Emergency room doctors see themselves in a health reform vise, squeezed on one side by administrators and payers who think they should work faster and better, and on the other by new penalty and billing rules they are only starting to understand.
That's what many said during the annual meeting of the American College of Emergency Physicians being held in San Francisco Saturday through Wednesday, which drew a record attendance of more than 6,000. Their concerns are prompting them to "redesign" what they do and how they work to improve both their value and their image.
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Emergency room doctors need to "consider stepping out of our perceived comfort zone and perception of only providing acute care," said ACEP's new president David Seaberg, MD, professor and dean of the University of College of Medicine in Chattanooga, during his opening remarks.
With this redesign, he said, emergency room doctors should drive "an additional team of health providers ? physicians, mid-levels, nurses, techs, case managers, and social workers" who would provide preventive care, immunizations, healthcare screenings, promote wellness through education on diet, exercise and other lifestyle choices.
That's a lot different than the usual practice, in which the relationship between the ED patient and physician ends when they leave.
"We can use our access to patients as a vehicle to enhance emergency medicine?s value by serving as a conduit to integrated medical care ? saving cost to the system and promoting quality care that keeps patients well," Seaberg said.
Emergency department doctors also should "enhance our observation units to further reduce readmissions and potentially avoid admissions, and develop better disease management and palliative care protocols," Seaberg said.
Meanwhile, these acute care frontline providers are also fighting what they consider to be erroneous perceptions ? that once healthcare reform is implemented patients who now go to emergency rooms seeking care will instead go to their primary physicians. That's not what happened in Massachusetts, and it isn't what will happen when healthcare reform coverage expansions take effect, he said, pointing to several research papers being presented during this forum.
Emergency physicians believe that primary care physicians ? even if there are enough around to see all the patients seeking care ? will still tell their patients to go to the emergency room, especially if it is after hours, when more than two-thirds of the 136 million ED visits occur.
Many doctors attending said they are already starting to do just what Seaberg suggests, even in a low-cost utilization area of Iowa City.
Hans House, MD, associate professor of the Department of Emergency Medicine at the University of Iowa Hospitals & Clinics, said that his emergency department ? as opposed to the hospital ? has already started to hire nurse managers and other care coordinators to visit patients and make calls to assure they and their families are getting appropriate care.
"We're pleased, because it's very well-received," he said.
One keynote speaker, Richard Wolfe MD, chief of emergency medicine at Beth Israel Deaconess Medical Center in Boston, said emergency room physicians can do more to be effective gatekeepers to keep patients out of the hospital if they don't need to be there.
"What is the most expensive thing we do?" He asked "It's that we admit patients to the hospital."
"If we can be effective gatekeepers, we can play an absolutely critical role (in reducing costs), but we need to start thinking about how we find other safe places to deliver care," he said. "And I would argue that if we build home care networks... (and make sure there are) checks with primary care physicians the next day, a much better social infrastructure, and use of nursing facilities for those patients we admit a little bit for medical problems but a lot because we don't think they're safe at home, we can have a very huge impact at that point."
ACEP's leaders are worried about cost cutting efforts taking place in many state Medicaid programs, such as a recent action in the state of Washington. There Medicaid officials ? in an effort to save $72 million a year ? have classified 700 patient symptom presentations as non-emergent, for which they will not pay even though many could indicate life-threatening conditions, such as vaginal bleeding during the third trimester, ACEP leaders said.
Other parts of the new state rule include a cap of three visits per month. The new rules were adopted without a comment period and without collaborating with the medical community, the Washington state emergency doctors say.
Nathaniel Schlicher, MD, associate facility medical director of St. Joseph Medical Center in Tacoma, and an official with the state's ACEP chapter, said hospital emergency rooms will have to provide this care regardless of the state's Medicaid rules, because patients will die if they don't.
The state's action is the subject of a recent lawsuit and temporary restraining order filed in state Superior Court of Thurston County.
But Schlicher said that what is even more worrisome is that some 19 other states are considering similar rules in an effort to save money.
Seaberg and many others attending said they know that they are in for a rough ride, but Seaberg articulated it best:
"The increased demands for our specialty underscore the challenges ahead," he said.
"The next three years of healthcare reform will likely affect the next 30 years of our practice. It will touch all aspects of what we do: how we work, how we are paid, and how we interact with our patients. In short, it will redefine the specialty of emergency medicine."