“And this half for the ED is for all of our patients are for all of our patients who have COVID-19 or are suspected to have COVID-19. Even though case counts are well beyond where things were back in March 2020, we’re getting squeezed on both ends without the drop-off of non-COVID-19 volume that we saw during the original surge.”

I spent part of my winter break working at Elmhurst Hospital Center, one of the public city hospitals staffed by Mt Sinai faculty and residents that was labelled the “Epicenter of COVID-19” during NYC’s original outbreak in March 2020. A year-and-a-half later, during the Omicron surge of cases sweeping across the city, our emergency departments continue to be universally stressed due to capacity, staffing, and resource limitations, but yet must remain open to serve as the safety net for our healthcare system.

As a husband of an EM physician and a med student interested in emergency medicine myself, I’m on one-hand worried about Workforce Predictions for 2030 that are already starting to play out for recent EM residency graduates struggling to find EM jobs due to volatile ED volume caused by COVID-19. On the other hand, I’m inspired by thought-provoking articles like this NEJM article “The Availablists: Emergency Care without the Emergency Department” to think through ways we can redesign our emergency care system to be more cost-effective, accessible, and equitable in a digitally-enabled age.

Shantanu Nundy’s reframing of primary care inspired me to apply the same type of thinking to emergency care -> “always available care”. Rather than pigeonholing EDs as “emergency” care, the more pervasive and powerful role emergency providers have in their communities is being always available and ready to receive any patient at any time.

Sherman Leung @sk_leung

I love this reframing of primary care and how/where primary care could be delivered if thought like a function. Emergency care, to me, reframed is "we are your 24/7 always available option for life-threatening and immediate care"

Shantanu Nundy, MD @DrNundy

Primary care is deeply misunderstood. It's not an asset, it's a function. It's not 'we have primary doctors' and 'we have clinics'. It's 'we are your trusted person' and 'we are responsible for all your physical and mental health needs'.

Virtual Urgent Care and Virtual “Provider-in-Triage”

As a former Oscar member, I’m a big fan of their virtual urgent care product and looking around, you can see that almost all payers have some sort of 24/7 telemedicine product (e.g., United Healthcare) that rarely goes used by their members.

On the provider side, there sometimes exists a “provider in triage” model (usually staffed by PAs) that helps Emergency Departments accelerate workup based on rapid 10-15m interviews in triage before they get assigned to a ED zone.

Rather than coming directly to an ED, we could direct patients first to a virtual triage portal where they could fill out evidence-based triage questionnaire (e.g., Schmitt-Thompson protocols) powered by companies like Clearstep. Based on the acuity level of these responses, they could automatically jump into asynchronous chat with a nurse or NP or into a synchronous video visit with a “virtual provider in triage” that can use patient answers to clarify more clinical aspects of their story (“does your chest pain worsen upon inspiration?” “do you feel the room is spinning?”).

If the virtual provider determines that they need to head to the emergency department, they can select the ED zone that they would start ordering labs and workup upon their arrival to an isolated holding area staffed by nurses. Importantly, their waiting time to arrive in-person to the ED could be updated like Yelp’s Live Waitlist based on the staffing and capacity ratios of the ED. Imagine a potential ankle fracture where an x-ray is clinically indicated that would initially require conservative pain management with ibuprofen that the patient can self-administer at home. Because the patient likely doesn’t need basic labs or even vitals, they can be scheduled to arrive 20-30m before a scheduled x-ray in the Emergency Department or directed to a nearby urgent care or ambulatory imaging center during day hours.

Business-wise, I really think the financial onus to innovate in this space lies on payers driving higher utilization of these services. We could partner with payers to create these virtual triage services that are staffed by NPs, EM physicians, and staffed 24/7 to route members appropriately to hospitals vs next-day follow-up. A venture in this space could be funded by the cost-savings payers would see across members who avoid expensive in-person ED visits and still receive appropriate (and likely less frustrating) experiences with emergency care by performing the majority of triage at home.

Emergency Care in the Home

The COVID-19 pandemic also exacerbated many existing health disparities for patients choosing to defer their own medical emergencies because of overwhelming COVID-19 volume. Beyond telemedicine, there is a clear opportunity and desire for patients to receive care from the comfort of their own home. Especially in cases like CHF or COPD exacerbation where there are evidence-based guidelines for management (Acute Decompensated Heart Failure guidelines), I believe there are ways to better integrate at-home services like Ready Responders (staffed by trained paramedics who get dispatched to the home) to obtain basic vitals to high-risk members at risk for re-admission. Imagine you could additionally train these paramedics or staff a medical assistant to most common bedside exam skills (e.g., Stanford 25) and equip them with smart stethoscopes (e.g., Eko Health) which can record noticeable heart murmurs. This combination of a super-powered onsite paramedic or medical assistant with a seasoned virtual physician could likely triage a good majority of patients that have well-documented records of pre-existing chronic conditions.

From a business-perspective, we could fund ventures in this space with risk-based models focused on managing COPD or CHF patients in a value-based contract.

Value-based Freestanding Emergency Departments (FSEDs) in Rural/Under-resourced Areas

Most prevalent in Texas, but Freestanding EDs function as super-powered urgent care facilities with one key difference - being able to bill Medicare if you’re hospital-affiliated. To share the main highlights from this overview of FSEDs:

To me, there are opportunities to build FSEDs in under-resourced areas as an integrated in-network provider for a payer or provider taking financial risk. Say I’m Blue Cross & Blue Shield of Mississippi or Medi-Cal managing the California Medicaid population, I could pre-negotiate rates for all of my members in an area where I’m already losing a bunch of money on CHF exacerbation, wound ulcers, etc… As a payer, I would save money on patients who have extensive medical histories that don’t need to get worked up and triaged at a far-flung out-of-network hospital that racks up large EMS bills for transport or need to start the workup from scratch because they don’t have the patient’s medical history. Suddenly I now have a much cheaper alternative to ED presentations that needed to be worked up in-person but not admitted. You’d have to figure out the inter-hospital economics since FSEDs can’t admit patients, but I imagine there are a number of non-admit emergencies in Central California or Upstate New York where payers are losing out that would benefit from a freestanding ED.

From a product perspective, the opportunity would be to connect these FSEDs to integrated virtual specialty services through hospital affiliations that potentially provide consult-only services. Virtual neurologists could support EM physicians on deciding on TPAs vs transfer to thrombectomy center. Exploratory laparotomies would need surgery to be on call or transferred to a surgery center, but a virtually-enabled FSED could handle the vast majority of true medical emergencies while being a more cost-effective site for always-available care.

Margins of Medicine

Value-based Emergency Medicine

The emergency department (ED) is the last place any patient wants to be. Patients end up in the ED because of an acute exacerbation that can’t wait for their next PCP visit, because they have nowhere else to turn, or because it’s simply the only provider they have. If you haven’t visited the ED yourself, you likely know a friend or family member who has…

2 years ago · 3 likes · Sherman Leung

As I mentioned in my post last year, I believe one of the many blockers to systems-based change to our emergency care system is the absence of value-based reimbursement drivers in the space. CMS’s ET3 model is one step in the right direction, but I would love to brainstorm with policy thought-leaders working in emergency care to pilot and potentially fund more cost-effective and equitable models of value-based emergency care.

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Encourage any responses or suggestions on ways we can re-design and re-frame our emergency care system - would love to hear from you!

Margins of Medicine

Re-designing Emergency Care