Published on October 30, 2014
PRACTICE MANAGEMENT COMMITTEE REPORT NEEL VIBHAKAR, MD, FACEP As you have read throughout this EPIC newsletter, the new waiver is very much upon us and it means we are practicing emergency medi- cine in an environment that is very different than it was just a few years ago. While the waiver will hopefully promote better outpatient evaluation, intervention and treatment, it does create an interesting challenge for emergency medicine providers across the state. This issue has very much been on the minds of your ED directors based on the questions posed to the Practice Management Committee. The most recent question was a 3- part question under the theme of ‘reducing admissions’ from the ED. Who is using Coronary CTAs (CCTAs)? Of the 17 responses, 6 stated they had CCTA availability. 3 of those institutions stated that while they have it available, they do not use it with frequency for a variety of reasons (too many hoops to jump through, too cumbersome, radiation con- cerns). The other 3 institutions have a specific protocol and for those patients with a negative study, they are discharged home from the ED. Another 2 institutions are in the process of developing a CCTA protocol and the other responses stated that they do not use CCTA in the ED. Most are probably discharging DVT patients. Have people started discharging PE's, as well? If so, do you have a protocol? Of the 17 responses, 16 stated that DVT patients are discharged presuming the patient is able to obtain the medication. None of the 17 who responded stated that they are routinely sending patients with PEs home. Do you have dedicated Care Managers in the ED? Of the 17 responses, 14 institutions have some sort of Care Man- agement coverage in the ED. That coverage varied from 8 hours/day to 21 hours/day. PUBLIC POLICY COMMITTEE REPORT ORLEE PANITCH, MD, FACEP The summer has passed. The primaries are over, and most of Mary- land’s 2014 elections are quite predictable at this point. We will be seeing a new Governor, and a new Secretary of DHMH in the coming months. With the new session of the legislature, we will be watching closely for new bills and issues to emerge. One issue that we have watched closely has been the definition of the ‘dangerousness standard’ for psychiatric patients. There has been much back and forth in committees, and it is anticipated that a fairly tight definition will stand. For emergency physicians, that will trans- late into a continued rigorous definition, with little ambiguity. Another issue that continues to develop is the creation of a Medicaid IRO process to adjudicate Medicaid MCO disputes and to regulate bad market conduct. A meeting was held at the Medicaid State offices with representatives of Medicaid, and ACEP President Steven Schen- kel, Public Policy Chair Orlee Panitch, and our lobbyist Pam Metz. Discussed were ideas of how the cost of reviews would be funded and how the processes will work. The Medicaid officials are aware of the problems with the MCO review process and the delays in payments and downcoding. The meeting was quite successful and we believe that there will be progress made this fall with the introduction of legis- lation. More to follow as things develop. -CONT. ON PAGE 3 SAVE THE DATE — March 20, 2015 MARYLAND ACEP 2015 Annual Educational Conference & Annual Meeting NEW LOCATION! BWI Airport Marriott 1743 West Nursery Rd Linthicum Heights, Maryland -MEDICARE WAIVER UPDATE CONT. FROM PAGE 1 rates with the HSCRC to some degree, and the rates at a given hospital may vary from other hospitals based on factors like the rate of self-pay patients. However, once the HSCRC determines rates for hospitals for a given year, the reimbursement from the payers is the same across all payers - Medicaid to third-party payers. The model has served Maryland, and presumptively CMS, well over the past 30-plus years. When the all-payer system started, the cost per admission for Medicare was 25% greater than the national average. In 2005, the cost per admission was 5% below the national average and this continued into 2007. Since then, however, the cost per admission has been increasing relative to the nation, and the “waiver” that allows Maryland to include Medicare and Medicaid in the all-payer system is in jeopardy. Rather than lose this waiver, Maryland began negotia- tions with CMS. The negotiations have led to the proposal and ap- proval of a new payment system for hospitals. For the next five years, this model will be in play, and if Maryland is not successful in imple- menting this plan, it will transition to the national Medicare hospital payment system. Beginning now, January of 2014, the payment model is shifting from a traditional fee-for-service model to expenditures per capita for all pay- ers. For the next 5 years, cost growth is capped at 3.58% for inpatient and outpatient care. For Medicare, Maryland will limit the growth to 0.5% less than the national growth rate per year. This is estimated to save Medicare $330 million in that five year period. For individual hospitals, their base rate is their total revenue from 2013, with the growth rate ceiling of 3.58% being imposed. Hospitals can choose from two models to transition. The first model would be to transition to a global budget model from the beginning. The second model in- volves a variable cost factor model that reduces the incentive for hospi- tals to make money by increasing volume. If volume goes up, hospi- tals keep a fraction of the increase, but they also retain some of the lost revenue if volume goes down. The intent of the change, besides the obvious cost savings, is to encour- age hospitals to move to a population-based approach in providing care. Hospitals will move away from being rewarded for inpatient volume to a system that emphasizes prevention, quality, and more care coordination. Keeping patients out of the hospital and working with medical homes and community resources could lead to better outcomes and a healthier population. If successful, this could lead to control of the total cost of health care for Maryland. Emergency Medicine will again be at the center of this process. Our “team” will need to include other personnel that can help navigate the options for patients. As this system unfolds, we hope the outcome will be getting our patients to the best place for care as they need it. -An edited version of this article originally appeared in ACEPNow, April 11,2014.