RAND Study Highlights Evolving Value of Emergency Medicine: Emergency Physicians Play Key Role as Gatekeepers to Hospital

Abstract

A new analysis provides confirmation of what most emergency physicians already recognize from their qualitative observations: emergency departments (EDs) are playing an ever more significant role in the US health care system, notably accounting for an increasing percentage of hospital admissions.1Gonzalez Morganti K. Bauhoff S. Blanchard J.C. et al.The Evolving Role of Emergency Departments in the United States. RAND Corp, Santa Monica, CA2013http://www.rand.org/pubs/research_reports/RR280Google Scholar Although emergency physicians are familiar with this trend, the formal RAND study should help disseminate an important message to decisionmakers about the centrality of emergency medicine to health care reform.“The take-home message is that emergency physicians are the decisionmakers for half of all hospital admissions in this country, and this number is likely to go up,” said Art Kellermann, MD, MPH, the senior author of the study conducted by the RAND Corporation.“If you take it a layer or two beyond that, the second point I would make is that that role is very important to hospitals because admissions pay their bill,” continued Dr. Kellermann, an emergency physician and senior researcher at RAND, a nonprofit think tank. “It's important to the economy because inpatient health care is a model for patient spending, and as the model shifts from fee-for-service to value-based purchasing, the role of the emergency department is going to shift from how do we get as many people in the door to how many people do we keep out.”The study, published in May, was funded by the Emergency Management Action Fund, a consortium of the American College of Emergency Physicians (ACEP) and other emergency care organizations, to generate additional support for advocacy efforts in Washington, DC. The study's purpose was to develop a more complete picture of how hospital EDs contribute to the US health care system.The study authors analyzed 4 data sets compiled and maintained by the US Department of Health and Human Services, as well as data from the Community Tracking Study, a decade-long effort that characterizes the changing use and delivery of health care in 60 US communities.Key FindingsAmong the study's key findings were the following: •Between 2003 and 2009, inpatient admissions to US hospitals increased at a slower rate than the population overall.•Emergency physicians are increasingly serving as the major decisionmaker for approximately half of all hospital admissions in the United States.•Medicare accounts for more inpatient admissions from EDs than any other payer.•In addition to serving as an increasingly important portal of hospital admissions, EDs support primary care practices by performing complex diagnostic evaluations and handling overflow, after-hours, and weekend demand for care.•EDs may be playing a constructive role in constraining the growth of inpatient admissions.The May release of the study comes as President Obama's Patient Protection and Affordable Care Act moves into its fourth year. During the formative years of the act, EDs were often targeted for cuts under the notion that they can be the most expensive place to provide medical care. However, evidence in the RAND study indicates that policymakers may have failed to appreciate the constructive role emergency medicine practitioners can play in controlling costs.“The RAND study and many others that are emerging support what we have been promulgating as reality for quite some time,” said Andrew Sama, MD, president of ACEP, senior vice president of Emergency Services, North Shore–Long Island Jewish Health System, Manhasset, NY; and chairman of the Department of Emergency Medicine, North Shore University Hospital at Manhasset, NY. “Emergency physicians already know this,” he said. “They are specialists at complex workups and expediting nonelective admissions with primary care physicians. The thing that emergency physicians are really contributing to, which we are not getting credit for, is that we're playing an increasingly constructive role in constraining the growth of hospital admissions. Nobody really has looked at it that way, but that's what this report shows.”Digging deeper into the study reveals important details about the key conclusions the RAND researchers made.Although hospital admissions did increase, nearly all of this growth was due to a 17% increase in unscheduled patient admissions from EDs, and this larger number of ED admissions was more than offset by a 10% decrease in admissions from primary care physicians and other outpatient settings. These changing numbers indicate that primary care physicians are electing to send some patients to the ED whom they previously admitted to the hospital themselves.Dr. Kellermann said interviews with primary care physicians provided qualitative data to back this trend up. What these physicians indicated in interviews, Dr. Kellermann said, is that especially with the advent of hospitalist medicine, primary care physicians increasingly see themselves as outpatient practitioners.ED As Diagnostic CenterThese findings are consistent with other research that has found that EDs are being used more often by primary care physicians to conduct diagnostic evaluations of patients with potentially serious medical issues.Stephen Pitts, MD, MPH, a professor at Emory University's School of Medicine, and colleagues documented this changing pattern of use during the last decade in a recent study,2Pitts S.R. Pines J.M. Handrigan M.T. et al.National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity.Ann Emerg Med. 2012; 60: 679-686.e673Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar finding that although fewer than 5% of physicians are emergency physicians, they handle a quarter of all acute care encounters.This is occurring for a number of reasons: EDs have ready access to all manner of technology, from computed tomography scanners to magnetic resonance imaging, unavailable in many physicians' offices.The findings indicate that EDs may have a significant role to play in reducing hospital admissions and readmissions, both goals of the Affordable Care Act.Illustrating the point are the 2 exceptions to the trend of increased admissions in the study: heart failure and angina. Although there was a 4.9% increase in ED visits by patients with these heart conditions, the number of hospital admissions declined by 5.7%, for a 10% decline in the rate of ED admissions for those diagnoses.“We believe emergency departments are playing a role in this decrease in admissions,” said Janice Blanchard, MD, one of the RAND study authors and a professor of emergency medicine at the George Washington University Department of Emergency Medicine. The authors believe but cannot prove that this decline is likely attributable to ED observation units and perhaps the admissions of borderline cases to “observation status” on an inpatient ward.Dr. Blanchard said the likelihood that emergency physicians are helping to limit growth in hospital admissions also emerged in another data set related to “prevention quality indicators” (PQIs). This is a metric, developed by the Agency for Healthcare Research and Quality, that tries to quantify hospital admissions that might have been preventable. These are conditions, such as diabetes, for which quality outpatient care or earlier intervention could potentially prevent the need for hospitalization.A federal Department of Health and Human Services report published in 2009 found that, between 2000 and 2006, “potentially preventable” hospitalizations for chronic conditions decreased from 1,213 to 1,078 hospitalizations per 100,000 adults in the United States, a decline of 11%. The report attributed the decrease to more effective management of patients by primary care providers. However, the RAND study authors decided to test whether this decline might in part be attributed to more active management of these patients in the ED.The RAND analysis found that, between 2000 and 2009, nonelective admissions to US hospitals increased by 14%, whereas admissions related to PQI remained level. The study found a large, 30% decline in these PQI admissions from non-ED sources. However, growth in PQI-related admissions during ED visits increased at only half the rate of nonelective admissions during other ED visits.The RAND study authors say that there are 2 explanations for the large decline in PQI admissions from non-ED sources. “One is that primary care providers did a better job of managing patients with ambulatory care-sensitive (ACS) conditions, thereby reducing flares of their illness and the subsequent need for inpatient admission,” the RAND study states. “The other, equally plausible explanation is that the reduction of PQI-related admissions from doctors' offices and other non-ED settings was largely due to the growing tendency of office-based practitioners to send acutely ill patients to an ED rather than directly admitting the patient to the hospital. The comments made during our interviews with ED, hospitalist, and primary care physicians support the latter explanation.”Dr. Blanchard said her analysis of the data is that emergency physicians are playing an important role in stabilizing these patients and keeping them out of the hospital. “I think a lot of the health care reform discussion has looked at the ED as something they want to prevent, but increasingly they need to think of emergency departments as an integral part of the system,” she said.EM in Health Care DebateIt's possible this message has begun percolating into the health care reform discussion.“I do sympathize with the emergency physicians because they haven't been the first people invited to the table and have not been well represented in some health care reform talks,” said Kavita Patel, MD, a fellow at the Brookings Institute's Engelberg Center for Health Care Reform. “I do think that people are starting to see the emergency department as a very useful partner in trying to reduce unnecessary utilization and costs.”Dr. Patel also served in the Obama administration as director of policy for the Office of Intergovernmental Affairs and Public Engagement in the White House. She said she sees other ways in which emergency physicians can be important partners in reducing costs and increasing the quality of care patients receive, including accountable care organizations and bundled care payments. For example, with bundled payments, Medicare will provide a fixed amount of funding for a particular procedure, such as a hip replacement, Dr. Patel said. This has the potential to benefit EDs because it gives the orthopedic surgeon incentive to communicate with the ED in the event follow-up care is needed for conditions such as infections and bleeding.“My sense has always been the problem that plagues most emergency departments is a lack of information about a patient and their care,” Dr. Patel said. “But in this system, the orthopedic surgeon has an obligation to see that care through, so there's an incentive for a coordination of care.”As noted earlier, the RAND study found that EDs are being used increasingly by primary care physicians to perform fast diagnostic evaluations. A downside of this approach is that an emergency physician will lack the primary care physician's familiarity with the patient. However, this deficiency could be addressed by a better focus on coordination of care and the continued implementation of electronic health records.“I think that emergency physicians need to redouble their efforts to address issues of health information technology,” said Dr. Kellermann, the senior author of the RAND study. “This is the kind of thing that makes a big difference in avoiding repetitive testing and follow-ups and helps to control costs.”Dr. Sama said it is incumbent on ACEP and its members to share the findings of the new study with policymakers. He said the organization is regularly meeting with legislators and Department of Health and Human Services and Centers for Medicare & Medicaid Services officials. He said ACEP is also advocating the development of additional metrics that could underscore the way in which EDs are helping to limit the costs of health care.“I think there's still a significant misrepresentation of the facts in the health care reform discussion,” Dr. Sama said. “But the facts will not cease to exist because everyone ignores them. The expenditures of emergency medicine are lower than most people think. We have to continually communicate this issue with everyone that matters.” A new analysis provides confirmation of what most emergency physicians already recognize from their qualitative observations: emergency departments (EDs) are playing an ever more significant role in the US health care system, notably accounting for an increasing percentage of hospital admissions.1Gonzalez Morganti K. Bauhoff S. Blanchard J.C. et al.The Evolving Role of Emergency Departments in the United States. RAND Corp, Santa Monica, CA2013http://www.rand.org/pubs/research_reports/RR280Google Scholar Although emergency physicians are familiar with this trend, the formal RAND study should help disseminate an important message to decisionmakers about the centrality of emergency medicine to health care reform. “The take-home message is that emergency physicians are the decisionmakers for half of all hospital admissions in this country, and this number is likely to go up,” said Art Kellermann, MD, MPH, the senior author of the study conducted by the RAND Corporation. “If you take it a layer or two beyond that, the second point I would make is that that role is very important to hospitals because admissions pay their bill,” continued Dr. Kellermann, an emergency physician and senior researcher at RAND, a nonprofit think tank. “It's important to the economy because inpatient health care is a model for patient spending, and as the model shifts from fee-for-service to value-based purchasing, the role of the emergency department is going to shift from how do we get as many people in the door to how many people do we keep out.” The study, published in May, was funded by the Emergency Management Action Fund, a consortium of the American College of Emergency Physicians (ACEP) and other emergency care organizations, to generate additional support for advocacy efforts in Washington, DC. The study's purpose was to develop a more complete picture of how hospital EDs contribute to the US health care system. The study authors analyzed 4 data sets compiled and maintained by the US Department of Health and Human Services, as well as data from the Community Tracking Study, a decade-long effort that characterizes the changing use and delivery of health care in 60 US communities. Key FindingsAmong the study's key findings were the following: •Between 2003 and 2009, inpatient admissions to US hospitals increased at a slower rate than the population overall.•Emergency physicians are increasingly serving as the major decisionmaker for approximately half of all hospital admissions in the United States.•Medicare accounts for more inpatient admissions from EDs than any other payer.•In addition to serving as an increasingly important portal of hospital admissions, EDs support primary care practices by performing complex diagnostic evaluations and handling overflow, after-hours, and weekend demand for care.•EDs may be playing a constructive role in constraining the growth of inpatient admissions.The May release of the study comes as President Obama's Patient Protection and Affordable Care Act moves into its fourth year. During the formative years of the act, EDs were often targeted for cuts under the notion that they can be the most expensive place to provide medical care. However, evidence in the RAND study indicates that policymakers may have failed to appreciate the constructive role emergency medicine practitioners can play in controlling costs.“The RAND study and many others that are emerging support what we have been promulgating as reality for quite some time,” said Andrew Sama, MD, president of ACEP, senior vice president of Emergency Services, North Shore–Long Island Jewish Health System, Manhasset, NY; and chairman of the Department of Emergency Medicine, North Shore University Hospital at Manhasset, NY. “Emergency physicians already know this,” he said. “They are specialists at complex workups and expediting nonelective admissions with primary care physicians. The thing that emergency physicians are really contributing to, which we are not getting credit for, is that we're playing an increasingly constructive role in constraining the growth of hospital admissions. Nobody really has looked at it that way, but that's what this report shows.”Digging deeper into the study reveals important details about the key conclusions the RAND researchers made.Although hospital admissions did increase, nearly all of this growth was due to a 17% increase in unscheduled patient admissions from EDs, and this larger number of ED admissions was more than offset by a 10% decrease in admissions from primary care physicians and other outpatient settings. These changing numbers indicate that primary care physicians are electing to send some patients to the ED whom they previously admitted to the hospital themselves.Dr. Kellermann said interviews with primary care physicians provided qualitative data to back this trend up. What these physicians indicated in interviews, Dr. Kellermann said, is that especially with the advent of hospitalist medicine, primary care physicians increasingly see themselves as outpatient practitioners. Among the study's key findings were the following: •Between 2003 and 2009, inpatient admissions to US hospitals increased at a slower rate than the population overall.•Emergency physicians are increasingly serving as the major decisionmaker for approximately half of all hospital admissions in the United States.•Medicare accounts for more inpatient admissions from EDs than any other payer.•In addition to serving as an increasingly important portal of hospital admissions, EDs support primary care practices by performing complex diagnostic evaluations and handling overflow, after-hours, and weekend demand for care.•EDs may be playing a constructive role in constraining the growth of inpatient admissions. The May release of the study comes as President Obama's Patient Protection and Affordable Care Act moves into its fourth year. During the formative years of the act, EDs were often targeted for cuts under the notion that they can be the most expensive place to provide medical care. However, evidence in the RAND study indicates that policymakers may have failed to appreciate the constructive role emergency medicine practitioners can play in controlling costs. “The RAND study and many others that are emerging support what we have been promulgating as reality for quite some time,” said Andrew Sama, MD, president of ACEP, senior vice president of Emergency Services, North Shore–Long Island Jewish Health System, Manhasset, NY; and chairman of the Department of Emergency Medicine, North Shore University Hospital at Manhasset, NY. “Emergency physicians already know this,” he said. “They are specialists at complex workups and expediting nonelective admissions with primary care physicians. The thing that emergency physicians are really contributing to, which we are not getting credit for, is that we're playing an increasingly constructive role in constraining the growth of hospital admissions. Nobody really has looked at it that way, but that's what this report shows.” Digging deeper into the study reveals important details about the key conclusions the RAND researchers made. Although hospital admissions did increase, nearly all of this growth was due to a 17% increase in unscheduled patient admissions from EDs, and this larger number of ED admissions was more than offset by a 10% decrease in admissions from primary care physicians and other outpatient settings. These changing numbers indicate that primary care physicians are electing to send some patients to the ED whom they previously admitted to the hospital themselves. Dr. Kellermann said interviews with primary care physicians provided qualitative data to back this trend up. What these physicians indicated in interviews, Dr. Kellermann said, is that especially with the advent of hospitalist medicine, primary care physicians increasingly see themselves as outpatient practitioners. ED As Diagnostic CenterThese findings are consistent with other research that has found that EDs are being used more often by primary care physicians to conduct diagnostic evaluations of patients with potentially serious medical issues.Stephen Pitts, MD, MPH, a professor at Emory University's School of Medicine, and colleagues documented this changing pattern of use during the last decade in a recent study,2Pitts S.R. Pines J.M. Handrigan M.T. et al.National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity.Ann Emerg Med. 2012; 60: 679-686.e673Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar finding that although fewer than 5% of physicians are emergency physicians, they handle a quarter of all acute care encounters.This is occurring for a number of reasons: EDs have ready access to all manner of technology, from computed tomography scanners to magnetic resonance imaging, unavailable in many physicians' offices.The findings indicate that EDs may have a significant role to play in reducing hospital admissions and readmissions, both goals of the Affordable Care Act.Illustrating the point are the 2 exceptions to the trend of increased admissions in the study: heart failure and angina. Although there was a 4.9% increase in ED visits by patients with these heart conditions, the number of hospital admissions declined by 5.7%, for a 10% decline in the rate of ED admissions for those diagnoses.“We believe emergency departments are playing a role in this decrease in admissions,” said Janice Blanchard, MD, one of the RAND study authors and a professor of emergency medicine at the George Washington University Department of Emergency Medicine. The authors believe but cannot prove that this decline is likely attributable to ED observation units and perhaps the admissions of borderline cases to “observation status” on an inpatient ward.Dr. Blanchard said the likelihood that emergency physicians are helping to limit growth in hospital admissions also emerged in another data set related to “prevention quality indicators” (PQIs). This is a metric, developed by the Agency for Healthcare Research and Quality, that tries to quantify hospital admissions that might have been preventable. These are conditions, such as diabetes, for which quality outpatient care or earlier intervention could potentially prevent the need for hospitalization.A federal Department of Health and Human Services report published in 2009 found that, between 2000 and 2006, “potentially preventable” hospitalizations for chronic conditions decreased from 1,213 to 1,078 hospitalizations per 100,000 adults in the United States, a decline of 11%. The report attributed the decrease to more effective management of patients by primary care providers. However, the RAND study authors decided to test whether this decline might in part be attributed to more active management of these patients in the ED.The RAND analysis found that, between 2000 and 2009, nonelective admissions to US hospitals increased by 14%, whereas admissions related to PQI remained level. The study found a large, 30% decline in these PQI admissions from non-ED sources. However, growth in PQI-related admissions during ED visits increased at only half the rate of nonelective admissions during other ED visits.The RAND study authors say that there are 2 explanations for the large decline in PQI admissions from non-ED sources. “One is that primary care providers did a better job of managing patients with ambulatory care-sensitive (ACS) conditions, thereby reducing flares of their illness and the subsequent need for inpatient admission,” the RAND study states. “The other, equally plausible explanation is that the reduction of PQI-related admissions from doctors' offices and other non-ED settings was largely due to the growing tendency of office-based practitioners to send acutely ill patients to an ED rather than directly admitting the patient to the hospital. The comments made during our interviews with ED, hospitalist, and primary care physicians support the latter explanation.”Dr. Blanchard said her analysis of the data is that emergency physicians are playing an important role in stabilizing these patients and keeping them out of the hospital. “I think a lot of the health care reform discussion has looked at the ED as something they want to prevent, but increasingly they need to think of emergency departments as an integral part of the system,” she said. These findings are consistent with other research that has found that EDs are being used more often by primary care physicians to conduct diagnostic evaluations of patients with potentially serious medical issues. Stephen Pitts, MD, MPH, a professor at Emory University's School of Medicine, and colleagues documented this changing pattern of use during the last decade in a recent study,2Pitts S.R. Pines J.M. Handrigan M.T. et al.National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity.Ann Emerg Med. 2012; 60: 679-686.e673Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar finding that although fewer than 5% of physicians are emergency physicians, they handle a quarter of all acute care encounters. This is occurring for a number of reasons: EDs have ready access to all manner of technology, from computed tomography scanners to magnetic resonance imaging, unavailable in many physicians' offices. The findings indicate that EDs may have a significant role to play in reducing hospital admissions and readmissions, both goals of the Affordable Care Act. Illustrating the point are the 2 exceptions to the trend of increased admissions in the study: heart failure and angina. Although there was a 4.9% increase in ED visits by patients with these heart conditions, the number of hospital admissions declined by 5.7%, for a 10% decline in the rate of ED admissions for those diagnoses. “We believe emergency departments are playing a role in this decrease in admissions,” said Janice Blanchard, MD, one of the RAND study authors and a professor of emergency medicine at the George Washington University Department of Emergency Medicine. The authors believe but cannot prove that this decline is likely attributable to ED observation units and perhaps the admissions of borderline cases to “observation status” on an inpatient ward. Dr. Blanchard said the likelihood that emergency physicians are helping to limit growth in hospital admissions also emerged in another data set related to “prevention quality indicators” (PQIs). This is a metric, developed by the Agency for Healthcare Research and Quality, that tries to quantify hospital admissions that might have been preventable. These are conditions, such as diabetes, for which quality outpatient care or earlier intervention could potentially prevent the need for hospitalization. A federal Department of Health and Human Services report published in 2009 found that, between 2000 and 2006, “potentially preventable” hospitalizations for chronic conditions decreased from 1,213 to 1,078 hospitalizations per 100,000 adults in the United States, a decline of 11%. The report attributed the decrease to more effective management of patients by primary care providers. However, the RAND study authors decided to test whether this decline might in part be attributed to more active management of these patients in the ED. The RAND analysis found that, between 2000 and 2009, nonelective admissions to US hospitals increased by 14%, whereas admissions related to PQI remained level. The study found a large, 30% decline in these PQI admissions from non-ED sources. However, growth in PQI-related admissions during ED visits increased at only half the rate of nonelective admissions during other ED visits. The RAND study authors say that there are 2 explanations for the large decline in PQI admissions from non-ED sources. “One is that primary care providers did a better job of managing patients with ambulatory care-sensitive (ACS) conditions, thereby reducing flares of their illness and the subsequent need for inpatient admission,” the RAND study states. “The other, equally plausible explanation is that the reduction of PQI-related admissions from doctors' offices and other non-ED settings was largely due to the growing tendency of office-based practitioners to send acutely ill patients to an ED rather than directly admitting the patient to the hospital. The comments made during our interviews with ED, hospitalist, and primary care physicians support the latter explanation.” Dr. Blanchard said her analysis of the data is that emergency physicians are playing an important role in stabilizing these patients and keeping them out of the hospital. “I think a lot of the health care reform discussion has looked at the ED as something they want to prevent, but increasingly they need to think of emergency departments as an integral part of the system,” she said. EM in Health Care DebateIt's possible this message has begun percolating into the health care reform discussion.“I do sympathize with the emergency physicians because they haven't been the first people invited to the table and have not been well represented in some health care reform talks,” said Kavita Patel, MD, a fellow at the Brookings Institute's Engelberg Center for Health Care Reform. “I do think that people are starting to see the emergency department as a very useful partner in trying to reduce unnecessary utilization and costs.”Dr. Patel also served in the Obama administration as director of policy for the Office of Intergovernmental Affairs and Public Engagement in the White House. She said she sees other ways in which emergency physicians can be important partners in reducing costs and increasing the quality of care patients receive, including accountable care organizations and bundled care payments. For example, with bundled payments, Medicare will provide a fixed amount of funding for a particular procedure, such as a hip replacement, Dr. Patel said. This has the potential to benefit EDs because it gives the orthopedic surgeon incentive to communicate with the ED in the event follow-up care is needed for conditions such as infections and bleeding.“My sense has always been the problem that plagues most emergency departments is a lack of information about a patient and their care,” Dr. Patel said. “But in this system, the orthopedic surgeon has an obligation to see that care through, so there's an incentive for a coordination of care.”As noted earlier, the RAND study found that EDs are being used increasingly by primary care physicians to perform fast diagnostic evaluations. A downside of this approach is that an emergency physician will lack the primary care physician's familiarity with the patient. However, this deficiency could be addressed by a better focus on coordination of care and the continued implementation of electronic health records.“I think that emergency physicians need to redouble their efforts to address issues of health information technology,” said Dr. Kellermann, the senior author of the RAND study. “This is the kind of thing that makes a big difference in avoiding repetitive testing and follow-ups and helps to control costs.”Dr. Sama said it is incumbent on ACEP and its members to share the findings of the new study with policymakers. He said the organization is regularly meeting with legislators and Department of Health and Human Services and Centers for Medicare & Medicaid Services officials. He said ACEP is also advocating the development of additional metrics that could underscore the way in which EDs are helping to limit the costs of health care.“I think there's still a significant misrepresentation of the facts in the health care reform discussion,” Dr. Sama said. “But the facts will not cease to exist because everyone ignores them. The expenditures of emergency medicine are lower than most people think. We have to continually communicate this issue with everyone that matters.” It's possible this message has begun percolating into the health care reform discussion. “I do sympathize with the emergency physicians because they haven't been the first people invited to the table and have not been well represented in some health care reform talks,” said Kavita Patel, MD, a fellow at the Brookings Institute's Engelberg Center for Health Care Reform. “I do think that people are starting to see the emergency department as a very useful partner in trying to reduce unnecessary utilization and costs.” Dr. Patel also served in the Obama administration as director of policy for the Office of Intergovernmental Affairs and Public Engagement in the White House. She said she sees other ways in which emergency physicians can be important partners in reducing costs and increasing the quality of care patients receive, including accountable care organizations and bundled care payments. For example, with bundled payments, Medicare will provide a fixed amount of funding for a particular procedure, such as a hip replacement, Dr. Patel said. This has the potential to benefit EDs because it gives the orthopedic surgeon incentive to communicate with the ED in the event follow-up care is needed for conditions such as infections and bleeding. “My sense has always been the problem that plagues most emergency departments is a lack of information about a patient and their care,” Dr. Patel said. “But in this system, the orthopedic surgeon has an obligation to see that care through, so there's an incentive for a coordination of care.” As noted earlier, the RAND study found that EDs are being used increasingly by primary care physicians to perform fast diagnostic evaluations. A downside of this approach is that an emergency physician will lack the primary care physician's familiarity with the patient. However, this deficiency could be addressed by a better focus on coordination of care and the continued implementation of electronic health records. “I think that emergency physicians need to redouble their efforts to address issues of health information technology,” said Dr. Kellermann, the senior author of the RAND study. “This is the kind of thing that makes a big difference in avoiding repetitive testing and follow-ups and helps to control costs.” Dr. Sama said it is incumbent on ACEP and its members to share the findings of the new study with policymakers. He said the organization is regularly meeting with legislators and Department of Health and Human Services and Centers for Medicare & Medicaid Services officials. He said ACEP is also advocating the development of additional metrics that could underscore the way in which EDs are helping to limit the costs of health care. “I think there's still a significant misrepresentation of the facts in the health care reform discussion,” Dr. Sama said. “But the facts will not cease to exist because everyone ignores them. The expenditures of emergency medicine are lower than most people think. We have to continually communicate this issue with everyone that matters.”