The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.
About two years ago, the hospital I practice at approached me about creating a 24/7 Observation unit (Obs). Our hospital is a large county hospital with approximately 120,000 to -130,000 annual ED visits averaging 1,000 to 1,200 admissions per month. A key reason why we started our Obs was that our one day stays were in the upper 30% range. The problem was that the hospital was losing revenue on these one day stays as they were denied payment by Medicare because these patients did not meet Interqual criteria for acute inpatient stays. Our goal for the Obs was simple: reduce one day stays to 25% as a starting point and see where we ended up.
About one third of US hospitals currently have Observation Units and this number is sure to grow. Researchers have recently estimated that the average cost savings per patient in a facility with an Observation Unit is $1,572, the annual hospital savings is $4.6 million, and the national cost savings is $3.1 billion. The cost savings for each individual hospital can vary, but the financial gains can come from avoiding the ACA’s readmission penalties and the Observation Unit’s added reimbursements. CMS now provides a one-time payment of around $500 plus any line item that the hospital bills for observation status that lasts from 3 to 72 hours, and the $500 is revenue that hospitals often did not collect in the past.
If the perception is that a visit to the ED represents a failure of the health care system, it sure makes it difficult for ACEP to assert that emergency physicians routinely provide valuable services to patients and insurers. Apparently, many policy makers hold this perception. It reflects the consequence of cost shifting (especially by hospitals) to cover the care of the under- and uninsured, which makes it appear that EPs are wasteful and inefficient. Health plans have aggressively promoted this misperception, using very distorted data. A good example is a recent study (“Many-ED Visits Could be Managed at Urgent Care Centers and Retail Clinics”) from the California Health Care Foundation, a very pro-managed care organization. Is it reasonable to compare the cost of treating strep throat in the ED versus the Urgent Care Center when the UCC turns away every patient with no money and no insurance? The attitude of the Health Plans is: “the uninsured are not our problem,” and would prefer to ignore our service to the uninsured in calculations of the value based proposition. The uninsured are not going away with Health Reform, and emergency physicians need to make sure that, in the value based purchasing calculation, no one takes for granted our mission to provide care to everyone regardless of ability to pay.
As I described in my last blog, the effective use of palliative care can actually lead to patients living better and longer lives. This practice of using fewer hospital resources while achieving better patient outcomes is something that will only grow in the future. But palliative care today is currently provided in an uncoordinated fashion. This can change as it becomes integrated with the emerging Medical Home and with the increased care coordination that is taking place across the Acute Care Continuum.
Coordinating the best palliative care for the patient is both a challenge and an opportunity within the Acute Care Continuum. The challenge is to get everyone who provides palliative care on the same page, and multi-disciplinary teams are already starting to connect with patients in order to facilitate palliative care. In the process of this emerging home patient care delivery system that resembles an ACO, the next logical step will be the interaction of the home care model with the ED in the most effective and efficient manner.
As the healthcare system is changing shape, and departments are realigning with the goal of increasing efficiency and care coordination, I hope that the big picture idea of the nature and purpose of healthcare does not get left behind. What is the value of human life? And how does this fit into the massive changes taking place in the organization and delivery of services?
At times, insurance companies and others try to estimate the value of human life for the purposes of cost/benefit discussions. Of course, this is an impossible task, as no one can assign a monetary value to a person’s life. Similarly, it is impossible to price out patients’ pain and emotional distress, or the ordeal suffered by their loved ones. But while I realize that businesses need to look at the bottom line, I hope that business decision makers realize that often the humanitarian perspective can benefit the bottom line. I hope that as the pressures mount and the Acute Care Continuum is forming, there is still time and a place for providers to ask, “What if this patient were my mother?”
It is very challenging in healthcare to talk with patients about death and dying. These are very difficult conversations to have, and even more challenging is that we usually only see patients in times of crises. But when we do learn about what patients want in advance, a lot can be done to give them the quality of life that they want. When I have seen palliative work to its full effect and potential, I have seen patients live better and live longer. In these cases we actually use less resources and the patients have better outcomes.
It is an unfortunate phenomenon that patients often times spend the last days of their life coming and going from a hospital. In our country, the default type of care given is having every possible machine used and the maximum radiation level given until the end. When there is a lack of conversation, it is always easy to do the most. But doing what’s right and doing the most are not always the right thing.
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