EMERGENCY CARE &

THE AFFORDABLE CARE ACT

ADAM INGRAM, JEREMY GRAY, BRANDON HARMON, WILLIAM OLOTUMASTER’S OF SCIENCE IN ALLIED HEALTH

HEALTH POLICY AND LAW 6500

PROF. PAUL LONGENECKER

26 APRIL 2016

OVERVIEW

• Introduction to the Affordable Care Act• History • Emergency care• Impact on access • Impact on quality

• Impact on cost• Conclusion• Recommendations• Questions

INTRODUCTION

• Literature has revealed that the there have been a tremendous increases in the use of emergency care and

emergency department (ED) services in the United States (US.); between 1999 and 2007, the annual number of US.

ED visits grew at roughly twice the rate of population growth.

(Joynt, Chan, Zheng, Orav, & Jha, 2015; Bo, Yifan, Shiying, Shin, & Yue, 2016)

INTRODUCTION (CONT’D)

• The introduction of the Patient Protection and Affordable Care Act (ACA) allows a citizen to explore the healthcare exchange for the best available and most affordable health insurance plan• Despite the ACA, use of emergency

departments is still high

INTRODUCTION (CONT’D)

• Three-quarters of emergency physicians are already seeing an increase in patients in their emergency departments since implementation of the  ACA

• American College of Emergency Physicians (ACEP)- did not take a formal position on the passage of the ACA• Support the provisions in the law that benefit emergency patients

• How does ACA impact access, cost, & quality?

HISTORY OF THE ACA

• Was initiated by president George W. Bush in 2004• March 23, 2010- President Obama signed the ACA• The ACA allows for:

• Options for health coverage• Access to free preventive care• Changed method of reimbursement• Expand Medicare and Medicaid coverage- state regulated

• Still debated in Congress and the legislative circuit• 25 June, 2015- Supreme Court ruled ACA constitutional (5-4 ruling)

President Obama and White House staff react to the House of

Representatives passing the bill on 21 March, 2010 (Wikipedia, 2010)

DEFINITION OF EMERGENCY CARE

“Life saving care that is provided in the nature of life threatening injuries”

• Examples: bloody vomit, car accident injuries, compound fractures, deterioration of mental status, ingestion of poison(s), massive hemorrhaging, pneumothorax, Zika virus

As defined by :American Academy of Orthopedic Surgeons (AAOS) (2014). Emergency Care and Transportation of the Sick and Injured (10th ed.). Jones & Bartlett Learning.

IMPACT ON ACCESS

• “ Strong evidence suggesting that the ACA access to primary care and specialty care is not timely…” – Orlee Panitch, MD, FACEP, Chair of EMAF (emergency medicine action fund)

• ED use higher among newly insured (Healthcare Exchange)• 75% of physicians report visit increases (n=2,099)

• 56% are Medicaid patients (n=1,175)• Ex:

• Oregon, 40% increase in ED use (has Medicaid expansion)• Georgia, 12% increase in ED use (does not have Medicaid expansion)

• Differences notable by state, due to the Medicaid expansion, or lack thereof

IMPACT ON ACCESS (CONT’D)

• Medicaid expansion• 32 states expanded

• 7,575,900 gain access with Medicaid expansion• California: ~2,113,000• New York: ~631,000• Ohio: ~454,000

• 19 states have not:• Alabama, Florida, Idaho, Kansas, Maine, Mississippi, Missouri, Nebraska, North Carolina,

Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Wyoming

• ~6,248,000 will not gain access to Medicaid without expansion

IMPACT ON ACCESS (CONT’D)

• ED physicians and support overwhelmed• Extended wait times within the ED

• CDC national study, 2014, n=1,650• 30 minute average wait time (0 minute- 440 minutes [+7hours])• 90 minute treatment time (22 minutes- 2,900 minutes [+2 days])

• Decrease in number of active EDs• 1996- 4,884 active EDs• 2009- 4,594 active EDs

• 6% decline• California, 26 EDs closed

IMPACT ON ACCESS (CONT’D)

• ‘Patient Centered Medical Home Model of Care’ (PCMHMC)• Personal physician, team approach, whole-person orientation, coordinated

care, quality care, enhanced access to care, payment reform• Attempt to reduce ED usage as primary care• Reduce ED overcrowding

• Reduce ED wait times• Reduce hospital acquired infections (HAI), reducing readmissions

• Cost effective

IMPACT ON QUALITY

• Creation of a new Accountable Care Organization (ACOS):• Improve care coordination & safety• Promote appropriate use of preventive health services                • Over 250 healthcare providers/insurance companies participates in

Medicare ACOS• Creation of health care law’s on EDs readmissions reduction program.

• Reduces Medicare reimbursement for high rate readmission on preventive illness.

• It encourages health provider to focus on safety and quality delivery.

IMPACT ON QUALITY (CONT’D)

• Volume to Value compensation method

• Medicare will not pay for repeated surgeries.

(QuantiaMD, 2014)

IMPACT ON QUALITY (CONT’D)

• Electronic health records (EHR) mandated for EDs under ACA• Easy access / transfer of patient information.• Enhances physician efficiency.• Increase patient satisfaction.

• Patient involvement in treatment decisions.•  “Shared decision making can lead to better treatment outcomes”

 (Ward et al., 2014)

IMPACT ON QUALITY (SUMMARY)

QUALITY BEFORE PPACA • No significant emphasis on quality care• Several readmission/physicians mistakes• No system that incentivize quality or

efficiency• Medicare/Medicaid reimbursement not associated with customer satisfaction survey• Limited use of technology in EDs

QUALITY AFTER PPACA• Keeps patients healthier in EDs.

• EDs avoid costly mistakes / reduction in readmissions.

• Rewarding quality instead of quantity• Use of EHR (smart-tablets, software, etc.)• Patient satisfaction survey is a large factor• Out-of-pocket payment to negotiate quality

care.

IMPACT ON COST

• American College of Emergency Physicians Survey, n= 2,099• 28% witness large increases in volume• 47% saw slight increases in volume

• Emergency departments have a federal mandate (EMTALA) to treat everyone, regardless of ability to pay. However, this mandate is unfunded

• Most ED visits occur outside of primary care business hours• Simply aren't enough primary care physicians (PCP) to handle all the newly insured

patients• Stanford University Medical School Study, 2015

• 90% of all ED visits have a preventative measure solution

IMPACT ON COST (CONT’D)

• Medicaid isn’t widely accepted by all PCPs due to reimbursement rates being too low

• 136 million patients in 2011- i.e. number of ED visits• Going to an ED when a PCP would suffice costs $580 more for each visit• Robert Wood Johnson Foundation = $78.8 billion in emergency care.

• 4,440 emergency departments in the U.S. in 2013• ~5,000 in 1993• This puts stress on ED’s, causes economic stress on providers/consumers, and

creates a distrust in the ACA

IMPACT ON COSTS (CONT’D)

• Patients covered under Medicaid pay $34/ED visit more as compared to those who are Medicaid eligible (low-income) • Reimbursement ratio is about 40% for Medicaid Covered vs. 34% Medicaid

eligible• Patients with private insurance coverage paid about $212 more per ED

services than those without insurance, but with incomes %138 greater than the federal poverty level (FPL)• Reimbursement ratio 54% private coverage vs. 39% Medicaid ineligible

IMPACT ON COSTS (CONT’D)

• Currently, the government pays between 50-75% of state Medicaid expenses.• No matter how large that total may be

• As consumers with insurance, we are paying a growing tax for those without. +/- $1000/year

• Consumers with insurance are less likely to use the ED because they tend to have a higher rate of having a family doctor, as for those with Medicaid, tend to not so they are more inclined to use ED instead of finding one. (only 17% visited ED w/ private insurance vs. 32% w/ Medicaid)

IMPACT ON COSTS: DEFINING ROLES

• •Consumers: preferences are not necessarily reflected in the prices that payers are willing to pay. Third-party payment is based on the value those third parties place on services, as well as on providers’ willingness to provide services at those rates, not necessarily the value patients place on these services• Example: If a hospital provides higher-quality care, it is unlikely to be paid a higher rate

—even if the patient were willing to pay more for such care• Providers: provide services that reflect the need of such service• The government is the single largest payer for health care and the single largest

provider of care- however, its role has been limited up until this point- potentially more federal legislation is needed

CONCLUSION

• Costs are still increasing at a substantial rate• Greater access to care overall

• However, access is not appropriate, care is not adequate• More quality measures have been implemented

RECOMMENDATIONS

• Give each state a lump sum of money at the start of each year, towards ED visits, that the state can use as seen fit and makes them more responsible. (Pipes, 2015) Increase incentives for primary care services

• Community paramedicine• Full Medicaid and Medicare expansion (all of 50 states)

• Medicare- more uniform across the country

REFERENCES

• Acep.org. 2013. American College of Emergency Physicians | News Room - Fact Sheets. (2013). Retrieved April 15, 2016.

• American College of Emergency Physicians (2015, March). [2015 ACEP Poll Affordable Care Act Research Results]. Published raw data.

• [Black and white star of life]. (n.d.). Retrieved April 17, 2016, from https://upload.wikimedia.org/wikipedia/commons/thumb/0/09/Gatunek_leczniczy_black_and_white.svg/120px-Gatunek_leczniczy_black_and_white.svg.png

• Dark, C. (2014). How the Affordable Care Act with affect emergency department payments. Annals of Emergency Medicine. Retrieved from. http://www.kevinmd.com/blog/2014/01/affordable-care-act-affect-emergency-department-payments.html

• Delgado, M.K. et al. “National Survey of Preventative Health Services in U.S. Emergency Departments,” Annals of Emergency Medicine, In Press, October 4, 2010

• Glans, M. (2015). Research and Commentary: Is the Affordable Care Act Helping Emergency Rooms? The Heartland Institute. Retrieved from.  https://www.heartland.org/policy-documents/research-commentary-affordable-care-act-helping-emergency-rooms

REFERENCES

• Glans, M. (2015). Research and Commentary: Is the Affordable Care Act Helping Emergency Rooms? The Heartland Institute. Retrieved from.  https://www.heartland.org/policy-documents/research-commentary-affordable-care-act-helping-emergency-rooms

• Joynt, K., Chan, D., Zheng, J., Orav, E., & Jha, A. (2015, September 15). The Impact of Massachusetts Health Care Reform on Access, Quality, and Costs of Care for the Already-Insured. Retrieved April 15, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/25219772

• Klemperer, D. (2015). Patient Involvement as a Means to Improving Care Quality. Deutsches Aerzteblatt International, 112(40), 663-664 2p. doi:10.3238/arztebl.2015.0663

• McClanahan, C. (2012, January 5). Secrets of the ACA: What is Medical Care Home? Retrieved April 17, 2016, from http://www.forbes.com/sites/carolynmcclanahan/2012/01/05/secrets-of-the-aca-what-is-a-medical-care-home/#7010e6493e6a

• McClelland, M., DNP, Asplin, B., MD,MPH, Epstein, S., MD, MPP, Kocher, K., MD, MPH, Pilgrim, R., MD, Pines, J., MD, MBA, MSCE, Kumar Rathlev, N., MD. (2014). The Affordable Care Act and Emergency Care. Retrieved April 15, 2016, from http://www.medscape.com/viewarticle/831955

REFERENCES

• The Medical Home Model of Care [Review of national conference of state legislatures Patient Protection and Affordable Care Act]. (2012, September). Retrieved from http://www.ncsl.org/research/health/the-medical-home-model-of-care.aspx#Overview

• Pipes, S. (2015). A New Cost of Obamacare: Surging Emergency Room Usage. Pacific Research Institute. Retrieved from. https://www.pacificresearch.org/article/a-new-cost-of-obamacare-surging-emergency-room-usage/

• Sebelius, K. (2013). The Affordable Care Act at Three: Paying for Quality Saves Health Care Dollars. March. 20.

• Ungar, L., & O'Donnell, J. (2015). Contrary to goals, ER visits rise under Obamacare. Retrieved April 15, 2016, from http://www.usatoday.com/story/news/nation/2015/05/04/emergency-room-visits-rise-under-affordable-care-act/26625571/

• Ward, M. J., Landman, A. B., Case, K., Berthelot, J., Pilgrim, R. L., & Pines, J. M. (2014). The practice of emergency medicine/original research: The Effect of Electronic Health Record Implementation on Community Emergency Department Operational Measures of Performance. Annals Of Emergency Medicine, 63723-730. doi:10.1016/j.annemergmed.2013.12.019

• Wu, J., Grannis, S. J., Xu, H., & Finnell, J. T. (2016). A practical method for predicting frequent use of emergency department care using routinely available electronic registration data. BMC Emergency Medicine BMC Emerg Med, 16(1). doi:10.1186/s12873-016-0076-3

Questions?