Institute of Medicine Releases Report on Emergency Medicine Services

"Knowing is not enough; we must apply.
Willing is not enough; we must do."
- Goethe

These are the opening lines to the Institute of Medicine Report on Emergency Medicine released today. In it, the Institute lays out several "systematic problems:"

• Insufficient Coordination
• Disparities in Response Times
• Uncertainty Quality of Care
• Lack of Readiness for Disasters
• Divided Professional Identity
• Limited Evidence Base

Not exactly a vote of confidence. The Institute, however, did roll out a few recommendations:

• "Congress establish a lead agency for emergency and trauma care
  within 2 years of the publication of this report. This lead agency should be housed in the
  Department of Health and Human Services, and should have primary programmatic
  responsibility for the full continuum of EMS, emergency and trauma care for adults and
  children, including medical 9-1-1 and emergency medical dispatch, prehospital EMS (both
  ground and air), hospital-based emergency and trauma care, and medical-related disaster
  preparedness. Congress should establish a working group to make recommendations
  regarding the structure, funding, and responsibilities of the new agency, and develop and
  monitor the transition. The working group should have representation from federal and
  state agencies and professional disciplines involved in emergency and trauma care."
• "The Centers for Medicare and Medicaid
  Services convene an ad hoc work group with expertise in emergency care, trauma, and
  EMS systems to evaluate the reimbursement of EMS and make recommendations
  regarding inclusion of readiness costs and permitting payment without transport."
• "Hospitals, trauma centers, EMS agencies, public safety departments, emergency
  management offices, and public health agencies develop integrated and interoperable
  communications and data systems."

I'm not feeling any better.

Granted, these aren't all the recommendations (there are three volumes totalling more than 600 pages). They are, however, the recommendations noted in their Executive Summary.

As a provider...basic questions such as (1) Who pays for the improvements? (2)How will hospitals (that compete with each other) be incentivized to work together? (3) When one out of three people who enter the ER can't pay for its services, how is Emergency Care even sustainable when fewer physicians (and hospitals) want to bear the cost and the liability?

Clearly complicated issues with complicated answers, but I'm afraid increasing government oversight and establishment of increasingly-specific legislative workgroups isn't going to get us there.

Instead, I would propose working on the issue at a micro level through three financing mechanisms:

(1) Subsidization of Hospitalist Programs to establish non-Emergency Medicine Physicians in the ER that will accept patients and steward them through their inpatient stay

(2) Establishing a Medicare Reimbursement Weight (much like CMS does for Medical Education) that helps hospitals pay for ER call in specialties that experience a significant call burden (i.e. when an individual has to take ER call for more than to nights a week).

(3) A formula be established that pays ERs for caring for a disproportionate share of the uninsured. Both physicians and hospital could participate in the plan and would have to show that they were not paid for services rendered.

Not a cure all...but at least a more functional way to respond to different markets without an increasing level of "market tampering."

Thoughts?

Setting a Foundation for Conversation

Given the democratic and capitalist bedrock the United States was founded on, very few in the mainstream media (and political environment) have debated the challenges related to applying market forces to public goods.

While education, law enforcement, water utilities, and other traditional "public goods" have been subject to competition from the private sector, few (with perhaps the exception of Energy) have financed private development through public funds to the degree health care has been in recent decades. Since their inception, Medicare and Medicaid have use public funds to provide cost based and fixed cost payments to facilities regardless of its government, non-profit, or for-profit status. In so doing, providers have been incentivized to reduce costs below the payment level in an effort to achieve some margin to be reinvested into the community (government/non-profits) or to provide a reasonable return to shareholders (for-profit).

Arguably, the for-profit sector has done an impressive job in modeling the ways in which health care costs can be reduced under this model and recent joint ventures with physicians have shown the savings that can be achieved when hospitals and physicians are together incented to cut cost and achieve ever-higher margins (see the latest quarterly results from USPI to glimpse the degree of magnitude).

Our discussion begins, however, with the nature of public goods. And as a global citizen, I will postulate that public goods must not only be run efficiently (which markets do impressively through Friedmans "Invisible Hand") but must also provide the service adequatly (i.e. with the greatest degree of quality) and equally (i.e. that the service is equally distributed as possible).

The policy challenge around health care therefore becomes one that does not solely maximize efficiency, but one that also achieves increasing levels of quality to a wider and wider spectrum of individuals regardless of race, geography, or socio-economic status.

Upon my own reflection, leaders and policy makers must then wrestle with how we provide and pay for health care services in order to maximize the "public good"... the founding question of this blog and the rubric in evaluating our policy and operational challenges of the past, present and future...

Welcome!

I've been a fan of blogs for some time, but I've never thought anything I've had to say would be something someone would want to read. There are, however, a number of topics I've always wanted to dialogue around and within - so hopefully - this experiment will start mindful debate and conversation here, around the water cooler, and amongst those who genuinely want to improve the health care provided here and abroad.

So please send your comments, musings, and topics which inspire us to realize the opportunities presenting themselves in each moment of our work...