Hard Rules for “Soft” Admissions

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altIn the coming years, there will be major changes in the way doctors and hospitals are paid. Namely, several government programs – along with contractual changes between health systems and private insurers – will focus on rewarding value over volume.

Future cost-cutting concepts in our brave new value-based payment world


In the coming years, there will be major changes in the way doctors and hospitals are paid. Namely, several government programs – along with contractual changes between health systems and private insurers – will focus on rewarding value over volume.

Terms such as “accountable care organizations,” “payment bundling,” and “value-based purchasing” have become buzz phrases. In the new system, “efficient” high-quality medical care as measured by costs, quality measures, and outcomes will be rewarded. As these changes roll out, the pressure to improve “value” will trickle down into the world of emergency medicine.

Healthcare and its costs are perpetually at the forefront of national politics. In 2009, President Obama said, “Make no mistake: the cost of our health care is a threat to our economy… it is a ticking time bomb for the federal budget. And it is unsustainable…” In 2010, the Affordable Care Act (ACA) passed Congress, and just last month, most of its provisions were upheld by the Supreme Court.


This fall, the economy and healthcare will be the focus of the presidential election. A commonly asked question among EPs is: “How will all this political stuff (or other expletive) affect us and our patients?” While the specific answer remains to be seen, what we do know is that many current reform efforts aim to lower ED use. Peruse any government program surrounding the ACA and you’ll find some reference to keeping people out of EDs.

Curb ED use? Bah! There’s no government program – short of instantaneously minting a robot army of primary care doctors and paying them a decent wage – that will really keep people from coming to the ED. And don’t forget the individual mandate. Millions of uninsured Americans are now set to gain healthcare insurance, and as the Massachusetts experiment suggests, insuring the uninsured means more ED visits. So the rapidly increasing demand for emergency care will likely not abate, even if greater access is achieved through promised medical homes or expanded primary care.

How will we as EPs be asked to play a role in reducing costs? This is still an open question. Policymakers can’t stop people from coming to the ED. And there is clearly hell to pay for proposing nonpayment policies for ED visits as we saw recently in Washington State. So maybe they will try to start influencing the decisions we make in the ED.

A spotlight on how we practice EM, in particular decisions to hospitalize people, may be in our near future. The cost of EDs is arguably small (about 2-4% of costs); the costs of inpatient hospitalization are much greater. In 2009, of $2.5 billion spent on healthcare, $759 million – or 30% of costs – were made up by hospitals. This was higher than any other single healthcare cost. Given that more than 40% of hospital admissions originate in the ED and that increasingly EPs are making most admission decisions, increasing scrutiny seems inevitable.


What could this mean for emergency medicine? Certain types of admissions may be impacted. Patients with acute myocardial infarction, major trauma, stroke, sepsis, etc . . . will always be admitted. Any admission reduction policies – beyond outright rationing – won’t impact care for these sorts of conditions.

However, a larger group of non critically-ill admissions could become a target for reduced costs. We know some of these patients get admitted for “soft” reasons: a moderate-risk complaint but negative ED testing, social admissions for “placement,” admissions to see a specialist where waiting for the same service could take months as an outpatient, or just downright diagnostic uncertainty. We also know that some of our colleagues are more apt to admit soft-call patients, while the more brazen among us are less so. And while there is almost always a clinical justification for these admissions, it is sometimes a judgment call with no right answer.

Soft admissions are a perpetual bone of contention between ED and hospital-based physicians, but the push-back seems to sometimes depend upon how hospital-based physicians are paid. In academic settings, the poor, overworked internal medicine resident has the least incentive when it comes to these soft admissions. During my training and in academic settings, the phrase, “Is this admission really needed?” has been a not uncommon refrain from certain hospital-based colleagues, often accompanied by an eye-roll.
But in some settings where hospitalists got paid per patient (i.e. fee-for-service), some of the very same complainers as residents have been known to troll the ED waiting room looking for business. I remember once working a shift during residency in a community ED in which I tried to pick up a chart for an 80-year-old female with undifferentiated weakness only to be elbowed out by an eager hospitalist. He told me not to bother seeing her since she was going to be admitted to his service anyway.

Regardless of the local payment scheme, the fundamental issue that won’t change around soft admissions is that the outcome for an ED discharge is still the ultimate responsibility of the treating ED physician, not the opining inpatient team. Dismissing a patient with a 1-2% risk of a catastrophic outcome may appear to be low-risk when you’re a policymaker looking at columns of data, but it’s not when you’re the one signing the chart. Unfortunately, nowhere in Washington are there any serious discussions around medical malpractice reform.

The rancor about admitting decisions is currently a localized phenomenon, but as payment models change, others will likely nose in on these decisions, like administrators. One example that is already happening pertains to 30-day hospital readmissions, which already impact hospitals’ bottom lines and will be more important in the future. When a patient bounces back into the ED after a recent hospital discharge, there is already pressure in some hospitals to discharge them instead of readmitting them.

Another way hospitals will deal with readmissions is to put patients on “observation” status, which does not reimburse like an admission but also does not count as a readmission. Observation coding has become more common in recent years and the trend will probably continue. Admissions not meeting some sort of written criteria, such as Interqual, will probably be downgraded to observation status as a way to reduce payments, regardless of whether the admission was the right clinical decision or not.

Maybe there are some bright spots here. Another reason for soft admissions is that there may not be an outpatient provider available or accessible to assume responsibility for a patient. Perhaps in the future, if primary care is truly re-engineered as planned, these admissions may actually diminish as clinics create trustworthy mechanisms for rapid follow-up appointments. Financial incentives are there to make physicians more, not less available to field ED calls. Perhaps we will stop hearing the all-too-common after-hours refrain on many primary care practice’s answering machines: “…if you are having a medical emergency, call 9-1-1.”

As another bright point, this could be a great opportunity for ED groups that are part of larger multi-specialty physician groups or health systems to create mechanisms to improve communication and help coordinate care to avoid admissions. For example, perhaps some low-risk chest
pain admissions could be discharged if a mechanism was in place for timely stress tests. And maybe that chronic abdominal pain patient who needs to be scoped (but not right now) can have it done outside the hospital, rather than being admitted for it.

If standards around who gets admitted to the hospital change, our practice patterns will need to follow. The two areas of opportunity are the aforementioned care coordination, and also using evidence-based decision rules.

But efforts to create decision rules for symptom-based conditions such as chest pain and syncope have not been entirely successful. The San Francisco Syncope Rule for identifying low-risk syncope patients unfortunately failed in its external Boston-based validation trial. Then again, failed validations are helpful, providing more evidence on why we actually do admit patients – such as those with syncope – who end up having negative work-ups.

It may be difficult, even impossible, to identify low-risk groups of ED patients with high-risk symptoms who universally have no chance of any short-term medical mishap. But other clinical decision rules that focus on specific diseases have been more successful. The Pneumonia Severity Index (PSI), for example, has been validated as a way to risk-stratify patients with pneumonia and help with admission decisions. In many hospitals, the PSI is not even a consideration when it comes to a pneumonia admitting decision.

Maybe it should be?
Finally, no article like this would be complete without a call for more research. Seriously, more rigorous research in this area really should be a major priority for emergency medicine in the new value-based reimbursement world. One argument that can never be refuted at the time of an admission decision (or payment policy) is high-quality evidence.

Jesse M. Pines, MD
Director of the Center for Health Care Quality; Associate Professor, George Washington University

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  1. Wayne Hardwick on

    Good article but we forget that even the best guidelines and the best double blind studies are trumped by any district court and 8 to 12 laymen with no medical experience. With any low risk admission the question should be asked: Has anybody ever been sued for not admiting a patient such as this? If the answer is yes (and it always is yes) you better admit. U.S. law is based on case law (one case establishes a pattern for all subquent similar cases). So even if we can prove that a patient had a very low risk of adverse outcome one case will establish law.
    Even if a physician prevails it court the cost are staggering and the physician or his insurance pays. There is no “loser pays” rule in the US as there is in the rest of the world.

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