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With less access to primary care and multiple gatekeepers adding to the expense of health care, perhaps EPs should be the final stop for many ED patients.

I’ve always known that I had ADD. That may be the primary reason emergency medicine appealed to me so much. Fifteen to twenty minutes with a single patient is about all I can tolerate, and I’m ready to move on to another challenge. Once I “have the answer,” the diagnosis, the treatment plan, etc, it is all too easy to leave the details of that treatment to others. That may not be so problematic with admitted patients. After all the attending has the final responsibility for carrying out what ever treatment plan he or she wants. But with discharged it’s another matter. All too often we have a scenario that sounds like this: “You have an ankle sprain. Here’s a splint and crutches. See your doctor for follow up.” The patient is then handed a set of pre-printed home-going instructions that may or may not exactly fit the patient’s problem or my presumed plan for them. Then they are asked to sign a form that they have been ‘instructed’. And out the door they go.

The good news is that we are trained to definitively manage 85% of the diseases and injuries that we see in the ED. So maybe it’s time we accepted this reality and planned for definitive care.

 

The problem lies in the fact that many of these patients will not follow up. They either don’t have a doctor, or don’t have the money, or both. In any event, emergency physicians are likely to be the one and only doctor that sees them for a given injury or illness. The good news is that we are trained to definitively manage 85% of the diseases and injuries that we see in the ED. So maybe it’s time we accepted this reality and planned for definitive care. Patients can still be encouraged to follow up. But to assume that it will happen may be missing a great opportunity to close the loop for many patients. Moreover, in today’s environment where there is pressure to hold down health care costs through bundling, it may be in everyone’s interest for the ED to be the one stop shop for as many illnesses and injuries as possible. 

But what will that mean to ADD docs like me? What kind of changes am I going to have to make?

Plan to allow time for extensive face to face home going instructions and education. How many of us have taken the time to personalize, expand, and particularize the standard set of home-going instructions such that they are complete, understandable, and reflect a clear outline of what a particular patient must do from the time they leave the ED to full recovery. It’s just too easy to defer to the pre-printed instructions. But often times we end up trying to shoehorn the patient into a general set of instructions. It’s no wonder they leave confused.

Use new media to provide more complete information. If you want to give a patient a set of generic instructions, consider using video seen in the ED and follow up info provided on the internet to provide the patient with real ongoing education and resources. Home-going instructions are sometimes pages long and still sometimes superficial. Try creating a library of videos with demonstrations of everything from dressing changes, suture removal, and rehabilitative exercises. Patients could view the instructions at the hospital, but then have ongoing access to them via the internet. 

More extensive use of follow up calls and return visits. In today’s environments of crowded ED waiting rooms we are often loathe to tell a patient to return to the ED. So use a little imagination on how you can speed up these return visits. Give them an ID card to bypass the administrative delay and proceed directly to fast track or a revisit clinic run by mid level providers. These same MLPs can be used to make call backs to check on patients to see if recovery is going well and if a revisit is even necessary. Patients will be encouraged to follow the rehabilitation plan more closely resulting in better outcomes. And complications will be picked up before they become big problems.

If you are like me you are probably saying “I’ve heard all of this before. I barely have time to see the patients I have, let alone make more work for myself.” But that is where you need to remember the axiom, “Don’t just work harder, work smarter.” Providing definitive care is not only better for the patient, but it can be better for you. Let’s look at some common examples.

A five-year-old falls and sustains a torus fracture of the wrist. It’s not uncommon to splint this injury and send the patient on to an orthopedist for follow up. The ED may charge for an evaluation and management charge plus a splint. However, the orthopedist may want to charge for definitive care. Consequently, or just as a matter of convenience, the orthopedist will re-X-ray the wrist, re-splint or cast, and follow in the office for three to four weeks, the same thing we could have done. If we take just a little extra time to take care of the complete problem, the patient (and the healthcare system that is paying for it) saves a bundle and we have a modest increase for our effort.

Here are some actual numbers. A torus fracture would be compensated at Level 3 (E & M) 1.80 RVUs (1.80 x $33.97 = $61.14), Level 4 (3.40 RVUs) if you documented follow up and/or a controlled substance was prescribed for analgesia (3.40 x $33.97 = $115.49). Furthermore, in most states (except Ohio), the EP can also bill for the diagnostic code 813.45 CPT 25600 RVU 7.44 (7.44 x $33.97 = $251.37). But this last amount is lowered 30% ($75.41) if the EP does NOT do definitive care. So total reimbursement to the EP could be $366.86 if he does definitive care and $291.45 if he doesn’t. 

The change is modest for the EP, but it could be huge from the patient’s perspective. Remember that all these costs are repeated when the patient goes to the orthopedist. There will probably be X-ray charges on top of that. What’s more, all of these are calculated on Medicare rates. Commercial insurance will pay from 100% to 335% of Medicare. By simply finishing the task, we can save the patient a thousand dollars or more, and earn ourselves $75 to $200. That seems like a smart thing for everyone.

How many times are there procedures that we have been trained to do, such as a simple extensor tendon repair, that you end up referring simply because you feel that the patient will need routine follow up visits? If EPs take more ownership of these cases, providing the same service as their specialty counterparts, they provide a valuable service to the patient and the healthcare system as a whole. Let’s face it, the healthcare system is going to have to become more efficient in order to lower costs without lowering quality. We know how to do it better than insurance companies or the government. But if we insist on maintaining business as usual, they will step in and mandate changes, possibly through across-the-board compensation cuts. This will only frustrate everyone with poorer quality care. If, however, EPs begin to look at ways to streamline care, by providing definitive care when it is appropriate, everyone will be better off.

 

Comments   

# That's nice, but...BW 2011-09-15 07:00
While this all makes sense in theory, the reality is that the amount of time that it takes to tell a parent "it's broken; we'll splint it; you need prtho f/u" is a tiny fraction of what it would take to provide definitive care. In addition, there is extremely low medico-legal risk to the former scenario (since you've already avoided the biggest hurdle by diagnosing the fx), while with the latter, we'd own it all, and, unlike the orthopod, we'd have no answer to the question in court: "Why didn't you send this to an orthopedist?"
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# BrandonMD 2011-09-26 00:11
I agree with BW. It's also problematic because I cannot predict what my future shifts will be like and that is hard to plan for any sort of follow-up. My luck I would have them come back and it would be one of those days where I am just struggling to keep up with the waiting room. It's not like we are in a clinic setting where we can plan ahead and make the appropriate space and time available.
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