Healthcare News & Insights

Emergency room diagnosis tied to payments: Why the model is flawed

Many insurance companies are cutting payments to hospitals for treating patients in the emergency department (ED) for what are considered “non-emergency” diagnoses. But a new study indicates this approach may be a bit flawed.

EmergencySignResearchers attempted to verify the validity of such policies by examining whether there was enough of a correlation between patients’ initial complaints and their final diagnosis to justify using diagnoses as a factor in reimbursement.

The results, published in a study in the Journal of the American Medical Association (JAMA), indicate that the relationship is weak at best.

In reviewing data about hospital ED visits during the 2009 National Hospital Ambulatory Medical Care Survey, researchers found that a little over 6% of visits were for problems that could’ve been treated by a primary care physician.

However, the patients in those cases also had the same initial complaints reported for nearly 89% of all ED visits – many of which were for serious conditions. In fact, over 11% of these visits required immediate care, and 12% were admitted to the hospital. Out of admitted patients, 3.2% went directly to surgery.

So, the question arises: How is a doctor or nurse supposed to know whether a patient’s chest pain is caused by a heart attack or heartburn when the person first arrives at the hospital?

Incomplete approach

As the JAMA study indicates, there’s no clear relation between a patient’s chief complaint and the final diagnosis the patient will receive. So staff can’t immediately tell which patients have non-emergency conditions.

Since there’s no clear way to know if a patient’s symptom is caused by a minor aliment or a life-threatening condition, cutting reimbursement for hospitals treating these patients isn’t likely the best solution to curb cost increases, as it could end up compromising patients’ quality of care.

After all, in the case of the patient who presents with chest pain, hospitals typically perform extensive testing to rule out any heart problems.  But if the patient’s final diagnosis turns out to be a stomach bug, the hospital won’t get reimbursed for that testing under the new reimbursement model, which isn’t fair.

This could potentially encourage hospital staff to take “minor” symptoms less seriously, causing patients that may be seriously ill to put off receiving care until their condition becomes dire.

And that could actually raise healthcare costs down the line.

How one state curbed ED costs

A better, more holistic approach to reducing costs and providing better healthcare may be found in a policy enacted by the state of Washington to curb ED use among Medicaid patients, detailed in a report on the Washington State Health Care Authority’s website.

There, the focus is on preventing patients from visiting the emergency room unless absolutely necessary. The program places a specific emphasis on those who are “frequent users” of the emergency room, informing them about other options they can use for care and giving them information about preventing health issues.

Frequent users are identified via electronic health records systems that are synced together for all hospitals in the state.  Hospital staff can see all previous diagnoses, prescriptions and treatment instructions, and tailor an appropriate approach to each patient based on this data.

Using these best practices, the state of Washington has already reduced its Medicaid fee-for-emergency costs by 10% – and projected savings could reach nearly $31 million. Not to mention the fact that ED visits by frequent users have decreased by 23%.

Moving forward

Instead of penalizing hospitals for treating patients who seek treatment in the ED for minor health issues, taking a more proactive stance to educate patients about better options could have a much more far-reaching effect.

Hopefully more payors will become more amenable to this approach down the line. But in the meantime, hospitals can work to diminish ED visits by making patients aware of other options where they can seek treatment, including urgent care clinics and primary care offices.

If a patient does choose the ED, it’s important for staff to give the appropriate attention to the person’s presenting symptoms and avoid downplaying his or her ailment – at least until the worst has been ruled out.

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