When looking at the impact of the newly insured, the Philadelphia market’s experience of an 8% rise in emergency department (ED) use is notable. Moving from uninsured to insured status may happen in a day, but new health service use habits take time. The impact of the newly insured – via Medicaid expansion or private exchanges – is still unfolding.
Truven Health forecasts on the impact of the newly insured mirror the statistics noted in the Philadelphia Inquirer article, “With Health Law, ERs Still Packed.” In fact, young adults and children are more likely to use an ED when they have insurance versus when they had less insurance. Surprisingly or not, children, Millennials and young Gen Xers are not primary care physician (PCP) loyalists.
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Vice President, Advisory Services
Listening to National Public Radio (NPR) on the way to work recently, I heard a very interesting report about Children’s Medical Center in Dallas incorporating full-time emergency department (ED) pharmacists to ensure appropriate and optimal drug therapy is provided to their patients in the ED setting. As a pediatric-trained pharmacist, anytime I hear about organizations embracing the pharmacists’ role in doing even more to support safe and effective drug therapy in this patient population, it’s particularly exciting. And this information was timely, as my colleague Tina Moen, Chief Clinical Officer for Truven Health, just shared her thoughts about the expanding role of the pharmacist in a recent blog post. While pharmacists have known for some time that we have a great deal to contribute to improving patient safety, it’s wonderful to know that others are taking notice now more than ever.
Important, key organizations such as the American Academy of Pediatrics (AAP) and Emergency Medical Services for Children (EMSC) are focusing much time and effort on improving pediatric services in U.S. emergency departments. This isn’t just for pediatric-specific emergency departments, but for any ED that will see neonatal and/or pediatric patients, whether frequently or infrequently. It’s estimated that up to 25 percent of all ED visits in the U.S. are pediatric patients, and approximately 90 percent of children’s visits to the ED are in non-pediatric hospitals.
EMSC – an organization that works to promote emergency medical services (EMS) and trauma system development at the local, state, regional, and national levels to adequately prepare for care of children – has developed 60 ED pediatric performance measures that comprehensively cover a broad range of assessable activities related to pediatric emergency care. I recommend visiting www.emscnrc.org to learn more about this resource.
As you would expect, some of the 60 EMSC performance measures and their potential outcomes are associated with drug therapy. For example, “timely treatment with anti-epileptic drugs for patients in status epilepticus” is one of the performance measures. The numerator for this performance measure is the number of patients who received an anti-epileptic drug within 10 minutes of arrival, and the required data elements include medication name, patient arrival time, and medication receipt time. As a pharmacist, however, there are many additional steps in this arena to further care and improve outcomes, simply by applying a medication-focused lens. For instance, while the patient may receive an anti-epileptic medication within 10 minutes of arrival, to assess the efficacy of the therapy, we need to know additional information and should do further assessment, including asking:
Without this further evaluation of medication practice, it’s difficult to affect outcomes and quality.
- Did the medication provided actually resolve the seizure?
- Was the right drug administered for this patient?
- Was the correct dose prescribed?
- What resource was used to determine the dose? How was it calculated?
- Was it administered correctly?
Other EMSC performance measures address pain management and sedation (e.g., the effective pediatric procedural sedation, treating and reassessing pain). While there are criteria for assessing adequate sedation or adequate pain relief, again, as a pharmacist, it’s clear that more information would lead to marked advancement in patient care. For example, if there were additional documentation required regarding the drug(s) used, the dose(s) used, the route of administration, etc., this would help to assess outcomes. As such, the additional detail can assist in developing protocols to assure adequate sedation or pain control in the majority of situations – a problem patients across the country routine indicate is an area of patient dissatisfaction in HCAHPS results each year. And this additional detail could identify inconsistencies or inadequate drug therapy, including drug dosing that leads to inadequate/ineffective sedation or pain control.
As the NPR story pointed out, not all hospitals will have the resources to hire a full-time, or even a part-time, ED pharmacist to manage pediatric drug therapy in the ED setting. However, a pharmacist’s focus and input have the potential to contribute greatly to improved pediatric emergency care. What has your ED done to be better prepared to treat children? How are pharmacists contributing to better emergency care? Let us know what first steps you have taken, or would like to take, to help your organization and others meet the mark for pediatric and neonatal care in the ED.
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Linda Elbers, Pharm.D.
Clinical Solution Advisor Neonatal/Pediatric Evidence-Based Practice
A recent survey of 74 C-suite executives, conducted by Health Affairs, revealed that 93% of hospital executives think that health reform will improve healthcare, and that is a testament to integrated hospital innovation that is already underway. These leaders, whose organizations on average, employed 8,520 workers and saw annual revenues of $1.5 billion, have an optimistic view and this is indicative of the continuing work undertaken by providers to make healthcare more accessible, cost efficient, and quality focused.
The executives in this study cited three strategies as critically important to address in order to reduce costs:
By demonstrating better cost controls and adaptations, our hospital clients have seen margin improvement from 3.5% to 5%.
- Reduce the number of hospitalizations
- Reduce the number of readmissions
- Reduce the number of emergency room visits
For every Emergency Department (ED) visit that is seen in a physician office, there would be a cost savings of $1171 per visit. 62% of the ED visits are URGENT, and not EMERGENT. This number has decreased annually over the last five years, but room still exists to cut costs further. By redirecting even 20% of the ED visits nationally, we could save $4.4B; a step forward that has many hospitals very engaged. Use of the ED for urgent care varies – with a range of 42% to 92% by market. An expanded primary care network, more accessible urgent care and one-on-one patient or prospect engagement are keys to shifting the use of the most expensive outpatient program, while making room for the true emergencies. This is a cost, quality, and access focal point for hospitals to continue their innovation, in addition to benchmarked cost effectiveness and care delivery quality excellence.
VP, Advisory Services
If you polled every physician, especially emergency medicine physicians, in the country, and asked if it would be valuable to have access to patient data from Health Information Exchanges to help prevent unnecessary admissions from the Emergency Department (ED); the answer would be 100% yes. I applaud the study by Joshua Vest PhD at the Weill Cornell Medical College to continue the national debate and increase the awareness about the importance of health information exchanges to reduce costs and unnecessary care in the country. The state of New York and others have been on the forefront to invest in the exchanges.
I realize that many are afraid to allow access to health records across a large spectrum because of HIPAA concerns, but I can tell you that as an emergency medicine physician, it’s safer for the patient. Emergency medicine physicians are the gate keepers and the ultimate patient advocate. If you become a patient in the emergency department, your physician will need to access records and diagnostic test results to avoid performing repeat tests and creating unnecessary readmissions. Many times a patient cannot remember what was done, where it was done, or even the results of the test performed. Yet, the patient is brought to a hospital in the middle of the night by ambulance to a hospital in town they have not been to. Yet, they had a vital piece of information during another stay that could mean the difference in whether additional test or admissions are performed. Even in the age of electronic medical records and advanced technology, it’s still challenging to try to get information from an unaffiliated hospital, clinic, or doctor’s office.
I actually worked a 12-hour shift in the Emergency Department just last week. I saw a patient who suffered an injury but went to an Urgent Care facility just a few hours prior to seeing me in the Emergency Department. The patient had an x-ray at the unaffiliated clinic, and therefore I didn’t have access to this information. It was a diagnostic test I needed to visualize to make the correct treatment and disposition decision. Fortunately, the urgent care clinic made a copy of the x-ray on disc and gave it to the patient. Thankfully, he brought it with him, preventing me from ordering another x-ray, adding to the cost of his treatment, and exposing him to additional radiation exposure. I was lucky in this scenario, but countless physicians (me included) could tell you stories where if we had access to information quickly, we could not only reduce cost, but improve customer service to the patient.
We must continue to educate and support the need to Health Information Exchanges to improve safety, reduce cost, and improve efficiency. This further buoys the conversation about Population Health and the continued need for integration of clinical and administrative data on a real time basis.
Byron C. Scott, MD, MBA, FACEP, FACPE
Medical Director, National Clinical Medical Leader
The recent New York Times article, As Hospital Costs Soar a Single Stitch Tops $500, discusses the cost of an Emergency Department (ED) visit. EDs are under intense scrutiny by all parties – payers, employers, providers, and the government – about cost, quality and patient-engaged care. In fact, nationally, 62% of ED visits are urgent care (not emergent), making them more of a “department of available medicine” than necessary. This varies across the country, where some markets show ED usage at 42% urgent visit share, while others tower north of 90%. Avoidable visits or overuse are typical of both Medicaid/self pay and commercially insured individuals. A national savings of $4.4 billion is possible if 20% of ED visits are redirected to an alternative or lower-cost care site.
Reform-based Medicaid expansion implies more demand for EDs, and requires adequate actual or virtual capacity. The opportunity is to provide alternative care settings. Some providers have had success in offering preventive screening physicals, care at urgent care centers (that accept insurance) and direct one-one patient engagement. One health system was able to reduce ED business by $1.5 million in Medicaid/self pay by reaching out to “frequent fliers” (5 or more ED visits per year) and educate them that the ‘next time,’ they can get the same or more appropriate care at a community health clinic. Providing the right capacity for the right care type in the right service setting goes a long way to protect the ED for the truly medically needy.
Commercially insured patients can also over-use the ED. 29% of employer-paid commercially insured patients, presenting with both an unavoidable and emergent condition, belong in the ED. 42% could have been cared for in a primary care setting. The net savings for redirecting commercially insured visits to a physician office setting is $1171 per visit. This invites a structure for an urgent care service line in physician offices.
The New York Times article states that compared to alternative outpatient care, the price of an ED visit is high, especially from the view of the cost-accountable consumer. However, EDs provide crucial health services, and there is a price for those life saving resources. What types of care belong in the ED is another matter that underscores its role at the eye of the storm of shifting outpatient care. All stakeholders – payers, employers, consumers, the government, and providers – are participating in the shift.
For more details, please download one of these publications.
Delivering Profitable Growth Through Market Intelligence, Dunn, MacCracken, 2012
Avoidable Emergency Department Usage, HealthLeaders Media Fact File, October 2013
VP, Advisory Services