Should hospitals and physicians be rewarded—or penalized—for emergency department wait times that don't meet benchmarks established by averaging the national wait time of patients with similar conditions? That's the proposal from two management scientists at the London Business School. (Harvard Business Review. Feb 6, 2019;http://bit.ly/2LWrdVs; Management Science. Jan 31, 2019; http://bit.ly/2YLqd8v.)
“Our paper provides a high-level guideline for regulators, such as the Centers for Medicare and Medicaid Services in the United States and the National Health Service in the United Kingdom, that have started monitoring ED waiting times on how to use waiting-time information in the reimbursement formula,” wrote Nicos Savva, PhD, and Tolga Tezcan, PhD, who wrote the paper with Ozlem Yildiz, PhD, of the Darden School of Business at the University of Virginia. “We believe that this is a promising alternative to top-down targets, such as the four-hour target that has been implemented in the U.K. for patients visiting EDs.”
Their recommendations avoid targeting the ED in isolation with penalties or incentives for wait times, said Dr. Tezcan, a professor of management science and operations at the London Business School. “It is well known that the issue of excessive waiting times needs to be addressed by a joint effort from EDs and other departments in the hospital. For example, it is well known that boarding more admitted patients in the ED increases waiting times for all patients in the ED, and EDs cannot address this problem without streamlining the admission procedures with wards. So we propose that incentives be applied to total payments to physicians and hospitals.”
But experts on quality of care in U.S. emergency departments said the authors' proposal misses the mark on a number of fronts. “They're ignoring the fact that pay-for-performance schemes already exist in health care, with performance metrics intensely tied to wait times,” said Shari Welch, MD, an emergency physician for more than 26 years, a consultant in health care quality improvement, and a research fellow at the Intermountain Healthcare Delivery Institute in Murray, UT.
“Anyone interested in ED operations lives and breathes wait times like door-to-doc, which is reported to the Centers for Medicare and Medicaid Services and publicly available,” she said. “Many other organizations do this for EDs. But this model takes federal regulation to yet another level, with another bureaucracy to manage and regulators financially penalizing poor performers. There is a lot known about EDs that are nonidentical, and these authors ignore the concept of volume bands and performance.”
Research led by Dr. Welch has identified volume-based differences in ED performance, indicating that ED volume is the strongest predictor of operational performance on metrics, with higher-volume EDs having longer patient lengths of stay and a higher percentage of patients who left before treatment was complete. (Jt Comm J Qual Patient Saf. 2012;38:395.) “ED performance measures should take ED volume, acuity, and other characteristics into account,” she noted.
Whether a target is top-down, like the U.K.'s four-hour window, or based on a formula like that proposed by the authors, it can still create disordered incentives.
“When the U.K. adopted the four-hour window with very strong incentives, while the average person did not spend less time in the ED, what occurred was that they ended up trimming off a lot of the outlier cases,” said Jesse Pines, MD, an adjunct professor of emergency medicine and health policy and management at George Washington University School of Medicine and Health Sciences in Washington, D.C. “But these very strong incentives—where the hospital administrators were reprimanded if less than 98 percent of patients had a stay less than four hours—resulted in rushed decisions, particularly with a spike in clinical decisions in the last 20 minutes before the window closes.”
No major adverse outcomes or deaths have been publicly tied to the U.K. policy, but Dr. Pines argued that rush decisions almost certainly compromise patient care. An analysis of the policy found that time to clinician only improved minimally and overall length of stay actually increased. (Ann Emerg Med. 201259:341; http://bit.ly/2WXddfo.) “We hoped that the target would have led to improved processes, resulting in patients being treated sooner and leaving earlier across the four hours, without diminishing time for physician-patient interactions and care. We did not observe this pattern,” wrote the authors led by Suzanne Mason, MD, FRCS, of the University of Sheffield in England.
Dr. Tezcan maintained that the new model would avoid these problems by using a risk-adjusted relative benchmark and risk-adjusted average wait times for different triage levels. “The four-hour target is arbitrary, and so it could be too stringent or loose. In the U.K. we observed that the former is the case, at least in recent years,” he said. “We believe that by setting the target on average waiting times, EDs will be incentivized to run efficiently for all patients. In addition, it is possible to use multiple performance targets. That is, one can set targets not only on waiting times or time in the ED but also for door-to-triage or door-to-doc times. However, with multiple targets, it may become more difficult to manage these programs both for regulators and hospitals.”
Unwanted Side Effects
Incentivizing ED wait times is challenging because of its multifactorial nature and the potential for unwanted “side effects,” Dr. Pines noted. “Any incentive to improve wait times in the ED or hospital throughput in general, no matter how you establish the target, would need to be balanced with other types of measures. Specifically, we need to consider any unintended consequences of pushing people through too quickly and also focus on the overall hospital journey as well as outcomes after.”
He noted that emerging literature suggests that incentives to reduce hospital readmissions may be leading to unwillingness to readmit patients who need full inpatient care. The Hospital Readmissions Reduction Program, enacted by the 2010 Affordable Care Act, appears to have led to an increase in deaths within 30 days of discharge in Medicare beneficiaries hospitalized for heart failure or pneumonia, according to one study. (JAMA.2018;320:2542; http://bit.ly/2Hu8htd.) The increase in deaths among heart failure and pneumonia patients was concentrated in those who had not been readmitted to the hospital. “With incentives like these, it's essential to monitor for such unintended consequences,” Dr. Pines said. “Particularly if you laser-focus on one measure, like ED wait times, you could conceivably cause downstream problems elsewhere.”
Brendan G. Carr, MD, the associate dean of health care delivery innovation at Thomas Jefferson University in Philadelphia, focuses his research on understanding how the organization of emergency care affects outcomes in unplanned critical illness. He suggested that the University of Colorado's adoption of a front-end split-flow model demonstrates potential for other institutions seeking novel approaches to reduce ED wait times. (Jt Comm J Qual Patient Saf. 2016;42:271.) This system uses attending physician intake to allocate patients immediately to sick or not sick tracks. “Not sick includes everything from simple things like medication refills, where you get them and go, to low-acuity diagnoses where you wait in an internal waiting room until you can be managed by ED attendings,” said Dr. Carr. “The sick track means you're high acuity, and labs and imaging are immediately initiated.”
Some critics suggest that this is, to some degree, gaming the system to meet the door-to-doctor benchmark easily, but Dr. Carr disagreed. “I'd say that after two decades in the ED, me laying eyes on someone and determining where in the queue they belong and the labs they need saves time on the back end. Imagine you're the receiving emergency doc. You grab the chart, walk into the room, and the labs and imaging are already done. You have all the information you need to make a decision. It's not foolproof, but it's really helpful to get first touch and first set of eyes on patients quickly.”
Dr. Carr cautioned that the American health care system has incentivized exactly the kinds of ED wait times and inefficient schedules currently in place. “Everything is based around efficiency in the scheduled care and inpatient system,” he said. “We have to be at 100 percent inpatient capacity or we lose money. We've just-in-timed ourselves into a maximally efficient system to save payers money.
“We don't need a triple aim—quality, cost, and experience. We need a quadruple aim, with readiness wrapping around those other three in case something like a weather-related event or a terrorist attack happens. Our EDs barely have the capacity to manage flu season, how do we think we're going to responsibly handle mass shootings or other large-scale events? And that's the real problem: We need a strategy to manage acute unscheduled care in the United States.”
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Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.