health care reform and emergency medicine

CONCEPTS

Health Care Reform and Emergency Medicine

From the Department of Emergency Medicine, Highland General Hospital, San Francisco*; Department of Medicine, University of California at San Francisco::; and Department of Emergency Medicine, University of New Mexico, Albuquerque. ~

Copyright © by the American College of Emergency Physicians.

Gary P Young, MD, FACEP *+

David Sklar, MD, FACEP §

See related editorial, p 692.

The twin goals of health care reform--providing universal coverage and limiting health care costs--will require increased primary care access and reductions in the overuse of inappropriate subspecialty interventions. The emergency department provides acute care access for all patients and nonemergency care for those patients unable to find other sources of care. Implementation of marketplace reforms may direct patients away from EDs to other primary care sites and reallocate residency positions now available for training of emergency physicians to other primary care specialties. These two effects may endanger the viability of the ED as the safety net of the health care system. The impact of health care reform on the emergency care system of the nation requires careful analysis to protect the important role of the ED in providing acute care and in guaranteeing access to care.

[Young GP, Sklar D: Health care reform and emergency medicine. Ann Emerg Med May 1995;25:666-674.]

INTRODUCTION

The nation~ emergency departments are the source of acute care for most critically ill or injured patients. EDs also have become the only guaranteed source of acute medical care for the nearly 40 million uninsured Americans. t-3 Insured and uninsured patients use EDs in minor injury or acute illness for various masons: the continuous availability of con- centrated diagnostic and therapeutic capabilities, and the lack of availability or capability of primary care providers to treat their acute problems. 4-6 All of these functions of the ED have evolved over the past 25 years as emergency medicine (EM) developed from one room in a hospital known as the "emergency room" (ER), to a new specialty with more than 100 residency training programs and nearly 100 million patient visits per year. The evolution was an acknowledgment that the specialty of EM represented a unique body of knowledge and that EDs met the needs of

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patients seeking around-the-clock urgent and nonurgent care. <5,r,s Indeed, the right of all patients to receive emergency care became law with the passage of the 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA). 9 This legislation guaranteed access to care for all patients presenting to the ED, regardless of their ability to pay, Current proposals for health care reform and rapid changes in the health care marketplace may alter the availability of emergency care through reimbursement strategies and limitation of training opportunities. 6,~°,1~ This article begins with a historic context from which to explore the effect of ongoing change in our health care system on the future delivery of emergency care.

HISTORIC PERSPECTIVE

Before the development of the specialty of EM, emergency care was sporadic, and the level of knowledge was rudi- mentau. Twenty-five years ago, there were no EM residencies. Physicians who staffed the ER often did so on a rotational basis as a duty of medical staff privileges. An acutely ill or injured patient who came to the ER might be cared for by a general practitioner or by a subspecialist in any discipline. Local physicians in private practice could not stay up all night in the ER and then work the next day seeing patients in their office or performing surgery, so they often took ER calls from home at night or from their office during the day A patient with an emergency might have to wait with the lone ER nurse for their own doctor or for the on-call physician to arrive from home or from the office. When a private practice patient experienced an acute problem, there was neither time nor capability in the office or clinic setting for it to be worked up. This still rep- resents an important contribution of EDs to the infrastructure of primary care in this country--backup support for primary care providers during regular office hours. <5,r,s

UNIQUE BODY OF KNOWLEDGE

Meanwhile, the science of resuscitation advanced. Prehospital resuscitation by trained personnel was shown to save lives, s2,13 Paramedics needed supervision by competent and motivated emergency physicians. The lifesaving skills needed to perform a successful resuscitation were not practiced by most medical staff. By devoting themselves exclusively to prehospital and emergency care without a practice outside of the ED, a group of physicians originally trained in other specialties became exclusively emergency physicians. They did not compete for patients with office-based practitioners, and they supported the practices of their non-EM colleagues by caring for their

patients during off-hours. Economic incentives through reimbursement provided by most insurance plans for ED treatment guaranteed the economic viability of the practice of EM. Finally, medicolegal decisions defined the level of emergency care expected from a hospital holding itself out as having an emergency physician on duty at all times. 14

CURRENT SHORTAGES AND FUTURE SCENARIOS

The first EM residency programs began in 197015, and the first board-certification examinations were held in 1980. ~6 The decline in the popularity of the other generalist specialties (internal medicine, pediatrics, and family medicine) in favor of subspecialty training has been chronicled elsewhere, zr49 In contradistinction, EM remains popular as a career choice among medical students. 19 The more than 100 EM residency programs (a near-doubling of programs in 10 years) graduate more than 700 residents per year. 19-22 As the most recently approved EM training programs mature into their full complement of residents, EM programs will eventually graduate more than 900 residents per year. 15,22,23 The following three scenarios represent potential supply-and-demand equations for emergency physicians.

Continued-Growth Scenario As early as 1980, the Graduate Medical Education (GME) National Advisory Commission identified EM as a shortage specialty. 24 It was estimated that more than 1,100 emergency physicians would have to enter the work force per year 24, which would require approximately 140 residency programs with eight graduates per year per program. 22-25 If one assumes no slowing in the growing demand for trained emergency physicians, this estimate remains accurate. More recently, in 1988, after reviewing ED staffing and housestaff supervision in teaching hospitals, the state of New York designated EM a "severe-shortage" specialty. 2~ But at the present rate of growth of four new residencies every year, it is projected that it will take another 10 years to meet the need for trained emergency physicians. 22-24 This continued-growth scenario requires more GME positions in EM until there are enough emergency physicians to replace the natural attrition in the specialty and to provide at least five residency-trained emergency physicians to cover 24 hours in every ED. Thus EM residency programs should be protected from the projected training cuts that will occur in other specialties to provide for more primary care GME positions. 27-29 And EM residency programs should receive a preferential level of support similar to that of the other primary care specialties. 2r

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Stable-Growth Scenario Because the heatth care system is undergoing rapid transformation, the continued-growth scenario just described may not accurately reflect the future demand for emergency physicians. Assuming a managed- care scenario for the future health care system, a recent analysis used current physician staffing patterns at health maintenance organizations (HMOs) to predict physician manpower needs. 3° The analysis was based on the per capita ratio of clinically active physicians in each specialty in the country as a whole compared with the numbers of specialty physicians employed by classic HMOs. The current ratio of emergency physicians in the health care system as a whole was found to approximate the anticipated need for emergency physicians in a managed care-based system. Emergency physicians were found to be the specialty in closest balance (1.1:1.0) with the needs of the patient population, lower than that of any other nonprimary care specialty. 3° This stable-growth scenario requires enough GME positions in EM to exist to ensure replacement for the natural turnover of emergency physicians, which will require more EM residency programs than currently exist. 24'25 Thus EM residency positions should be protected from training cuts in other specialties to make room for more primary care GME positions. 27- 29 The difference from the continued-growth scenario is that EM residency programs cannot expect to receive as much added support as may be preferentially channeled to primary care specialties,

Decreased-Demand Scenario In addition to the first two scenarios, a third scenario would result in less-than- anticipated demand for emergency physicians. An underlying assumption of some health care reform models is that both the number of hospitals and the number of EDs will decline. 6,sl In this scenario, patients without urgent conditions will not receive care from emergency physicians. Nonurgent patients will receive care from their primary care providers. According to a nationwide survey performed by the US General Accounting Office 4, the growth in ED use (from approximately 80 million visits per year in 1980 to almost 100 million visits per year in the 1990s) is multifac- torial. This and other surveys conducted by the federal government find that increased use of EDs is attributed to many different patient groups4-6: more seriously ill patients, more elderly patients Oe, Medicare), those with other forms of government-paid health insurance (ie, Medicaid), more uninsured patients, and a large number of ED patients with nonurgent conditions but no primary care provider. However, there is no gold standard for defining a true emergency, so the topic of what constitutes a "nonurgent" condition remains a controversial issue that has been

addressed elsewhere. 3>33 Regardless of the final number of hospitals and EDs, this third scenario still must meet two basic requirements for the health care system: first, that enough GME positions in EM exist to ensure replacement for the emergency physicians leaving the specialty21,25; and second, recognition that a steady state of supply and demand has yet to be reached in the specialty of EM. 2t,25 The bottom line is that only if the number of ED visits drastically decreases will a reduced need for emergency physicians justify cuts in current and approved-but-not-yet-existent EM residency training programs.

RESIDENCY MANPOWER ISSUES

Governmental and other official decisions will also affect the future supply and demand for emergency physicians. The Council of Graduate Medical Education (COGME), a division of the federal Health Resources and Services Administration, recommended that GME training positions be shifted toward primary care and away from specialty care. 2r EM, although a provider of much primary care, was never studied by COGME as a potential primary care specialty. COGME has also not analyzed EM as a shortage specialty, despite the evidence of a shortage of emergency physicians. The labeling of EM by organized medicine as a support specialty--like radiology, anesthesiology and pathology--should be reanalyzed. 29 If not, EM will be scrutinized for reduction of training positions to be trans- ferred to the traditional primary care programs or to the four nonprimary care specialties that have been designated shortage specialties by COGME (the only nonprimary care specialties evaluated by COGME to date). 11,2r Recently, the data from the appendix to the COGME report, known as COGME III, were used to model "Goal Oriented Projections. 'ql Assuming the goal of training 50% of residents in primary care specialties and supporting selected nonprimary care "shortage" specialties, it was projected that EM resident entry positions would be reduced 40%, from the 777 positions in 1992 to 475 positionsJ 1 It is questionable whether the specialty could sustain itself, even if in the future only patients with bona fide emergencies will present to the ED (in which case these critically ill patients certainly need trained emergency physicians).

The historic forces that have created the current supply- and-demand equation in EM will not be reversed quickly. Unless a substantial and immediate decrement occurs in the demand for emergency care, the transfer of training positions from EM for the production of more primary care physicians should not occur precipitously. And unless

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there is a definite decrease in the demand for emergency care, the loss of EM training positions will likely result in a shift in physician coverage of EDs away from specialty- trained emergency physicians to the substitution of primary care-trained doctors. This is based on the historic trends in emergency physician manpower before the introduction of EM training opportunities. Because EM is a young specialty, most physicians practicing in EDs were not trained in EM but, largely, in primary care specialties. 34 EM is not even close to reaching a steady supply of trained emergency physicians to staff the nearly 5,000 EDs in the United States. 2~ Cutbacks in EM training programs would exacerbate the current shortage of residency- trained emergency physicians. 34 In this scenario, many primary care-trained physicians would choose to work in the available ED positions. But they would have to get on-the-job training to broaden their experience in emergency care. This unfortunate eventuality would result in double jeopardy for our health care system by removing primary care-trained physicians from the primary care pool and placing inappropriately trained physicians in EDs. Given that there are 10 times as many residents in internal medicine as in EM, any decrease in the number of EM positions would scarcely affect the large number of positions in the traditional primary care specialties, a2,23

PRIMARY CARE STATUS OF EMERGENCY PHYSICIANS

Much of the health care reform debate focuses on the current perceived excess of subspecialists and the need for more generalist physiciansS ,28 Some would argue that emergency physicians are primary care physicians. 35 EM residency training provides physicians with broad general skills similar to those needed in primary care settings. 36,3r The emergency physician's practice is more general than that of either the pediatrician or the internist, and it is almost as general as that of the family physician. 36-38 In 1989, the legislature in Texas, a largely rural state, designated EM as a primary care specialty9 Yet it is noteworthy that only EM, of the generalist disciplines, has been classified as a %upport specialty."29 Currently, emergency physicians provide three of the four typical attributes of primary care identified by the 1978 Institute of Medicine report4°: accessibility, coordination, and comprehensiveness of services. Communication and collaboration between emergency physicians and primary care physicians serves to maximize cost-effective, comprehensive services for patients. Emergency physicians coordinate their patients'

care, minimizing the need for expensive specialty consul- tations or unnecessary hospitalizations.

The argument against primary care in the ED revolves around the lack of continuity of care--specifically, different emergency physicians providing sporadic acute care. 38 Primary care physicians are trained to address preventive measures, many of which would be inappropriate for the ED setting 38, although the benefit of many screening measures continues to be debated. "~1 It has been sug- gested that the lack of a continuity of care relationship with a physician will adversely affect implementation of personal preventive health strategies. 38 There are arguments in favor of emergency physicians supplementing the inadequate degree of primary prevention for underserved populations. 42-44 Emergency physicians have positively enhanced injury-prevention activities through local or state emergency medical service overseeing, as well as on a national level, such as the formation of the Physicians for a Violence Free Society. 45-4r Recently, the Residency Review Committee for Emergency Medicine added patient education about illness and injury prevention to the Special Requirements for Emergency Medicine Residency Training. 3r

What is the evidence that acute, episodic care is delete- rious or inferior to continuous primary care? Few studies compare intermittent care with continuous care, and the results have been mixed. 38,48,49 Some studies have shown that longitudinal care of patients with chronic illnesses by the same practitioners can decrease ED usage and emergency admissions. 4s,5° None has examined the outcomes for otherwise healthy patients who seek care for an acute illness in an KD instead of at their doctors' offices. Whether the additional expertise of emergency physicians in acute care will balance their lack of continuity experience with a particular patient is situation specific.

Ultimately, there must be a tradeoff between continuity of care and convenience of access to care. No physician will be available 24 hours a day, 7 days a week for his or her patients. 33,5 >56 However, new medical informatics systems may ensure continuity of information for patients with chronic illnesses who arrive in the ED. For more chronically ill patients, continuity and convenience of care are both important, at different times. For healthy populations, convenience of access may outweigh continuity of care. Changes in the health care system should allow for expression of these different patient-care needs by supporting appropriate ED access for both types of patients.

As the need for primary care physicians increases, EM residents or practicing emergency physicians could help fill these needs, although the amount of any additional training they might need is unknown at this time. 5r For

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example, as more emergency physicians age, it is assumed that they will be less tolerant of the demands of acute patient care in the ED setting. 2~,25 They may trade in their night shifts with more acute presentations for the more predictable nature of patient care in primary care settings. The use of emergency physicians to provide longitudinal primary care, as opposed to episodic primary care, is a complex issue that will require careful analysis should the need arise. 35,5r

UNIVERSAL COVERAGE VERSUS COST CONTROL

The twin goals of health care reform--providing universal coverage and limiting health care costs--may have contradictory effects on the future demand for emergency physicians. Cost control is one of the underlying premises for the decreased-demand scenario described above. On the other hand, evidence suggests that the ED patient census may increase as a result of universal coverage. 5s-6° Experiences in other countries with universal coverage demonstrate increased use of EDs. 51-54 Eor example, Canada's per capita ED use is 83.5% higher than that in the United States. 5s,61 If the millions of uninsured each receive a wallet card entitling them to health care beyond that provided by EDs, the current supply of primary care providers will not meet the initial demand. 17,1s,62 Until the primary care infrastructure is built, even more of these patients may present themselves to their local ED expecting care because their medical bills will be paid, 5s-6°

Attempts to control health care costs, such as the current experience with managed care, may also have contradictory effects on the future demand for emergency physicians. For example, the impact of capitation will depend on the incentives built into different capitation schemes. 63,64 Capitation may decrease ED use by requiring patients to first receive approval for the ED visit from primary care physicians ('~gatekeeping"). If primary care physicians are financially at risk for the ED visit, they will be less likely to approve the ED visit. One result may be a barrier to appropriate use of EDs for emergencies. 55,56 On the other hand, as capitation replaces fee-for-service arrangements, there could be less incentive for primary care providers to provide services for which they will not receive more reimbursement. ~o,63 This may result in EDs being the only source of care for many managed-care patients, particularly at inconvenient times for the primary care provider. For these reasons, emergency physicians may expect to become even busier.

Many managed-care organizations have implemented "gatekeeper" telephone-triage systems that require patients

or ED personnel to seek preauthorization before the ED is used by their insured patients, s° Over the phone, without benefit of an in-person triage evaluation, primary care gatekeepers triage away patients who are still at home or who are already at the ED to receive care in another location at another time. Without preapproval, insured patients may be responsible for the ED bill, which often means that emergency physicians end up providing free emergency care. 10.63 Managed-care gatekeepers do their jobs in an effort to save money, a new form of cost-shifting. But there are relatively little cost savings from the ED because EDs only represent between 1% and 2% of the health care dollar. 65 Patients will continue to present to the ED with acute conditions, initially unaware of or unconcerned about the possibility that their insurance may not cover the bill for their possible emergencies. Federal COBRA transfer legislation mandates that patients presenting to the ED must receive a medical "screening" examination and any necessary emergency care to %tabilize" them. 9 Emergency physicians not only have to concern themselves with "prospective" denial of reimbursement by managed- care insurers for the federally mandated ED screening examination and stabilizing treatment.~°,63,64 The "retro- spective" denial of reimbursement for previously rendered ED services is also a common business practice among third-party payers, s0,63,64 For example, reimbursement is denied for some ED patients on the basis of their chief complaint and for other patients because of their final ED diagnosis. The end results of lack of fair financial support for EDs will be their closure and the loss of emergency care access for all patients, insured and uninsured alike. 2,3

REIMBURSEMENT ISSUES

The assumption that ED acute care is more expensive than office-based or clinic-based primary care is generally true under our current payment system. Given current health care reimbursement mechanisms, an increase in ED use will not control costs. But EDs do not have to be more costly than care in other primary care settings. In one Canadian study, the cost for providing primary care in EDs was found to be no higher than that in physician offices. 66 There are fixed costs in keeping the ED open and available for critical emergencies, but additional patients actually reduce the average fixed cost per patient. 6r Hospitals also add charges to the ED bill to pay for non- ED clinical services used by ED patients. But to compete in the marketplace, hospitals will have to find other ways to pay for their administrative overhead. The advent of universal coverage and a better payer mix of ED patients

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should result in more realistic billing practices so that actual costs may be similar to those in other ambulatory settings, as opposed to reliance on cost-shifting mechanisms.2,6s, ~9

Many policymakers are only interested in the direct costs paid by the government or by third-party payers. The public values the financial benefits of access to acute care after hours or on weekends. Comparisons between ED costs and primary care office or clinic costs should factor time lost from work as patients make daytime appoint- ments for problems that could have been diagnosed and treated at other times in the ED. r ° ,n More important is that delays in care of patients with emergency conditions may result in increased morbidity and mortality r>r4 The 24-hour availability and concentration of resources may be the most cost-effective way to deliver acute care, regardless of the type of health care delivery system.r.s,51-54 There is a need for health services research to test this hypothesis; the applicable studies are not current or are from countries with different health care systems, r,8,51-54

Gatekeeper activities also interpose a degree of clinical risk for the patient. Studies have shown that both denial of care for patients already at the ED and telephone advice directing patients not to come to the ED are often inappropriate, with the potential for increased costs associated with patient morbidity. 55,56,75,r6 In one study, most on- call primary care physicians in the gatekeeper role and most emergency physicians reported that managed-care policies and procedures were "burdensome and inappropriate. ''56 In their traditional triage role, a central mission of emergency physicians has always been to ensure that only sick patients get admitted to the inpatient services of the hospital. A recent example is the introduction of pro- longed (ie, 6 to 24 hours) observation of patients in the ED, which is already providing a cost-effective alternative to hospitalization. 7r The true costs and potential disad- vantages for the patients of gatekeeper systems should be carefully analyzed before these systems are implemented for the micromanagement of emergency care. 10,63,64

Should emergency physicians only treat life-threatening emergencies? Given current reimbursements, EDs could not survive financially if they only cared for truly urgent cases and bona fide emergencies. 2,3,6s,69,rs As in much of the financing of the health care system, EDs depend on cost-shifting onto a high volume of less-urgent patients to remain financially viable and available for the fewer numbers of emergencies. 2,3 Because of cost-shifting, the ED bill for the most critically ill or injured patients has always been more reasonable (how much does one charge for saving a life or a limb?) than the charge for providing less

urgent care in the ED because of cost-shifting, r9 Even if all critically ill patients had insurance--and many do not-- the bill for ED patient care would need to be increased substantially to make up for the lack of nonurgent ED patient volume, r9 An economic lesson was learned by many hospitals that signed on as trauma centers but then gave up their trauma center status because even fewer trauma victims have insurance. 6s,69,r8 As a result, trauma centers must resort to cost-shifting onto insured patients to pay for the expense of continuously available trauma care.

IDENTIFIED PROBLEMS AND POSSIBLE SOLUTIONS

Careful reforms in GME must be made rather than reversal of the successful, relatively recent introduction of EM residency training. 19 It may be unclear what the needs will be for emergency physicians in the health care system in the next century, but in the near future more emergency physicians will be needed. 2°,2125 Thus it would be prudent to continue the generalist training of emergency physicians at current levels or higher levels to reach steady state in the specialty. At the least, EM residency training slots must be protected at their present levels, allowing for already-planned increases for the immediate future. Many arguments support the value to our health care system of a continuing increase in the numbers of EM training programs. Certainly there will always be a need for emergency physicians in EDs and in urgent care settings. There may also be opportunities to utilize their broad-based, generalist training outside the ED setting. 5r More than practitioners in most specialties, emergency physicians will be able to augment the primary care pool of providers. Once it is clear that the need for emergency physicians is decreasing, then reallocation of EM residency positions can be addressed from the proper perspective.

Emergency physicians and EDs are responding to the dictates of the marketplace in an attempt to provide more cost-effective care and to make up for the current shortage of trained emergency physicians. The use of physicians' assistants, nurse practitioners, and technicians in the ED is increasing. 8°,ss Physician extenders have long been a part of the ED clinical setting in the effort to provide more efficient acute care for less urgent patients and to partially offset the shortage of emergency physicians.

Urgent-care delivery systems adjacent to EDs also provide a cost-effective alternative for less-urgent ED patients. 82 These "fast tracks" are one way of reducing cost per patient while not totally displacing these patients from the ED environment during the initial evaluation of

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their urgent problems. There are clinical advantages to juxtaposing urgent patient care in the confines of the larger ED. It has been documented that some patients who present to the ED are initially unaware that they have a true emergency. 31 These settings provide acute diagnostic capabilities often not available in doctors' offices or only available after hours in the ED setting. The economic advantages of ED-based urgent care clinics have not been lost on managed-care organizations, which are considering starting their own to compete for this subset of ED patients. Unfortunately, this is another example of a major problem with our present health care system: duplication of both physical plants and personnel in disregard of the fact that these patient care services are already available in EDs. 63'64

The interposition of primary care gatekeepers between patients and emergency care is another managed-care concern for emergency physicians.i° Rather than inter- rupt the efficient flow of ED patient care by requiring direct contact between gatekeepers and ED personnel whenever another insured patient arrives, many EDs have negotiated waivers from this requirement from private and government third-party payers. The legally mandated medical screening examination is reimbursed by the insurer. Then, on the basis of the results of this screening examination, the emergency physicians agree to provide care appropriate to the urgency of the condition and the insurers agree to reimburse this appropriate level of care. Rather than micromanaging "competition," mature manage&care organizations prefer that primary care gatekeepers and emergency physicians work together to solve the problem of nonurgent patients applying for ED care. Is it not fraud to sign up patients, promising to pay for emergency services, but to subsequently not reimburse appropriate ED care? 63'64

Market-based health care reforms may threaten the financial viability of EDs as providers of essential community services. 2,3 As more acute primary care patients are removed from the ED, EDs must rely on a smaller number of truly emergency cases to finance their 24-hour-a-day operation. Ideally, EDs and emergency physicians would be allowed to increase the charges for saving a life or a limb to reflect the true value to society of emergency care. Otherwise, a less preferable option--but one that may merit serious consideration on the local, state, and federal levels--would be to provide tax-based funding for ED services, similar to those tax assessments that have stabilized the funding for prehospital emergency medical systems and trauma centers. Just as prehospital care providers and fire departments have "down" time, in which no emergency care is needed but the paramedics are waiting in a state of readiness, so too will EDs if they are to be staffed

appropriately for rapid response to life-threatening emergencies for all patients, insured and uninsured. The costs of supporting such down time in the ED will be consider- able and should be integrated into the overall costs to the public of a comprehensive EMS system, as other payment sources that now support EDs are withdrawn.

SUMMARY

The current emphasis on increasing primary care access and reducing health care costs may affect emergency medical care through reductions in emergency medicine residency training positions and regulation of patient use of EDs by primary care gatekeepers. These changes may have the unintended effects of causing a severe shortage of trained emergency physicians, an increase in the cost of care at the remaining EDs, and a further reduction in access to quality emergency care for all patients, insured and uninsured. The critical role of the ED in filling in gaps in our health care system and guaranteeing access to care should be acknowledged and protected from unwise changes that, if implemented, will adversely affect the health care safety net found in EDs.

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Reprint no. 47/1/63708

Address for reprints:

Gary P Young, MD, FACEP

1411 East 31 st Street

Oakland, California 94602

510-437-8496

Fax 510-437-8322

E-mail [email protected]

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health care reform and emergency medicine

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