Episodes of Care: Is Emergency Medicine Ready?

Emergency Department Visits After Surgery Are Common For Medicare Patients, Suggesting Opportunities To Improve Care

“…[41][42][43] However, as our study demonstrates, the reality is that ED visits after acute hospitalizations are commonplace, frequently the source of readmissions, and highly variable across institutions.…”

Aligning emergency care with the triple aim: Opportunities and future directions after healthcare reform

“…Emergency care is built to treat symptoms at presentation, not diagnoses over a broad arc of care. 13 This tension, for example, produces significant reluctance to perform screening tests in the ED (e.g., HIV screening) or manage chronic conditions without an acute component during the presentation (e.g., hypertension without hypertensive urgency or emergency). Such limits are consistent with an episodic, fee-for-service approach but discordant with a patient-centered, efficient system which would demand reasonable optimization of every patient encounter.…”

Payment reform in emergency care

“…51 Similarly, disease-specific capitation may be confounded by overlapping interrelated conditions (e.g., is an acute myocardial infarction included in the annual bundle for diabetes care?). 52 Further, EDs may be pressured to disposition patients based not just on their clinical symptoms, but on how a visit fits into an episode: if admission would trigger a new episode and payment, then the incentives are equivalent to the current volume-based FFS system, but if it would be included in a current episode whose bundle has already been triggered, no further reimbursements would be received. 49 While bundled payments, coordinated care, and P4P seek to align incentives to minimize complications and overuse while improving quality, most EDs are uniquely constrained by the Emergency Treatment and Active Labor Act and are unable to select patients or influence care-seeking behavior for the most part.…”

“…49 While bundled payments, coordinated care, and P4P seek to align incentives to minimize complications and overuse while improving quality, most EDs are uniquely constrained by the Emergency Treatment and Active Labor Act and are unable to select patients or influence care-seeking behavior for the most part. 52 As bundled payments are distributed to care networks and hospitals, institutions will be responsible for distributing payments among providers, and hospitals tend to overestimate the costs of ED care while underestimating rates of patient insurance and revenue generated from EDs. 53 Given that ED care is typically viewed as high cost episodic care and may not be considered a central part of the outpatient care coordination model, some EDs may be in danger of being marginalized in negotiating a role in the ACO model.…”