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?