Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Healthcare Financing and the Difficulty of Making Good Decisions Under Stress

8/10/2012 4:32:12 PM | 0 comments

With rising health care costs, declining reimbursements, and increasing numbers of uninsured and underinsured, hospital CEOs face ever growing challenges to meet their narrowing margins. In addition, local and state officials are attempting to meet their budgets in the face of exploding Medicaid expenses, while the federal government is dealing with the fact that Medicare could go bankrupt in a few years. Needless to say, the stress level in this country regarding medical care is very high.  This is a bit disconcerting, as people rarely make good decisions while under stress.

That said, these are very exciting times, even historic times, and we are right in the middle of them (or at least we should be).  The Affordable Care Act has generated a lot of angst and everyone is trying to position themselves to succeed in this, soon to be, new reality.  Just look at the ACOs, the bundled payments, the medical homes, and the government think tanks (boy there is an oxymoron).  The healthcare landscape is like a land grab, and you will only be included if you can prove that you are useful (and cheap).  As ED physicians, we are at a disadvantage as more focus is being placed on the outpatient area.  On top of that, we are seen as being a big part of the problem, because of ED over-utilization by patients (never mind that the ED only accounts for a very small amount of health care dollars). 

That logic escaped the state of Washington (and other states) who are facing budget crises.  These States want to deny payment for ‘non-emergent’ ED visits and they have a list of 500 conditions that do not apply.  Forget the fact that we are required by EMTALA to see all comers and to perform a medical screening exam (which may include labs and other studies).  If we determine that the source of your severe abdominal pain is constipation and not an AAA (Abdominal Aortic Aneurysm), well then, that was a non-emergent visit and you won’t get the 15% of charges reimbursed.  Thank you very little. 

Like I said before, people rarely make good decisions while under stress (except for ED physicians). Luckily, the Washington state legislation is now held up in the courts and alternatives are being drafted.

That means, we, as physicians need to step up and provide feedback, input, and leadership; or else programs like those emerging in Washington state will occur more and more.  That means we need to actively participate on hospital committees where policy decisions are made and help find appropriate solutions. Better still, we should all get involved in medical staff leadership (Chief of Staff, Department Chair, Committee Chair), get on the Board of your hospital, health system, or the local IPA.  These are areas where significant decisions are made that will affect people across many specialties.  We need to work to influence those decisions so that they are good ones.  We also need to build relationships with local leaders so that they can understand and trust our input.

I never really realized the impact of Wes Curry’s statement “if you aren’t at the table then you could be on the menu” until recently.  Now it resonates strongly.  It is not that people are out to get you, it’s just that we are in a time of famine with regard to medical finances and people have to eat.  Rarely, do they volunteer themselves for the meal.

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