By Joshua Tamayo-Sarver, MD, PhD, FACEP
CEP America is excited to announce the launch of Reform Realtime here on Perspectives. The initiative aims to examine the impact of health exchanges on acute care through:
- Up-to-the-minute data sharing
- Expert analysis
- On-the-ground reports from hospitals and physician leaders
- And much more
The goal of Reform Realtime is to provide you with an in-depth view of trends and changes affecting our industry.
So how can we do this? That's where our data comes in.
Numbers speak volumes
Leveraging across our billing, clinical, operational, malpractice, provider and external data sets, CEP America compiles a wealth of data from 120 practice locations in nine states. We use comprehensive data analysis and reporting tools to track over 900 data points for each emergency department we staff. Our sites represent every size and type of hospital, from tiny critical access facilities in rural areas to large urban hospitals and academic teaching centers.
Of course, we're not the only organization tracking and reporting the effects of healthcare reform. The Centers for Medicare & Medicaid Services (CMS) manages one of the largest repositories of healthcare data in the country. And state organizations like California's Office for State Health Planning and Development (OSHPD) are also keeping a close pulse on the rollout.
What makes Reform Realtime unique is its:
- Diversity of practice settings and patient populations
CMS and most states won't be publicizing today's data for 2–3 years. By contrast, we're able to share mature data within 2–3 months. This gives you a fairly accurate snapshot of what's happening in hospitals from month to month.
Payer mix is another limitation of CMS data. CMS only tracks Medicare and Medicaid patients. But because Reform Realtime tracks patients of all payer groups as well as the uninsured, we're able to present a fuller picture — including insights into the health behavior of the 7 million people who just joined state and federal health exchanges.
A few small caveats
While the Reform Realtime data is robust, no data set is perfect. So as you're viewing our content, here are a few things to keep in mind.
First, it's important to remember that our industry is in a transitional period. We'll likely be able to draw firmer conclusions as new pieces of the reform puzzle fall into place.
For example, payer data from January 2014 shows a sharp increase in the number of self-paying patients. However, hospitals are reporting that they're seeing many patients who say they've signed up for health exchanges, but haven't yet received their insurance cards. So my guess is that this bump in self-payers will be temporary and will decrease as the exchanges catch up on their paperwork.
Another caveat: for some states, we're still figuring out how to differentiate exchange patients from other payer types. This is especially tricky in California, which chose to run its health exchange through Medi-Cal (its state Medicaid system). So while our payer data for January shows an uptick in "Medicaid managed care" patients, many of these may actually be using a health exchange product. Again, we hope to bring you more meaningful insights as we refine our collection and analysis.
Trends to watch for
So what can we expect Reform Realtime to reveal over the next year or so? Well, I should probably start by saying that our main goal with the project isn't to predict but to observe and report. But just for fun, I'll venture a few educated guesses on what the future might hold.
First, based on existing literature, I predict we'll see an uptick in ED visits, particularly in rural areas.
To understand my reasoning, consider the experience of Massachusetts, which expanded healthcare coverage to nearly all citizens in 2006. Over the next several years, ED visits in that state crept upward by 3 to 7 percent. Compared to a 10 percent annual increase across the country, that wasn't much. But when you broke the data down by county, it was apparent that most of the increase came from rural areas of western Massachusetts.
A similar pattern played out recently in the largely rural state of Oregon, which conducted its Medicaid expansion by lottery. This created a unique "controlled experiment" in which the newly covered and non-covered populations served as randomized test and control groups respectively. So far, the newly covered have been making significantly more ED visits than their non-covered counterparts.
So it appears that lack of access in rural areas is one factor driving more patients toward EDs for non-emergent care.
And the impact of exchanges on access is a second trend I'll be watching closely. Conventional wisdom says that when more patients are insured, everyone wins. The patients can afford to go to the doctor. And physicians will provide less "charity care" to the uninsured.
But it doesn't necessarily play out that way. Back in my academic days, my research found that physicians and hospitals actually collect fewer dollars from Medicaid patients than they do from uninsured patients who self-pay. (This wasn't necessarily true in every state, but it was for the country as a whole.)
Physicians depend on a balanced payer mix and sufficient patient volume to generate adequate market-based compensation for recruitment and retention. Speaking hypothetically, having patients with private insurance (which can reimburse $300 or more per encounter) allows a doctor to see Medicaid patients for $50 or self-paying patients for $100 to generate net income goals for his/her practice, given the usual and variable overhead costs specific to each specialty and location.
So what I'm really wondering — where will health exchanges fit into this mix? Could physicians actually end up receiving less pay for seeing an exchange patient than they currently do for an uninsured patient?
I don't think we've got enough data to make an educated guess on that one yet. But if it's the case, it could further exacerbate the access issue and drive ED volumes upward.
Share your thoughts
Now that I've had my .02 (and then some), what predictions to you have? What will you be watching for as Reform Realtime unfolds? Leave us a comment below to share your thoughts.
Joshua Tamayo-Sarver, MD, PhD, FACEP, is director of clinical data analysis and research at CEP America, overseeing the organizational data strategy, evaluating the effects of programs and practices and leveraging data to provide the information needed for CEP to provide the highest quality and most efficient patient care. Dr. Tamayo-Sarver joined CEP America in 2008 as a fellow in administration and data. In addition to being the director of clinical data analysis and research, he works as a staff physician in the emergency department at Good Samaritan Hospital in San Jose, Calif., where he is also vice chairman of the emergency department and director of quality improvement. He holds a bachelor's degree with honors in biochemistry from Harvard University, a medical degree from Case Western Reserve University and a certificate in medical informatics from Oregon Health Sciences University. Dr. Tamayo-Sarver completed his PhD at Case Western Reserve University in epidemiology and biostatistics, where his dissertation was the development and publication of a novel model describing how physicians make clinical decisions in practice. He completed his residency in emergency medicine at Harbor-University of California, Los Angeles. He also spent a year working as an EMT and health educator in El Salvador.