Drs Robert Glatter, Jesse Pines, and Stephen Schenkel discuss a novel approach to reimbursement for emergency medical services.
https://www.medscape.com/viewarticle/...

-- TRANSCRIPT --
Robert D. Glatter, MD: Hi. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Joining me today to discuss a novel approach to reimbursement for emergency medical services is Dr Jesse Pines, chief of clinical innovation, US Acute Care Solutions; professor of emergency medicine at George Washington University and Drexel University; and an expert in health policy.

Also joining me is Dr Steve Schenkel, professor of emergency medicine at the University of Maryland School of Medicine, medical director of the emergency department at Mercy Medical Center in Baltimore, and also an expert in health policy.

I want to welcome both of you gentlemen to this discussion.

Jesse M. Pines, MD, MBA, MSCE: Thanks for having us.

Insights Into Alternative Payment Models
Glatter: Jesse, your article with Dr Leubitz in the recent ACEP Now really resonated because, obviously in emergency medicine, we're trying to reduce costs where we can but also provide high-quality care. The impact of this is felt everywhere, and what we do at the beginning in the emergency department matters. The fact that Maryland has had the ability to craft such general and advanced APMs is interesting. According to your article, this dates back to the 1970s, I believe.

I'll start off by asking you to educate our audience: What is an APM?

Pines: Basically, an APM is an alternative payment model. The operational definition is one that is not traditional fee-for-service, which tends to be transactional, where a patient and a clinician get together, there's a bill, and there's really no change in that bill based on the quality of care or the value delivered — that's traditional fee-for-service.

APMs do it in a different way, and it can be done by either paying a bonus to the clinician for providing better-quality service or taking money away from that clinician for providing lower-quality service, through some sort of gain-sharing model where there may be some savings from doing things a different way. That would be shared. The highest level of APMs is global capitation, where there's a fixed amount of money to take care of a population.

Glatter: Can you describe the mechanics of this model, including how it operates, how it works, how calculations were made, and also explain how you arrive at the moneys that emergency physician groups and hospitals can retain? Obviously, also discuss the behaviors that they can engage in and practice to make this APM work.

Pines: There's variation in physicians' decisions to admit patients to the hospital. Work that I had done years ago demonstrated that there was two- to threefold variation within and across hospitals in terms of this decision that emergency physicians make. That was really the beginning of the basis for this: Can we start leveraging some of that variation, get clinicians to put in evidence-based protocols, and then provide some shared savings back to the clinician for appropriately reducing admissions where the patient may not need to be in the hospital?

Basically, the architecture of this is that it focuses on Medicare fee-for-service patients only because that's the group that is regulated by the group at the Health Services Cost Review Commission (HSCRC) of Maryland. It hones down to diagnoses where there's variation in the decision to admit. That includes diagnoses like chest pain, pneumonia, and syncope, and takes out things like severe trauma, heart attacks, and strokes. It also takes out things like ankle sprains and abrasions where there's just not going to be much variation.

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https://www.medscape.com/viewarticle/...