Trump's Impact on Emergency Medicine

Robert Glatter, MD; Jesse M. Pines, MD, MBA, MSCE


December 16, 2016

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Editor's Note: This is the second part of a two-part series of discussions on the subject of Trump's election and its impact on medical care acts and payment systems. To view part 1, please click here.

Robert Glatter, MD: Hi. I am Dr Robert Glatter, assistant professor of emergency medicine at Northwell Health and also attending physician at Lenox Hill Hospital in New York City. This is part 2 of my discussion with Dr Jesse Pines, who is professor of emergency medicine and health policy management and also director for the Center for Healthcare Innovation and Policy Research at George Washington University in Washington, DC. We are continuing to discuss the Affordable Care Act (ACA) and also the effect of the Medicare Access and Chip Reauthorization Act (MACRA) and the Merit-based Incentive Payment System (MIPS) and other various topics from the economics of the change in administrations.

I want to touch on medications and, certainly in the era of EpiPen® and Daraprim®, these fiascos where the drug industry is under scrutiny. Trump has talked about medications being imported to help foster more competition in pricing. Do you see this, first of all, as a safety issue and quality control issue? What is the feasibility of this?

Jesse M. Pines, MD, MBA, MSCE: First off, drug prices are a big issue if you look at the amount that the United States spends on specific drugs compared with other countries such as Canada and the United Kingdom. We definitely spend a lot more on drugs. The big question is: How do you actually control drug prices in a safe way? The concept of importing drugs from other countries would be one way to handle it. But like you said, there could be safety issues that would need to be handled. It would create a lot of other potential issues about bringing in drugs from abroad, and certainly that could put some downward pressure on pricing, but it would potentially mean a lot more regulation. Also, the other question would be whether this really aligns with the rest of the agenda, and when I looked recently on the website of the policies that the Trump transitions team is looking at, I think that has actually come out.

Dr Glatter: I appreciate it. Any other tidbits you wanted to add to our discussion here that you thought would be important at this time?

Dr Pines: I think it is a broader question that comes up. What is going to be the impact of these programs on emergency medicine? That is really central for our specialty, so I just want to break it down into a few categories. One would be: It would be an insurance reform. If more people lose insurance if the ACA is repealed, that could potentially drive more people into the emergency department (ED) for care. We know that there is a relationship between insurance and ED use, and how that changes based on different types of insurance varies. But in general, more people having insurance and access outside the ED is going to have an effect on emergency care.

The second thing is really out-of-pocket costs. If we are going in the direction that we are, where there is more scrutiny on the insurance, insurance companies are really trying to lower costs as there is more pressure to reduce premiums. In the ED, we are going to see probably more denials and potentially higher costs of actually recovering payments as more barriers are potentially put in place to reimburse emergency care.

Third, I would say that the Emergency Medical Treatment and Labor Act (EMTALA) is unlikely to go away. EMTALA really creates a backstop. The nation's safety net is in our emergency care system. I do not see that going away in the future. But through insurance reform and through other types of reform, I think that revenue could potentially go down along with volumes going up. There is going to be a lot more work for us to do in the ED to care for these patient populations. However, on the other side, when you think about payment reform, there are a number of things that actually could turn the tides; specifically, when it comes to making providers focus on sharing health information, on improving interoperability, which will improve quality, and specifically on creating mechanisms for care coordination in the ED. We would not necessarily have to admit people for social admissions. There may be more resources in place to actually get the patients care in the outpatient environment.

Dr Glatter: They talk about patient-centered care homes now being part of the value-based care package. It seems like a nebulous kind of idea. To you, is that something that will potentially be helpful?

Dr Pines: I think that patient-centered medical homes are a great concept. This is really sort of revamping primary care to include elements such as same-day access, electronic health records, and care coordination. We did a study that was published in Annals of Emergency Medicine about a year ago that looked at the early experience with patient-centered medical homes. What we found was that there was about a 25% reduction in outpatient ED use in patient-centered medical homes before and after they implemented a lot of these programs. There is really a lot that can be done in the primary care world to improve access.

If you look at what other countries that have moved to a government-funded payment model are doing, or they do not have beeper service (eg, Canada, United Kingdom, Australia), there are major problems in accessing the outpatient environment in those countries. As a result of moving to decapitated models, you do see longer waits.

The patient-centered medical homes model will go a long way toward potentially trying to fix some of those problems. The issue that comes is: What do patients in medical homes do with EDs? What really needs to happen there is better coordination between the patients, the medical home, and the emergency care system. That is going to be really key to make sure that people get the most value out of their ED visit.

Again, I have said this before in other arenas, but people are going to continue to come into the ED no matter what. People are going to continue to get sick no matter how much we do to try to prevent disease from happening. Illness and injury will always happen, and our nation's emergency care system is the backstop for that. The issue is how that system can interact with this broader, longitudinal system that is trying to repair itself. I think that we need more connections between patient-centered medical homes and EDs to really improve care.

Dr Glatter: I agree, and I think that using technology and telemedicine to bridge that gap is really one of the goals that should be seen as the next frontier. That may help reduce costs and readmission. Any thoughts about that?

Dr Pines: That is a great question about telemedicine. We have seen a major increase in a lot of different types of telemedicine and telehealth out there. You have telemedicine in a number of different categories (eg, direct-to-consumer telemedicine—the ability to get a doctor on an iPad at any time of the day or night for a small out-of-pocket cost). That telemedicine certainly improves access, but it is additive. It is going to add costs without really having a big impact on ED visits. This is very similar to the Annals of Emergency Medicine article that was actually just released a few days ago that looked at retail clinics. Increasing the density of retail clinics has very little impact on emergency care. The question is: How do we leverage telemedicine to actually reduce costs?

There are a lot of great examples out there. Within the United States, Kaiser does a fantastic job of trying to have a system where people are not calling into a disconnected provider who does not have the rest of their information but that is actually connecting with a health system that is taking care of them longitudinally. There is a real chance for telemedicine to reduce costs, especially if it is connected to the rest of the system.

Another great example of telemedicine that reduces costs in this country is poison centers. People can call in any time of day or night into these local poison centers, and there is a really major impact on ED visits with poison centers. Other countries also have done a great job of this (eg, Denmark, The Netherlands, Germany) and have national call-in lines that can actually help you figure out where to go. Those countries are also somewhat different because they have more capacity for general practitioners and more frontline primary care providers. I think, conceptually, telemedicine is going to have the ability to reduce costs in both the short term and long term, but it really needs to be connected to that patient's longitudinal care.

Dr Glatter: Great. I agree. This has been a great discussion. I wanted to thank you so much for your time, Jesse. I think that there are a lot of other subjects and topics we can continue to talk about. I want to thank you again for your time. Much appreciated.

Dr Pines: Thank you for having me.

Dr Glatter: My pleasure.


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