Making ER Call Better Solutions: Reimbursement

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Making ER Call BetterSolutions Reimbursement

• Douglas R. Dirschl, MD
• UNC Department of Orthopaedics
• Chapel Hill, NC

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Conclusions/Theses

• Reimbursement for providing availability/care in
  the ED is a problem
• It is not THE problem
• There are a variety of potential solutions to the
  reimbursement issue
• Reimbursement alone will not be a viable solution
  in most communities
• One solution will not fit all communities

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Reimbursement is a Problem

• EMTALA requires hospitals to provide services to
  patients presenting with urgent medical
  conditions
• If capacity and capability are available
• Regardless of patients ability to pay
• Physicians provide this care
• This is an unfunded mandate (for hospitals and
  physicians)
• Shouldnt logic dictate that a flow of funds
  would follow the mandate, if the importance is
  high?

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Reimbursement is a Problem

• 2008 Survey by American Orthopaedic Associations
  Orthopaedic Institute of Medicine (OIOM)
• 1527 practicing orthopaedists (AAOS members)
• 41 Community Generalists
• 42 Community Specialists
• 17 University Practice
• 75 participated in general orthopaedic call
• 70 viewed call coverage in their community as
  problematic

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Reimbursement is a Problem

• 57 received no pay for ED call coverage
• 16 less than 1,000
• 6 between 1,000 and 2,000
• 2 greater than 2,000
• Pay Considered Adequate
• 6 500
• 32 1,000
• 26 1,500
• 18 2,000
• 10 gt2,000

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Reimbursement is not THE Problem

• Ranking of Major Barriers to ED Call Coverage
• Disruption of Lifestyle
• Inadequate Compensation
• Disruption of Practice
• Monetary impact of uninsured
• Liability risk
• Inadequate training

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Reimbursement is not THE Problem

• Actions that would make call coverage more
  acceptable
• Subsidization for Indigent Care 73
• Tort Reform 66
• OR for fracture management 41
• Universal coverage 20

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Solving Reimbursement

• Better reimbursement will not, in most
  communities, be the only solution
• Reimbursement can be part of a viable community
  solution

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Solving Reimbursement

• Local Solutions
• Stipend for availability
• Pay for care delivered in ED
• Subsidy for indigent/underinsured care
• Payment in-kind
• Partnership with Hospital

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Solving Reimbursement

• Stipend for Availability
• Stipend for each 24-hour period on the call
  schedule
• Group or individual
• Rate negotiated (must be market reasonable)
• Strengths
• Simple, many precedents
• Weaknesses
• No quality/outcomes expectations
• Shared goals or partnership?

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Solving Reimbursement

• Pay for ED care delivered
• Pay triggered when actually present in ED
• Activation fee or hourly rate
• Often combined with stipend
• Rate negotiated (must be market reasonable)
• Strengths
• Simple, many precedents
• Pays for care actually delivered
• Weaknesses
• No quality/outcomes expectations
• Shared goals or partnership?

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Solving Reimbursement

• Subsidy for Indigent/Underinsured Care
• Guaranteed reimbursement rate for care of
  uninsured/underinsured patients in ED
• Definition of underinsured
• Rate negotiated (market reasonable)
• 103 Medicare
• Strengths
• Rational method to pay for care
• Can include quality metrics
• Weaknesses
• Not as simple
• Requires effort by physicians
• Partnership with Hospital

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Solving Reimbursement

• Payment In-Kind
• Provision of services/resources that improve
  efficiency/effectiveness of physician hospital
  practice
• Physician Assistants
• Strengths
• Truly beginning to align behind goals
• Less scrutiny by the OIG
• Weaknesses
• Value proposition more complex
• Hospital budget/management

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Solving Reimbursement

• Solutions must be individualized for each
  community
• One size will NOT fit all!
• Most solutions will combine a variety of
  reimbursement solutions with some
  non-reimbursement solutions

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Example

• Reno Orthopaedic Clinic
• JBJS, 2009 91227-235.
• No stipends for general ortho call
• 2,400/d for trauma call
• ED contact fee (200/patient)
• Assured reimbursement for indigent care
• 100 Medicare rate
• Fracture Room, other resources, etc

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Other Examples

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Available after February 5, 2009www.aoassn.org
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Conclusions/Theses

• Reimbursement for providing availability/care in
  the ED is a problem
• It is not THE problem
• There are a variety of potential solutions to the
  reimbursement issue
• Reimbursement alone will not be a viable solution
  in most communities
• One solution will not fit all communities

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Thank You