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Heres the latest installment of my series of threads on ill conceived and just downright *****ic policies that EPs will be suffering under in the near future. To recap Ive addressed deferral of care policies:
Trouble on the EM Horizon-Deferral of Care
(Heres what ACEP says about these policies BTW)
And CMSs program to render antibiotics ineffective and over beta block bogus chest pain patients AKA Core Measures.
More Trouble on the EM Horizon-"Core Measures"
The latest bolus of abject stupidity is called HCAHPS. This is a program to link reimbursement to patient satisfaction.
CMS's info on HCAHPS
Most of us already labor under some degree of obligation to patient satisfaction surveys via Press-Ganey or Gallup or similar consultants. Many EPs have their contract renewals linked formally or informally to these scores. In other words most of us already have incentives to satisfy patients beyond the desire to practice good medicine and take good care of the legitimately emergent patients. HCAHPS will actually link EP pay to these scores for all CMS patients with private insurers to follow.
Patient satisfaction in terms of Emergency Medicine is a very problematic concept. While at face value care that satisfies the patient would seem to be an admirable goal that ideal is fraught with problems. Patients who are denied antibiotics for viral illnesses or denied inappropriate services via the ED such as completion of work comp forms and disability documents will be unsatisfied. Patient held due to lack of capacity such as those who are intoxicated or mentally ill will not be satisfied. The list of patients who will be unhappy with their appropriate care is long.
Another problem with HCAHPS is that it will be hospital wide and will not separate the ED experience from the inpatient experience. There will only be one survey that asks the patient how they felt about various aspects of their experience during the whole hospital stay. This is a crucial concept and fatal flaw of the program in that the only patients who will be evaluating the ED alone are those who were discharged. Thus the acute MI patient who received excellent care and went to the cath lab in 18 minutes will not evaluate the ED. The intubated patient wont even remember the ED. Rather it will be the patient who stubbed his toe and felt a 30 minute wait to see the doctor was too long and then didnt get the X-ray he wanted because it wasnt indicated will be the one rating the ED. The back pain who wanted to be admitted on a Demerol drip and was sent home with Motrin will be the one rating the ED and determining the EPs pay.
Ultimately my main problem with this program is that its goals are ill conceived. The ED is already the preferred place for patients to go because it is free, fast, has the full array of diagnostics not available in a PMDs office and, lets face it, so many people just have no access to primary care at all. We as EPs are given the job of trying to educate these patients about the proper use of the ED and the proper venue for their primary care issues. We all know this to be a difficult task. Now we are given the absolutely contradictory goal of trying to make the ED an even more inviting and satisfying place for patients. It is just not what medicine as a system needs right now.
Beyond the erroneous thinking that has led to this urge to make the ED warm and fuzzy is the fact that it will cause bad medicine. Under the gun of making patients satisfied at all costs or taking a pay cut how many docs will refuse the inappropriate antibiotics or narcotics or diagnostics? Clearly this program will make satisfaction paramount over the goals of education and evidence based medicine.
Since the aim of this program is so far off the mark people who actually work in the system might start to wonder what CMS could possibly be thinking. There is no real mystery. For CMS this is a cost savings program. The deal is that if you do well in this *****ic charade you dont get a pay cut. If you dont you get cut. So someone is going to be at the low end of the curve and will get cut which means, presto, savings for CMS.
Like many of the innovations weve been subjected to in recent years this HCAHPS program is a bad idea at the wrong time. And like the rest of these innovations those of us who actually work in the system will be dealing with the fallout and unintended consequences for years to come.
Trouble on the EM Horizon-Deferral of Care
(Heres what ACEP says about these policies BTW)
And CMSs program to render antibiotics ineffective and over beta block bogus chest pain patients AKA Core Measures.
More Trouble on the EM Horizon-"Core Measures"
The latest bolus of abject stupidity is called HCAHPS. This is a program to link reimbursement to patient satisfaction.
CMS's info on HCAHPS
Most of us already labor under some degree of obligation to patient satisfaction surveys via Press-Ganey or Gallup or similar consultants. Many EPs have their contract renewals linked formally or informally to these scores. In other words most of us already have incentives to satisfy patients beyond the desire to practice good medicine and take good care of the legitimately emergent patients. HCAHPS will actually link EP pay to these scores for all CMS patients with private insurers to follow.
Patient satisfaction in terms of Emergency Medicine is a very problematic concept. While at face value care that satisfies the patient would seem to be an admirable goal that ideal is fraught with problems. Patients who are denied antibiotics for viral illnesses or denied inappropriate services via the ED such as completion of work comp forms and disability documents will be unsatisfied. Patient held due to lack of capacity such as those who are intoxicated or mentally ill will not be satisfied. The list of patients who will be unhappy with their appropriate care is long.
Another problem with HCAHPS is that it will be hospital wide and will not separate the ED experience from the inpatient experience. There will only be one survey that asks the patient how they felt about various aspects of their experience during the whole hospital stay. This is a crucial concept and fatal flaw of the program in that the only patients who will be evaluating the ED alone are those who were discharged. Thus the acute MI patient who received excellent care and went to the cath lab in 18 minutes will not evaluate the ED. The intubated patient wont even remember the ED. Rather it will be the patient who stubbed his toe and felt a 30 minute wait to see the doctor was too long and then didnt get the X-ray he wanted because it wasnt indicated will be the one rating the ED. The back pain who wanted to be admitted on a Demerol drip and was sent home with Motrin will be the one rating the ED and determining the EPs pay.
Ultimately my main problem with this program is that its goals are ill conceived. The ED is already the preferred place for patients to go because it is free, fast, has the full array of diagnostics not available in a PMDs office and, lets face it, so many people just have no access to primary care at all. We as EPs are given the job of trying to educate these patients about the proper use of the ED and the proper venue for their primary care issues. We all know this to be a difficult task. Now we are given the absolutely contradictory goal of trying to make the ED an even more inviting and satisfying place for patients. It is just not what medicine as a system needs right now.
Beyond the erroneous thinking that has led to this urge to make the ED warm and fuzzy is the fact that it will cause bad medicine. Under the gun of making patients satisfied at all costs or taking a pay cut how many docs will refuse the inappropriate antibiotics or narcotics or diagnostics? Clearly this program will make satisfaction paramount over the goals of education and evidence based medicine.
Since the aim of this program is so far off the mark people who actually work in the system might start to wonder what CMS could possibly be thinking. There is no real mystery. For CMS this is a cost savings program. The deal is that if you do well in this *****ic charade you dont get a pay cut. If you dont you get cut. So someone is going to be at the low end of the curve and will get cut which means, presto, savings for CMS.
Like many of the innovations weve been subjected to in recent years this HCAHPS program is a bad idea at the wrong time. And like the rest of these innovations those of us who actually work in the system will be dealing with the fallout and unintended consequences for years to come.
