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.

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Which Hospital-Based Physician Specialty Will Wield The Mightiest Pen In The Future?

In my last two blogs I examined how the dynamic behind bundled payments will create a vacuum to be filled by those with the most leverage. The leverage wielded by any physician specialty group will be determined not only by its ability to generate the most revenue and to save the most money, but also by the size of its integrated group.  And as CMS puts greater emphasis on hospital-acquired infections and readmission rates, I believe we will see the hospitalist emerge as the hospital-based physician specialty that holds the most leverage within the hospital in the new healthcare environment.

In the past, hospitalists have been on the lower end of average compensation for all hospital-based physicians, but that can be expected to change significantly in the future. Although they are a relatively new specialty compared to their colleagues, the growing leverage of the hospital medicine physician within the hospital may soon overshadow that of the other, more-established hospital-based physicians. Their importance to the financial performance of the hospital continues to become more apparent with new compensation methods being promoted by both commercial and public payers. 

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8/14/2012 5:13:24 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).
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8/10/2012 4:32:12 PM | 0 comments

As we continue in our Lean journey, much of what we are experiencing and learning so far relates to the methods of Lean, such as the vocabulary and multi-day improvement events. It's now time to develop further expertise with an equally important aspect of Lean: The Lean mindset.  The Lean mindset refers to an underlying focus on continuous improvement and problem-solving. The great news is that the method of problem solving is similar to what you  already use during a standard patient evaluation.  After reading my blog and reviewing the table below, I hope this is clear enough to apply to a problem you're having in your ED.

First, I would like to introduce another Lean term-- The Improvement Kata.  Kata is the Japanese term for routine. In Lean, the routine, or kata, we aim to repeat involves constantly defining new target conditions, or desired states, then using problem solving and PDCA (plan-do-check-act) in short cycles to get there.

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8/7/2012 8:14:05 PM | 1 comments

Based on the analysis I have posted here, there appears to be a fairly direct relationship between health plan competitiveness in state markets, allowable payments for in-network emergency care services (i.e. contracting rates for ED services), and access to Board Certified emergency physicians in these markets.  The data shows that lack of competition between plans for emergency physician services is associated with low contracting rates for these services, and that low payments from plans for in-network emergency physician services is in turn associated with lower numbers of board certified emergency physicians per 100,000 population in these states.  This data suggests that health insurance regulators should consider promoting health plan competition and mitigating the impact of health plan monopsony on the quality of health care services in the commercial health insurance market. 

Emergency physicians are subject to coercive contracting by health plans that use their market leverage with hospitals to coerce emergency physicians to accept deeply discounted below market rates for emergency physician services, or lose their opportunity to staff the hospital’s ED.  In addition, emergency care services, are subject to the EMTALA obligation to provide care to everyone, even if the insurer refuses to pay fairly, or negotiate reasonable contract rates.

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8/6/2012 9:43:44 PM | 0 comments

Occupational health systems today are efficient. Patients are seen more quickly and procedures are more easily authorized in occupational settings than in most traditional medical offices.  But under the Affordable Care Act (ACA), this may be about to change.

In the current version of health reform, there is less attention paid to occupational health than there was in the Clinton efforts back in 1993. The Clinton plan would have taken medical benefits out of workers’ compensation leaving only disability—a loss of 40% of funding for worker’ comp.  That would have significantly impacted the program, which traditionally provides medical treatment as well as payment for work leave and rehabilitation services, and benefits for permanent impairment and death.

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8/2/2012 8:50:58 PM | 0 comments
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