(+) Jay A. Kaplan, MD, FACEP

Emergency Department Directors Academy – Phase I February 16-20 Dallas, TX Containing Cost While Providing Prudent Care The effective ED leader must understand cost appropriate care and efficient utilization of critical resources. Financial realities place pressure on all participants in the healthcare environment and frequently necessitate a critical review of utilization. Too many CTs, admitting patients eventually denied by third party payors, unnecessary laboratory tests, staff cutbacks, etc., are all areas of frequent ED review. Critical review, peer comparisons (locally and nationally), and effective communication all play a role in defining appropriate utilization. The presenter will describe methods of encouraging practitioner (utilization) behavior change, when appropriate.

Objectives  

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Define resource utilization and cost containment. Identify the major types of over-utilized resources in the delivery of ED services (imaging studies, staff, inpatient services, laboratory studies, etc.) Describe several tools available to the ED director and management team to assist with demand forecasting and cost management. List institutional leaders traditionally most concerned about over-utilization. Describe the potential risk of under-utilization. Describe successful methods of demonstrating findings and creating behavior change.

2/18/2015 10:15 AM-11:15 AM WE-13 DISCLOSURES: (+) No significant financial relationships to disclose

Dr. Kaplan is Director of Service and Operational Excellence for CEP America Emergency Physician Partners and Medical Director of the Studer Group. He is a current member of the American College of Emergency Physicians Board of Directors. A graduate of Harvard College and Harvard Medical School, Dr. Kaplan won teaching awards in 1996 and 1999 and in October 2003 was named the American College of Emergency Physicians’ Outstanding Speaker of the Year. In 2007, Studer Group honored him with the prestigious Physician Fire Starter Award. In January 2011, he was awarded the Grace Humanitarian Award by the Thomas Jefferson University Hospital Department of Emergency Medicine. Dr. Kaplan served as Chairman of the Department of Emergency Medicine (1985-2001) and as a Medical Staff Officer including Chief of Staff (1992-2001) at Saint Barnabas Medical Center in Livingston, NJ. As Chairman of Emergency Services for his health system (1998-2001), he led his system’s emergency departments to the 98th percentile in patient satisfaction and his own emergency department was in the > 90th percentile for 6 years in a row (1996-2001). As a national speaker and facilitator, Dr. Kaplan presents to and coaches hospital leadership teams, emergency departments, medical groups and physicians to the highest levels of clinical quality and service excellence. He engages and interacts with his audience and makes listening fun. His approach is tactical and directed toward implementation not just ideas, toward results not consults. Dr. Kaplan continues to practice clinically because he loves the clinical practice of medicine, and caring for patients helps him remain close to the patients’, the hospital staff’s, and the physicians’ current experience. He lives with his wife and family in the San Francisco Bay area approximately 20 minutes north of the Golden Gate Bridge.

Containing Cost While Providing Prudent Care

Jay Kaplan, MD, FACEP Director, Service & Operational Excellence, CEP America Member, Board of Directors, American College of Emergency Physicians

Outline

Definition of “Resource Resource Utilization” Utilization and “Cost Cost Containment” Major types of over-utilized resources: Staff/Imaging/Lab/Inpatient admissions Tools available to assist in this process Physician profiling and change management

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Definitions Resource Utilization: The percentage of time a resource is busy Use compared to availability

Cost Containment: A wide variety of strategies or methods whose primary goal is to control the rising cost of health care. include, care These strategies and methods may include but are not limited to government regulation, managed care programs, payment policies, global budgets, rate setting, consumer education, and utilization management

Cost = $$ Spent – Benefit = “ROI” People

Systems Process Outcomes

Nurses Techs/UC’s Physicians/MLP’s

Efficient Flow

Scribes

ED Inpatient

Effective use

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Why Is This Important? Example 1: Workforce Shortage

Average cost to replace: Med-Surg $45-50,000 Critical Care $60-70,000

Example #2: Revenue Maintenance

“Here you go… thought you might like this” Not . . .

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Let’s Be Clear About $ Cost

Emergency Department visits 2% of the health care dollar 2/3 visits after hours (1/3 during “business hrs”) Non-urgent visits: CDC 8%, Rand Corp. 17%, HCA 40% treated and released 20% of the least urgent treated-and-released ED visits account for 4% of ED cost Decrease 1/12 CT scans done in US has the same effect as driving all of those pts out.

Let’s Be Clear About Cost

In 2008, 124 million ED visits US expenditures on emergency care: $47.3 billion Total US expenditures on health care: $2.4 trillion = 2% of the health care dollar Of that 2% . . . CDC says only l 8% did nott require i medical di l care within 2 hours 2/3 visits occurred after usual physician hours ED visits increased by 10% in 2009

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But . . .

20% of least costly non-admitted ED visits account for 4% of the total cost of all non-admitted ED visits. Could save as much $ if reduce CT scans 1/12. AND . . . Medicaid in most states is the single largest line item in the budget! AND . . . In terms of admissions and other costs, EP’s control 32%!

In Terms of $ Cost, the Real Questions Are

Do you need to order that imaging study on that patient? Do you really need to admit that patient? Status: Observation or Inpatient? Level Care: M Med/Surg or T Tele L l off C d/S l or ICU?

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The Real Question is not . . .

“Quality vs Cost” but rather “How to Engender Quality and Generate $ through C t Eff ti Throughput Cost-Effective Th h t and d Effective Use of Resources”

The Real Issue is Not $ Spent . . . But

What Do You Get for the $$ You Spend?

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The Real Issue is Not $ Spent . . . But

You have to learn to talk the language of ROI . . . Return on Investment

Note Re: Revenue Enhancement Your patient visits have continued to increase dramatically, with visits up 48.4% for the year and admissions up 68.4%. 3% Patients seen actually increased even more more, up 59 59.3%, due to the fact that you had fewer patients who sought treatment but departed prior to receiving treatment. Overall you saw 14,147 patients more patients this fiscal year compared to last, and you admitted 1956 more patients this year over last. You had 985 fewer patients g treatment. Taking g into account who left before receiving average revenue per patient of $350 for patients treated and discharged, and for patients admitted an average of $2200 per day with an average length of stay of 4 days, this equates to $21,479,650 additional revenue for FY 2011 over FY 2010 via the emergency department.

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The Cost-Effective Use of Human Resources . . . Ensure that no one is doing something that could be done by someone who costs less! (but has the skills and knowledge to get the job done well)

Patient Care Technicians The Care Pair Concept: Nurses • Transport • Do D EKG’ EKG’s • Draw blood • Take/document vital signs • Document “patient resting

comfortably” • Change stretcher linen • Take bedpans • Enter orders/write order slips

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Clinical Information Managers - Scribes The Care Pair Concept: Physicians • Transcribe • Document D t • Gather lab results • Know when x-rays are completed • Follow up on consultants called • Change stretcher linen • Take T k b bedpans d • Enter orders/write order slips

More Techs, MLP’s, HUS’s, CIM’s

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Staffing – Resource Allocation Dedicated Consistent Charge RN Charge/Lead Physician Flexibility: – Floats – Liberal use of extenders – CIM’s – On-call

Geographic allocation?: – Nurse, Physician, both – Pros/Cons

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Clinical Information Managers = Scribes

Go to bedside with you Document history and physical exam Transmit orders to unit clerk Follow up/gather/record outstanding lab/ x-ray Alerts physician when patient ready for disposition

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Saint Barnabas Medical Center Avg Patients per Physician Service Hour 2.50 2.45 2 40 2.40

Pts Per Hour

2.35 2.30

y = 0.0187x + 2.1884 2.25 2.20

y = 0.0078x + 2.1561

2.15 2.10 2.05

CIM’s implemented 2.00

5 = very good 4 = good 3 = fair 2 = poor 1 = very poor

Quality of Life for Emergency Physicians Pre- and Post-Implementation of Clinical Information Managers May 1999/February 2000

pre-CIM post-CIM

5.00

4.50

Average Satisfaction Score

4.00

3.50

3.00

2.50

2.00

1.50

1.00 Efficiency MD