Healthcare 2 (2014) 184–189

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Aligning emergency care with the triple aim: Opportunities and future directions after healthcare reform Shantanu Agrawal n, Patrick H. Conway Centers for Medicare & Medicaid Services (CMS), 200 Independence Avenue, SW, Mailstop 325H, Washington, DC 20201, United States

art ic l e i nf o

a b s t r a c t

Article history: Received 3 February 2014 Received in revised form 10 May 2014 Accepted 22 May 2014 Available online 7 July 2014

The Triple Aim of better health, better care, and lower costs has become a fundamental framework for understanding the need for broad health care reform and describing health care value. While the framework is not specific to any clinical setting, this article focuses on the alignment between the framework and Emergency Department (ED) care. The paper explores where emergency care is naturally aligned with each Aim, as well as current barriers which must be addressed to meet the full vision of the Triple Aim. We propose a vision of EDs serving as a nexus for care coordination optimally consistent with the Triple Aim and the requirements for such a role. These requirements include: (1) substantial integration in coordinated care models; (2) development of reliable and actionable data on ED quality, population health, and cost outcomes; (3) specific initiatives to control and optimize ED utilization; and (4) payment models which preserve surge and disaster response capacity. Published by Elsevier Inc.

Keywords: Emergency care Coordinated care Payment innovation Health policy

1. Introduction: the Triple Aim The Triple Aim has become a fundamental framework for understanding the need for broad health care reform since described in a 2008 article by Berwick and colleagues.1 At its core, the Triple Aim is a “system of linked goals” designed to achieve a high value, equity-based health care system, one that “contribute[s] to the overall health of populations while reducing costs.”2 The first “aim” is Better Care or improving the individual experience of care. This aim is frequently articulated by the six drivers for improvement in the Institute of Medicine (IOM) report Crossing the Quality Chasm – safe, effective, timely, patient-centered, equitable, and efficient care delivery. The second aim, Better Health, captures improvement in the overall health of populations, which includes traditional health care services and disease prevention and health promotion. This aim seeks to integrate numerous aspects of population health, such as socioeconomic, physiological, and behavioral factors to lower disease burden, reduce mortality, and improve health and functional status. The final aim, Lower Costs, encapsulates the full range of expenses in the health care system – public and private payer, consumer out-of-pocket, public health, and indirect expenditures – to understand and lower the true cost of care for populations.

n

Corresponding author. Tel.: þ 1 202 205 9220. E-mail address: [email protected] (S. Agrawal).

http://dx.doi.org/10.1016/j.hjdsi.2014.05.005 2213-0764/Published by Elsevier Inc.

The three aims of this framework are in constant tension and can at times be in competition or complementary to one other. A particular delivery system change, such as a new expensive medication, may increase the cost of care while improving care provision or population health. Or provision of services in a low cost environment may improve the timeliness of care delivery but have negative impact on individual or population health outcomes. The framework requires a broad time horizon and viewpoint to be effective; over time, a responsible delivery system could work to correct such imbalances by lowering per capita cost while maintaining quality outcomes and access to care. The Triple Aim does not necessarily require equipoise today, but prioritizes equity above all else and demands a constant drive towards equipoise. The required balance and need to optimize all three aims is what distinguishes this framework from the current market and regulatory approach. Relatively little work has been done to apply the Triple Aim framework to particular clinical environments. This article focuses on the alignment between the Triple Aim and Emergency Department (ED) care, so often depicted as too expensive, uncoordinated, and unintegrated with broader delivery reform. ED care could be viewed as being at odds with the Triple Aim. This paper will explore where emergency care is naturally aligned with each Aim of the framework, as well as current barriers to alignment (Fig. 1). We will also discuss specific innovations in emergency care pushing the field further along toward realization of the Triple Aim. Finally, we will propose a vision of EDs serving as a nexus for care coordination and the requirements for such a role.

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Triple Aim Better Care

Current Alignment

Barriers

Demonstrated Improvements

Quick and effective management of acute and life-threatening conditions

Lack of integration in longitudinal care; episodic approach to care

Ability to deal with unscheduled and unpredictable care

Current economics rely on patient volume and quick disposition

Desired setting for “first contact” care Expedited, often complex evaluations

Short-comings in experience of care: wait times, crowding, boarding, quality outcomes Disparities in care

Better Health

Safety net: care of the uninsured, underinsured, and other disenfranchised populations Complex patients with numerous comorbidities and elevated acuity

Lower Cost

Comprises 2-4% of national healthcare expenditure Higher intensity care may prevent hospitalizations EDs preserve system response capacity to healthcare needs and disasters

Lack of preventive services, specialty care, or outpatient integration Lack of comprehensive, EDbased metrics of performance and outcomes High cost, resource intensive care Outlier billing behavior Expensive, complex decision making (e.g., patient admission)

Increased ED integration in coordinated care models: improved quality and performance measurement, availability of primary care to appropriately leverage ED care, focus on high cost and complex conditions Promotion of high value ED utilization: eliminate excess utilization, offer more longitudinal services and consistent followup, technology enhancements Creation of specialty EDs: focused, efficient services for specific patient populations Incorporation of efficient, Lean manufacturing processes: parallel processing, rapid intake and team triage

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Vision: Nexus for Care Coordination

Substantial integration in different models of care and delivery system approaches: structural and cultural integration, public health support Development of reliable and actionable data on ED quality, population health, and cost outcomes Specific initiatives to control and optimize ED utilization, streamline processes, eliminate waste Payment models which preserve surge and disaster response capacity

Fig. 1. Alignment of Emergency Care with the Triple Aim.

2. Better care: efficient ED diagnosis and care of complex conditions Optimizing care delivery for individuals requires that it be safe, effective, timely, patient-centered, equitable, and efficient. On many of these metrics, ED care shows significant alignment with this Aim. Unlike many specialties, IOM drivers for improvement are explicit in much of ED care. EDs are equipped and designed to quickly and effectively manage acute and life-threatening conditions and are judged routinely on timeliness and efficacy: 90 min for percutaneous intervention of certain heart attacks, three hours for diagnosis and treatment of stroke, four hours to antibiotics in pneumonia, and the “golden hour” of trauma care are some examples. All of this occurs in an unscheduled, unpredictable, and open environment under tremendous volume pressure: the number of ED visits has increased by 34% over the last 15 years and now exceeds 130 million visits annually.3 Improving throughput and efficiency through lean processes is a common approach to enhancing the timeliness and patient-centeredness of ED care.4 EDs are also increasingly being demanded by patients for “first contact care.” Over the last 10 years, treatment location for acute care visits has been shifting from physician offices to EDs – though ED physicians comprise less than 5% of the U.S. physician workforce, they now manage and treat over one-quarter of all acute care encounters.5 The highest increase in ED visits by time of day has been during traditional outpatient office hours.6 There are numerous factors leading to this shift, including symptom severity, convenience, the lack of other options, and limited hours or availability of primary care settings. Lack of insurance coverage does not appear to be the primary determinant of this trend, as many studies have documented a correlation between increasing insurance coverage and increasing ED utilization.7–10

Outpatient physicians too are demanding ED care for their patients, primarily to expedite diagnostic workups.11,12 A major benefit EDs offer is the availability of numerous resources, including a wide range of diagnostics, procedures, services, and access to specialty care. EDs are able to leverage these resources with efficiency gains over other outpatient settings. A patient requiring laboratory and radiologic testing and specialist consultation for the evaluation of a new or changing condition will often be referred to the ED, where such an evaluation can be performed in hours instead of days. The improvement in patient experience can be dramatic. Numerous factors contribute to this trend, including increasingly busy primary care providers, decreasing reimbursement, and the growing burden of complex patients. For both patients and physicians, ED care can offer value unduplicated in other settings. 2.1. Current challenges to care: lack of longitudinal care and crowding Despite their role in improving the individual experience of care, EDs face significant challenges in this aspect of the Triple Aim. One critical limitation is the lack of integration in longitudinal care. EDs typically adopt an episodic approach to care. Emergency care is built to treat symptoms at presentation, not diagnoses over a broad arc of care.13 This tension, for example, produces significant reluctance to perform screening tests in the ED (e.g., HIV screening) or manage chronic conditions without an acute component during the presentation (e.g., hypertension without hypertensive urgency or emergency). Such limits are consistent with an episodic, fee-for-service approach but discordant with a patient-centered, efficient system which would demand reasonable optimization of every patient encounter.

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Buttressing this attitude is an emerging view of ED care as a preventable, costly departure from a higher, more elegant care plan – essentially a failure of the system.14 Policy-makers and health system analysts will, for example, construct episodes or bundles of care which presume that little to no ED treatment is required, despite the numerous co-morbidities, lack of socioeconomic support, or simple disease progression among some patients which all but predict the need for ED care. This view also ignores the current economic model of most EDs, which rely on the rapid disposition of easily managed, low acuity patients for profitability; eliminating such visits could lead to ED closures and harm the social capacity to provide emergency or disaster care without alternative financing. In addition, EDs continue to be poor environments for the experience of care for some patients. Many EDs, particularly those in urban settings, are overrun and forced to have long waiting times or frequent delays in patient care progression. The stress on EDs is evident: between 2001–2008, ED visits increased 15%, average ED length of stay increased 21%, and average occupancy increased 27%.15 This occurs despite numerous systems and processes to expedite patient flow – such as placing stretchers for patient evaluations in hallways and ordering tests and diagnostics at triage. Numerous studies have demonstrated that EDs are getting more crowded, and a 2006 IOM report identified crowding as one of the five most important issues facing emergency care in the United States.16–18 ED crowding and boarding – the “holding” of admitted patients in the ED for extended periods – stem from numerous factors typically outside of ED control. Rather, they are the outcome of elective surgical schedules, hospital staffing levels, and broader hospital occupancy and length of stay issues. In essence, ED logjam is a downstream symptom of hospital-wide forces and decision making. ED patients frequently bear the ethically challenging consequences of competing interests within a hospital to maximize elective procedures and admissions while keeping the ED open for acute and unscheduled care.19 Crowding and boarding can have significant consequences on health care outcomes and the quality of ED care. A comprehensive review of over 360 research studies found ED crowding leads to a statistically significant increase in in-hospital mortality, particularly for intensive care unit (ICU) admissions; left-without-being-seen (LWBS) rates; and timeliness of critical clinical interventions.20 The authors also identified anecdotal evidence linking crowding to adverse events and errors, as other studies have found.21 Finally, the experience of crowding and its outcomes are borne mainly by populations in urban and socioeconomically deprived areas. This speaks directly to its ethical challenges and equitability of care.1

3. Better health: ED care for complex and safety net Patients Berwick and colleagues identified necessary preconditions for implementation of the Triple Aim, among them specifying a “population of concern” for which better health at lower cost can be pursued. EDs are open to all so is it possible to define a specific population of focus for ED care? By virtue of the Emergency Medical Treatment and Labor Act (EMTALA) and the changing role of ED care already discussed, EDs principally serve two specialized and important populations: the disenfranchised and medically complex patients. 1 Safety and quality issues are broader than the crowding discourse alone. EDs face a host of safety and quality challenges including hand-offs in care, potentially inappropriate medication administration, rate of 72 hour returns (“bounce-backs”), the availability of consultant backup, nurse staffing shortages, and availability of follow-up care, to name just a few.

First among the disenfranchised are uninsured or underinsured patients, the traditional safety net role. About 17% of ED visits are by patients without insurance – though to be clear patients with insurance are equally or more likely to utilize the ED.22 The salient difference is that the un- or under-insured have comparatively fewer options for care.23 Uninsured patients have less access to primary and specialty care, often facing appointment delays of up to 21 days. EDs address a higher proportion of their needs, even for conditions which are better handled in other outpatient settings. The result is a higher volume and cost burden on EDs.24 In addition many social ills share the common pathway of ED care. Substance abuse and withdrawal, intimate partner violence, child or elder abuse and neglect are part of the epidemiologic undercurrent of emergency care.25 Implementation of the Affordable Care Act (ACA) is expected to significantly reduce the uninsured population through Medicaid and private insurance expansion, but the ED role in serving the disenfranchised will certainly continue. Sick patients with numerous co-morbidities are a second ED “population of concern.” Complex care has increasingly become the norm for emergency physicians. Owing to the growing concentration of acute care visits and the rising use of EDs as diagnostic centers, numerous studies have documented growing medical complexity. Visits among adults older than 65 years of age have increased about 25% over the last 10 years.12,26 Nearly every indicator of medical utilization has also increased: use of radiologic studies has increased by about 10%, laboratory testing by over 15%, medication and intravenous fluid administration between 5–15%, procedure rates by about 6%, and lengths of stay by 27%.6 Perhaps most telling is that ICU admissions have risen dramatically: EDs are the single largest source of ICU admissions and the rate of admission increased nearly 50% from 2002–2008.27 This is three times faster than general ED visit rates, implying a huge increase in ED critical care delivery. ED-based intensive care has been credited with significant survival increases in severe sepsis, heart attack, trauma, stroke, and cardiac arrest. Alternative explanations for increased ED intensity of services have been raised, discussed below, but few analysts have argued that ED care has not gotten more complex. 3.1. Current challenges to health: lack of outpatient care options and measuring ED impact As discussed earlier, the lack of significant longitudinal care or adequate integration with such care is the single greatest barrier EDs face with respect to population health. This is especially true for the specific populations of focus in EDs. Despite offering care to the un- or under-insured, EDs do not typically offer preventive services or elective specialty care. Acutely ill, complex patients who are admitted to inpatient settings do not currently require the same level of longitudinal thinking, but this paradigm will shift as delivery and payment reform emphasize home and community based services or reduced hospital admissions. EDs will need to offer or access outpatient solutions for continued management of these patients in order to meet Triple Aim goals. The same holds true for social services addressing substance abuse, violence, or other psychosocial issues. Related to the issue of longitudinal integration is the barrier of measuring ED impacts on the quality and outcomes of population health. As discussed earlier, EDs are not typically included in broader “episodes” of care; characterizing their influence on disease burden, mortality reduction, and improved health and functional status is therefore highly limited. Comprehensive EDbased metrics beyond simple process measures have not been designed, standardized, or implemented. Doing so will require a cultural shift in how emergency care integration is envisioned, as much as technical problem-solving and additional research.

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4. Lower costs: a high cost but complex picture

5.1. Integration in coordinated models

Cost is particularly challenging for ED care. A narrative of EDas-cost-center has emerged as payment and delivery reform take hold, and one often cited solution is to eliminate ED utilization.14 The reasoning is understandable. As detailed earlier, ED care is increasingly resource intensive. While patients are sicker and more complex, part of the utilization can be attributed to a lack of knowledge of patient baseline status, diagnostic duplication, the push to eliminate rare but emergent diagnoses, defensive medicine, easy availability of expensive technology, and perverse reimbursement incentives. Once thought to have low marginal costs due to efficiencies of scale, analyses have demonstrated EDs to have marginal costs $200– 400 higher than other outpatient settings.28 Additionally, ED billing charges have risen at a much higher rate than other clinical settings over the last decade; it has emerged as an outlier compared to other billing in Medicare Part B.11,29 There are numerous factors underlying this trend – but EDs are clearly more expensive than originally understood. Emergency physicians also routinely make one of the most expensive decisions in medicine – the choice of whether to admit a patient to the hospital. Admissions from the ED have risen about 17% over the last decade, accounting for nearly all of the 4% growth in this metric and about half of all elective and non-elective inpatient admissions.12 Admissions from other care settings actually declined over the same period. The financial impact of admissions will likely continue to rise, particularly as readmission penalties are applied. ED cost is far more complicated, however, than these details would suggest. First, EDs comprise a small portion of national healthcare expenditure, just 2–4%.12 They contribute to about 10% of all outpatient spending, which is roughly equivalent to their portion of outpatient visits. Eliminating ED costs would not solve broader healthcare solvency issues. Second, there is evidence that higher intensity ED care may actually lower the rate of preventable hospitalizations. The mean expense of ED visits not resulting in admission increased 77% over the last decade, but costly diagnostic testing such as CT scans or other interventions may obviate far more costly inpatient evaluations.6,11,30 Patients on the “borderline” of admission can be assessed and observed to a sufficient degree for discharge. Third, even if lower ED utilization is the ideal outcome, it remains unclear how to divert patients or shift them to less expensive settings on a sustainable and large-scale basis. There are no universally accepted standards of what defines an urgent condition versus those that could be evaluated in other outpatient settings. Clear admission triggers are also lacking. ED triage itself demonstrates this difficulty as presentation conditions do not always correlate with discharge severity; predicting who will be admitted or what interventions will be necessary is imperfect.31 Illness severity, compromised follow-up conditions, and EMTALA requirements limit how much volume can simply be diverted away from EDs. Also at stake is preserving emergency care capacity such that EDs will be staffed and capable of dealing with a variety of disasters or surge needs, which would not be feasible under current payment models with significant decreases in ED volume.32,33

Several public and private payment and delivery reforms are underway – through, for example, the Affordable Care Act – which incentivize care coordination. Reforms include the creation of accountable care organizations (ACO), use of patient-centered medical homes, greater emphasis on home and community based services, implementation of value-based purchasing, and application of payment penalties for lack of coordination (e.g., readmission penalties). Integration of ED care is an inherent requirement for success in these programs.14 All of these efforts emphasize improved quality and performance measurement, availability of primary care to appropriately leverage ED care, and a focus on high cost and complex conditions which are among the most commonly evaluated in EDs.32,34

5. Continued innovation: EDs as a nexus for coordination Innovation is at the heart of achieving Triple Aim goals. Several examples are available of new approaches and disruptions to traditional ED care delivery which are helping to meet challenges in care and lower barriers to achieving the Triple Aim.

5.2. Promotion of high value ED utilization There are numerous examples of interventions designed to limit and focus ED care to expunge elements of waste discussed earlier. Some solve common problems which can lead to excess utilization – for example, the availability of prior diagnostic results to discourage redundant testing.35 Other solutions include placing hospitalists or primary care providers in EDs to offer more longitudinal services and consistent follow-up, which can reduce ED-based services. Kaiser Permanente Mid-Atlantic, for example, provides scheduled ED care in multi-specialty, free-standing centers which increase access to primary care services and provide substantial specialist support to ED physicians. Technology enhancements, such as widely accessible and interoperable electronic health records (EHR) or telemedicine can offer similar benefits to EDs on a macro scale. 5.3. Specialty EDs New models of ED care have emerged with a focus on a variety of patients. Urgent-cares and retail clinics emphasize less acute cases with focused and limited evaluations and quick disposition, which also improve patient experience of care. Such settings challenge the waste and expense of traditional ED care, especially for simpler presentations. Other examples include EDs focused on geriatric care, designed to optimize complex care of the elderly to reduce complications and admissions, and “MidTrack” service areas, which expedite care for patients too complex for fasttracks but lower priority than the sickest patients.36 Through these divergent approaches, EDs are tailoring solutions in a particular service area for patient groups in greatest need of delivery improvements. 5.4. Efficiency and lean processes To reduce ED crowding, length of stay, and timeliness of acute care processes, several centers have focused on parallel processing models and other principles of lean production. One health care system leader, ThedaCare, has been implementing lean manufacturing approaches for years across numerous clinical services including the ED.37 Among several positive outcomes, improved management of acute MI in the ED has led to door-to-balloon times of 37 min on average, meeting timeliness requirements in 100% of cases. Other approaches include Rapid Entry and Accelerated Care at Triage (REACT) and team triage, which focus on rapid intake at triage and initiation of appropriate evaluations.38 These examples provide important lessons for the continued evolution and improvement of ED care. A more fundamental question is asking what role EDs should play in broader care coordination. How can they serve as an important nexus for

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coordination? Doing so could significantly alter their role as payment and delivery reforms take hold. Patients and providers are conveying a straightforward message: certain patients are best served by the resources and capabilities of EDs due to the acuity or complexity of their conditions. Attempting to decrease the role of EDs in these cases would require substantial, costly, and likely undesirable alteration of other clinical settings. It may also increase the risk of delay of necessary evaluation or treatment. In addition, despite the expected decline in the uninsured population from implementation of the Affordable Care Act (e.g., expansion of private insurance, coverage of pre-existing conditions, coverage under parental plans), EDs will continue to provide a social safety net for the significant remaining numbers of uninsured individuals and to address a host of psychosocial issues. Serving as a nexus for care coordination would mean embracing these functions to leverage ED care when it is most appropriate and necessary. There are several preconditions for such a change. First, ED care would need substantial integration in different models of care, whether in medical homes, ACOs, capitation, bundled payment, or other delivery system approaches. Some of this integration is structural, such as shared access to patient information – electronic health records, health information exchanges – improved communication, and performance management systems. This integration would extend the boundaries of the ED and create a continuum between outpatient and inpatient services through the nexus of emergency care. Rather than a discordant approach to emergency care, EDs should be considered an extension of outpatient care when patient acuity or complexity demands expedited and high intensity evaluation or treatment. Even expensive evaluations may prove to be cost-effective if focused by longitudinal care providers, informed by ED expertise, and able to leverage easily accessible diagnostics and specialty care. Patients could be offered the right care at the right time and ultimately spend fewer days in the hospital. Cultural integration across providers is also key to allowing shared decision-making, appropriately prioritizing ED patients, and, importantly from an ED standpoint, distributing risk, especially when dealing with complex care or incentivizing outpatient management strategies. ED providers cannot shoulder the burden of medical risk alone as processes and systems are put in place to divert away from inpatient care. Finally, integration is needed across care processes, functions, and roles. Case management and care coordinators need to be more visible members of the ED team, to communicate across the delivery system, reduce duplicative testing, and ensure smooth transitions and hand-offs. While this would address a great many issues, EDs continue to need support in providing safety net care. Public health systems should consider establishing medical homes for vulnerable populations, to coordinate with EDs just as any other integrated system would do. Secondly, EDs must obtain more reliable and actionable data on their quality, population health, and cost outcomes. This means research, development, and validation of measures which incorporate ED care in broader episodes and bundles of care and more specific understanding of the impact of crowding and boarding on the experience and quality of care. Understanding the impact of EDs to a far greater degree is necessary to leverage them appropriately. Ultimately, EDs can function financially under a global payment or capitated framework, but doing so would require far more detailed data on the real costs of appropriately leveraging ED care, as described, rather than interpreting emergency care as capitation failures or non-value driving utilization. Thirdly, initiatives to control and optimize ED resource utilization must be enacted. This includes continuing efforts to make EDs more efficient by stream-lining processes and implementing

principles of lean production. ED volume and the stress it places on providers and safety processes is clearly an issue which must be addressed. Capitated systems will need to assess the number of ED beds required to address patient and outpatient provider needs – this may require stabilizing the current decline in beds. EDs need staffing levels and other methods of volume control consistent with EMTALA which better manage current safety and quality risks. Since EDs are evaluating sicker, more complex patients and becoming the primary feeder of ICU cases, staffing should be consistent with standards already in place for higher intensity clinical environments, both in the types of providers and ratio of providers to patients. Specialized EDs or clinical areas dedicated to certain patient types may facilitate this and allow matching of physician extenders to lower acuity cases, while ED physicians and trained intensivists can focus on higher acuity. Delays in necessary care with concomitant adverse outcomes cannot be tolerated in high-quality, integrated systems. This commitment will require making difficult choices which prioritize ED throughput (e.g., bed availability, consultant support) over elective procedures and other financial interests of hospital administration in order to eliminate significant crowding and boarding. Both public and private payers should consider payment reforms to incentivize this strategic need and movement away from boarding as an attractive financial choice. Finally, regardless of the objectives of any single payment or delivery reform, the surge and disaster response capacity of EDs must be preserved as part of the broader national emergency system. No other clinical setting is capable of stepping into this role and offering the same degree of efficiency and impact. Novel payment models must incorporate ED needs and continue investment in this public resource. For this reason, while perhaps the majority of ED revenue can ultimately be capitated with other at-risk models, such as medical homes or ACOs, there may always need to be at least a component of alternative financing. This would incentivize longitudinal care and cost containment while preserving an escape valve for social preparedness. Unlike other clinical environments, emergency care is subject to the most extreme risk by definition and is impacted directly by both natural and man-made disasters. Research can elucidate what staffing and preparedness levels are required to preserve response capacity; paying for this capacity may require broader systems of “emergency capitation” – at the regional or state level for example – or a continued fee-for-service approach for the most unexpected cases. Such mixed financing may be essential for optimal risk management. Emergency Departments connect inpatient and outpatient care and should be major players in health system transformation. As opposed to being viewed as “a setting to be avoided,” delivery systems need to focus on the most appropriate use of emergency care that help achieve better care and better health at lower cost.

6. Disclosure The views expressed in this manuscript represent the authors' views and not necessarily the views or policies of the Centers for Medicare & Medicaid Services.

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