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ERs Have Become Central Staging Area for Acutely Ill Patients

More Complex Care Provided in a Challenging Health Care Environment

WASHINGTON, Dec. 27, 2012 /PRNewswire-USNewswire/ -- Lack of stable medical homes and reduced inpatient capacity are key factors that could be responsible for a shift toward higher billing levels over the past decade in U.S. emergency departments, according to a new report from the New England Journal of Medicine ( Changing standards of care and the implementation of electronic medical records are additional potential factors in this shift that is accompanied by increases in higher-complexity, higher paid visits for Medicare emergency patients.


Study authors were responding to a recent report by the Office of Inspector General, a watchdog organization of the U.S. Department of Health and Human Services, which suggested a widespread phenomenon of "upcoding" in all specialties, but especially emergency medicine.  Subsequent reports in news organizations, including The New York Times and Washington Post, embellished this assertion with separate analyses and specific examples. The authors of this perspective piece, however, examined a nationally representative sample in order to refine these assertions, and concluded that blaming upcoding alone oversimplifies what is happening.

"Care that used to be provided on in-patient floors is now being done in emergency departments," said Dr. Andy Sama, president of ACEP. "Also, in the past decade, primary care physicians increasingly have sent their patients to the emergency department for more prompt and definitive work-ups. They may simply be seriously concerned, overburdened, or the patient may have complex issues that can't be diagnosed easily in a primary care setting. But this puts the burden of accurate and efficient diagnosing on emergency physicians, which leads to higher complexity, and higher billed visits."

In addition, wider trends in the use of technology in health care play a major role.  According to the report, higher use of diagnostic technology is "magnified" in the emergency department, where physicians have ready access to advanced imaging, such as computed tomography (CT), magnetic resonance imaging and ultrasonography. Further analysis might reveal this also could have an unexpected effect of lowering overall health care costs, because some of these higher paid visits prevent hospital admissions, and hospital admissions are much more expensive than ER visits.

As an example, the report says "technological innovations have revolutionized care for abdominal pain," which is one of the three top symptoms that bring Medicare patients into the emergency department. Now patients with abdominal pain can often be discharged from the ER after a negative CT rather than being admitted to the hospital.

"The world just expects more of us than it used to," said study author Dr. Stephen Pitts, associate professor at Emory University School of Medicine.

The article also directly addresses whether electronic medical records are affecting billing charges. 

"The use of electronic medical records may facilitate increased billing, because they are designed to capture and bill for every single clinical action," said Dr. Pitts. "This has reduced historical underbilling, where emergency physicians wouldn't always accurately capture everything that happened during the ER visit. Of course it also may facilitate increased billing. One reason we may be seeing a steeper trend in ER billing is just that ERs are early adopters of health IT."

ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. 

SOURCE American College of Emergency Physicians (ACEP)

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