian practices or hospitals for maintaining adequate capacity, such as the 24/7 readiness of EPs and EDs, and surge capacity for public health emergencies. As a result, efforts to keep patients healthy, reduce the de-

livery of services, and deliver services in lower cost settings (e.g., in a

Benefit to EPs The EP would have the ability to deliver additional

services to patients and enable patients to avoid hospital admissions. EPs would receive higher revenues from achieving better outcomes for their patients, not based solely on the volume of patients seen.

primary care office instead of an ED) can threaten the financial viability of EDs that we rely on for public health emergencies and disasters.

Table 2

APM #2: warrantied payment.

Benefits to payers Significant savings potentially could be achieved by

reducing the number of hospital admissions following ED visits.

Goal Reward EPs for successful diagnosis and treatment and reduction of ED visits

Similar approaches in other APMs

Payments to support patient-centered medical homes provide additional payments to primary care practices in return for accountability for reducing rates of Avoidable ED visits and hospitalizations.

Change from FFS payment

Payments would be increased for existing Evaluation and Management service codes, but payment would no longer be made for E&M services to the same patient who returns to the ED within 7 days.

problem with FFS is simply that it incents the delivery of more services,

Example The initial visit payment for “low back pain” would be increased, but return visits within 7 days would not receive additional payment.

there is a more serious barrier in FFS that must be addressed in order for APMs to successfully improve care for patients [5]. In the FFS system used by Medicare and most commercial payers, there is no payment or inadequate payment for many high-value services, such as communi- cation and coordination between PCPs and EPs, patient education, Case management, and transportation assistance for patients. For example, the University of Colorado “Bridges to Care” program, which uses a home-based model to address social and medical needs for frequent ED utilizers, resulted in a 43% reduction in ED visits and generated sig- nificant savings for payers, but its services are not billable in the current FFS model. APMs that do not remove the barriers to high-value services will be unlikely to lead to sustainable approaches to care.

Unique challenges in payment reform for emergency care

Although the barriers described above affect the care delivered by

Ensuring adequacy of payments

Accountability for spending and quality

The payment amount for E&M services would be increased based on an expected rate of return visits and the savings from fewer repeat ED visits. Higher payments would be made for types of patients or complaints that require more time in the ED and currently have higher rates of return visits, such as elderly patients with vague complaints, or patients with Psychiatric comorbidities.

Accountability for quality would be built into the payment, since the EP would receive higher revenues per patient if the rate of repeat ED visits is lower. To ensure that repeat visits are not avoided simply by admitting patients to the hospital, the risk-adjusted rate of hospital admissions would also be measured and the payment amounts for E&M services would be reduced if hospital admission rates increase significantly from past levels. Quality and outcomes would also be monitored using follow-up patient well-being scores.

many types of physicians, there are three unique challenges that have to be addressed in developing APMs specifically for emergency care.

Episodic interactions with patients

A key goal of APMs is to pay for improved outcomes for patients,

Benefits to EPs The EP would receive increased resources for patient

care during the initial visit to the ED. EPs would be rewarded for reducing repeat visits to the ED, rather than receiving higher revenues when patients return more frequently.

Benefits to payers Payers would spend less, not only through fewer repeat

ED visits, but by avoiding the hospital admissions that could result from the repeat ED visits.

rather than merely the delivery of services. Most APMs, such as medical homes and surgical episode payments, seek to improve outcomes mea- sured over 90 days, a year, or even longer. These APMs implicitly

Similar approaches in other APMs

Episode payments for inpatient care provide the same total payment to a physician or hospital regardless of the rate of readmissions to the hospital.

diagnostic uncertainty“>908 N.J. Harish et al. / American Journal of Emergency Medicine 35 (2017) 906–909

Payment models must acknowledge this mandate and factor it into ef- forts to reduce overall spending.

High diagnostic uncertainty

Table 4

APM #4: population-based payment.

Goal Enable EPs to address Acute care needs in the most cost-effective way possible.

Emergency care is also unique in the high degree of diagnostic and clinical uncertainty faced by providers. Many patients present to an acute care setting with signs or symptoms that could represent a serious underlying diagnosis, but turn out to represent a minor self-limited ill- ness, and vice versa. Whereas most APMs are focused on either patients

who have already received a particular diagnosis or who have already

Change from FFS payment

EPs would receive a monthly payment for each individual in a population of patients, such as the patients in a primary care practice or the employees of a business. The EPs would no longer receive payments for individual visits with patients. The EPs could deliver services in any way appropriate – in urgent care clinics, in primary care practices, and through telemedicine links as well as in traditional EDs.

been determined to need a particular procedure to treat that diagnosis, APMs in emergency medicine will need to support the time and exper-

Example Each EP receives a monthly risk-adjusted payment covering care for all members of a defined cohort of patients.

tise required to determine a diagnosis and the appropriate treatment.

Goals for physician-focused emergency medicine APMs

If the goal of APMs is to improve care delivery for patients, then the design of successful APMs for emergency medicine should be based on a vision of how Emergency care delivery should be improved. There are at least three areas where, with an appropriately supportive payment sys- tem, EPs could potentially improve the Delivery of care in ways that would be beneficial for patients and reduce spending for payers:

Reduce avoidable admissions. The decision to admit a patient to the

hospital is among the most expensive decisions that an EP can make and drives significant costs within the healthcare system. In many cases, however, it is likely that EPs decide to admit a patient simply

Table 3

APM #3: condition-based bundled payment.

Ensuring adequacy of payments

Accountability for spending and quality

The amount of the payment would be set at or below the current average spending on EP services for the population of individuals based on the amount of savings expected from care redesign. The amount would be risk-adjusted based on characteristics of the individuals (e.g., chronic diseases and health risk factors) that affect the frequency of acute care needs. Accountability for quality would be built into the payment, since the EP would not receive higher revenues if the rate of repeat visits increases. To ensure that repeat visits are not avoided simply by admitting the patient to the hospital, the risk-adjusted rate of hospital admissions would also be measured and the population-based payment amounts would be reduced if hospital admission rates increase significantly from past levels. In addition to monitoring follow-up patient well-being scores, care stinting could be assessed through patient surveys about access to care and monitoring for Delayed presentations of high-acuity diagnoses.

Goal Reward ED physicians who diagnose and treat ED patients at low overall cost per visit.

Benefits to EPs EPs would succeed financially by addressing patients’

acute care needs in the most cost-effective way, rather than receiving higher revenues solely based on the

Change from FFS payment

Instead of current service-specific payments, ED physicians would receive a bundled payment covering all of the testing and treatment services delivered in the ED. Alternatively, a per-patient budget would be

number of patients who come to the ED

Benefits to payers Payers would able to spend less on addressing acute

needs since more patients could be served in lower-cost settings.

established, and payments to EPs would be based on the amount remaining in the budget after payments for other ED services are made.

Example A single billing category for “abdominal pain,” which would be adjusted based on age, gender,

co-morbidities and presenting vital signs. A specific code might therefore be “abdominal pain in male aged 18-39 with no major comorbidities, without fever or

Similar approaches in other APMs

Accountable Care Organizations and other provider organizations that receive risk-adjusted global payments are paid a single monthly payment per patient to address the patients’ needs and they have the flexibility to deliver services in non-traditional ways.

Ensuring adequacy of payments

Accountability for spending and quality

tachycardia”. In this system, the level of payment would exceed the cost to care for some patients (e.g. simple gastroenteritis), but may be less than cost for patients requiring advanced imaging and specialist consultation.

The amount of the payments/budgets would be based on the current average total cost of ED services per patient for each condition. Payment/budget amounts would differ for patients with different complaints/symptoms based on current differences in the average cost of testing and treatment.

To ensure that the cost of services is not reduced by providing inadequate services, the risk-adjusted rate of repeat ED visits would be measured and the bundled payment/budget amounts would be reduced if the rate of ED visits increased. To ensure that lower spending is not achieved by admitting patients to the hospital, hospital admissions would also be measured and the bundled payment/budget amounts would be reduced if hospital admission rates increase significantly from past levels. Quality and outcomes would also be monitored using follow-up patient well-being scores.

because they do not have the time or resources needed to arrange for the necessary services in the community that would be required to en- sure the patient’s safety if they were discharged. The current payment system is a major cause, if not the major cause, of this problem: [1] EPs are not paid for the time (or for additional staff to support them) to develop a discharge plan and ensure that it is implemented, [2] the more time EPs spend arranging for a discharge, the less time they have to spend seeing other patients in the ED, and [3] current ED perfor- mance measures disproportionately focus on throughput (e.g. NQF Measure 0495, which targets ED length of stay [7]) and thereby penalize providers for keeping a patient long enough to ensure they are safe to discharge or to develop and implement a safe discharge plan. An APM that pays for the services needed to avoid preventable hospitalizations could potentially generate net savings for payers as well as benefit patients.

Reduce downstream care and costs. Although avoiding a hospitaliza- tion that isn’t necessary is one way EPs can create savings, there are also ways that EPs can reduce the costs of the hospitalizations that are

Benefits to EPs EPs would receive higher revenues if they can diagnose

and treat patients more efficiently, rather than higher revenues from providing additional services.

Benefits to payers Payers would spend less per ED visit.

needed and reduce the costs of future healthcare services for those pa- tients who are discharged. Rapid, accurate diagnosis and initiation of ap- propriate treatment in the ED can significantly reduce inpatient costs

Similar approaches in other APMs

Prospective payment systems for inpatient admissions (DRGs) pay a single case rate for all of the services delivered during a hospital stay.

and improve outcomes for many patients, with diagnoses ranging from cellulitis [8] to heart failure [9]. In addition, patients who receive an accurate diagnosis in the ED can avoid the need for additional tests

N.J. Harish et al. / American Journal of Emergency Medicine 35 (2017) 906–909 909

and visits after discharge and avoid the expense and potential harm of receiving outpatient treatment for the wrong condition. If APMs provide EPs with adequate time and resources to determine accurate diagnoses, appropriate treatment and follow-up services, the EPs can improve downstream care outcomes and decrease costs for payers.

Reduce ED visit costs. Emergency medicine has been a leader in devel- oping outcome-based decision rules that help to guide the appropriate utilization of resources (e.g. the PERC [10] and NEXUS rules [11]) and counteract defensive medicine practices. However, there remain signif- icant barriers to reducing overuse of testing in the ED, including throughput pressure, inadequate payment for time spent on obtaining a good history, and payment based on the number of tests performed. Properly structured APMs can support appropriate use of testing and re- duce the costs of ED visits for payers.

Potential physician-focused emergency medicine APM frameworks

Once specific opportunities for improvement and the barriers in the current payment system are clearly identified, a successful APM can be designed to overcome the barriers and allow the opportunities to be achieved. There are four components that must be included as part of any APM: [5]

What services will be covered by the payments under the APM?

What aspects of spending will the physician or other provider be held accountable for in return for the payment?

What aspects of quality will the physician or other provider be held accountable for in return for the payment?

What mechanism will be used to ensure that payments are adequate to enable the delivery of high-quality care to patients and remain ad- equate over time?

An APM for emergency medicine should give EPs adequate resources and flexibility to deliver the right care while holding them accountable for aspects of costs and quality they can control (e.g. avoidable compli- cations, avoidable admissions, utilization of testing, and appropriate use of low cost medications). EPs should not be forced to take substantial fi- nancial risk or risk for costs and outcomes beyond their control, such as unavoidable complications and decisions made by other providers.

Although there are many different ways that APMs might be struc- tured to achieve the opportunities and overcome the payment barriers described earlier, Tables 1-4 demonstrate examples of potential APMs for emergency medicine based on APM concepts that have been used in other specialties [6]. Based on these APM frameworks, risk-based contracting arrangements could be devised that take into account prac- tice-specific factors, such as the proportion of patient visits that are paid through an APM.

Conclusion

There are many opportunities to improve the value of emergency care, but there are many unique challenges that must also be addressed. Properly designed APMs could benefit EPs, payers, and patients. At a time when hospitals, insurers and policymakers are actively engaged in payment reform, it is imperative that EPs engage with other stake- holders to integrate emergency medicine into new payment models, and begin to design APMs that will improve patient-centered care out- comes and appropriately value the care they provide.

Prior presentations

None.

Funding sources/disclosures

NJH: Nothing to disclose. HDM: Nothing to disclose. JMP: Nothing to disclose. RDZ: Nothing to disclose. JLW: Nothing to disclose.

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