Editing Emergency medicine (section)

===Reimbursement===

Many hospitals and care centres feature departments of emergency medicine, where patients can receive acute care without an appointment.<ref>{{Cite web|url=https://www.acep.org/Clinical---Practice-Management/Definition-of-Emergency-Medicine/|title=Definition of Emergency Medicine|website=Clinical & Practice Management|publisher=American College of Emergency Physicians|access-date=16 November 2016|archive-url=https://web.archive.org/web/20161128195011/https://www.acep.org/Clinical---Practice-Management/Definition-of-Emergency-Medicine/|archive-date=28 November 2016|url-status=dead}}</ref> While many patients get treated for life-threatening injuries, others utilize the emergency department (ED) for non-urgent reasons such as headaches or a cold. (defined as "visits for conditions for which a delay of several hours would not increase the likelihood of an adverse outcome").<ref>{{Cite journal |last1=Uscher-Pines |first1=Lori |last2=Pines |first2=Jesse |last3=Kellermann |first3=Arthur |last4=Gillen |first4=Emily |last5=Mehrotra |first5=Ateev |date=2016-11-28 |title=Deciding to Visit the Emergency Department for Non-Urgent Conditions: A Systematic Review of the Literature |journal=The American Journal of Managed Care |volume=19 |issue=1 |pages=47–59 |pmc=4156292 |pmid=23379744}}</ref> As such, EDs can adjust staffing ratios and designate an area of the department for faster patient turnover to accommodate various patient needs and volumes. Policies have improved to assist better ED staff (such as [[emergency medical technician]]s, [[paramedics]]). The emergency department, welfare programs, and healthcare clinics serve as a critical part of the healthcare safety net for uninsured patients who cannot afford medical treatment or adequately utilize their coverage.<ref name=":6">{{cite journal |doi=10.1111/j.1553-2712.2012.1446.x |pmid=22994373 |title=The Changing Landscape of America's Health Care System and the Value of Emergency Medicine |journal=Academic Emergency Medicine |volume=19 |issue=10 |pages=1204–11 |year=2012 |last1=Sasson |first1=Comilla |last2=Wiler |first2=Jennifer L. |last3=Haukoos |first3=Jason S. |last4=Sklar |first4=David |last5=Kellermann |first5=Arthur L. |last6=Beck |first6=Dennis |last7=Urbina |first7=Chris |last8=Heilpern |first8=Kathryn |last9=Magid |first9=David J. |doi-access=free}}</ref> 

In emergency departments in Australia, the government utilises an "Activity based funding and management", meaning that the amount of funding to emergency departments are allocated money based on the number of patients and the complexity of their cases or illnesses.<ref name="ww2.health.wa.gov.au">{{Cite web|url=https://ww2.health.wa.gov.au/Our-performance/Activity-based-funding-and-management|title=Activity based funding and management}}</ref> However, rural emergency departments of Australia are funded under the principle of providing the necessary equipment and staffing levels required to provide safe and adequate care, not necessarily on the number of patients.<ref name="ww2.health.wa.gov.au"/>

====Compensation====

In the United States, Emergency Physicians are compensated at a higher rate than some other specialities, ranking 10th out of 26 physician specialities in 2015, at an average salary of $306,000 annually.<ref>{{Cite web|url=http://www.medscape.com/features/slideshow/compensation/2015/public/overview#page=3|title=Medscape Physician Compensation Report 2015|website=medscape.com|access-date=2016-11-28}}</ref> They are compensated in the mid-range (averaging $13,000 annually) for non-patient activities, such as speaking engagements or acting as an expert witness; they also saw a 12% increase in salary from 2014 – 2015 (which was not out of line with many other physician specialities that year).<ref>{{Cite web|url=http://www.medscape.com/features/slideshow/compensation/2015/public/overview#page=4|title=Medscape Physician Compensation Report 2015|website=medscape.com|access-date=2016-11-28}}</ref> While emergency physicians work 8–12 hour shifts and do not tend to work on-call, the high level of stress and need for solid diagnostic and triage capabilities for the undifferentiated, acute patient contributes to arguments justifying higher salaries for these physicians.<ref>{{Cite web|url=http://www.medscape.com/viewarticle/750482|title=Physician Compensation Report 2015|website=medscape.com|access-date=2016-11-28}}</ref> Emergency care must be available every hour of every day and requires a doctor to be available on-site 24/7, unlike an outpatient clinic or other hospital departments with more limited hours and may only call a physician in when needed.<ref>{{cite book |last1=Shi |first1=L |last2=Singh |first2=D |title=Delivering health care in America: A systems approach |edition=6th |location=Burlington, Massachusetts |publisher=Jones & Bartlett Learning |year=2015 |page=264}}</ref> The necessity to have a physician on staff and all other diagnostic services available every hour of every day is thus a costly arrangement for hospitals.<ref>{{Cite web|url=http://newsroom.acep.org/fact_sheets?item=29928|title=Fact Sheets|website=American College of Emergency Physicians {{!}} News Room|access-date=2016-11-28|archive-date=5 May 2019|archive-url=https://web.archive.org/web/20190505041429/http://newsroom.acep.org/fact_sheets?item=29928|url-status=dead}}</ref>

====Payment systems====

American health payment systems are undergoing significant reform efforts,<ref>{{cite journal |pmid=15923928 |year=2005 |last1=Bebber |first1=R. J. |title=Reimbursement challenges for emergency physicians |journal=The Health Care Manager |volume=24 |issue=2 |pages=159–64 |last2=Liberman |first2=A |doi=10.1097/00126450-200504000-00009}}</ref> Which include compensating emergency physicians through "[[Pay for performance (healthcare)|pay for performance]]" incentives and penalty measures under commercial and public health programs, including Medicare and Medicaid. This payment reform aims to improve the quality of care and control costs, despite the differing opinions on the existing evidence to show that this payment approach is effective in emergency medicine.<ref name="ReferenceA">{{cite journal |doi=10.1056/NEJMe1212133 |pmid=23134388 |title=Will Pay for Performance Improve Quality of Care? The Answer is in the Details |journal=New England Journal of Medicine |volume=367 |issue=19 |pages=1852–3 |year=2012 |last1=Epstein |first1=Arnold M.}}</ref> Initially, these incentives would only target primary care providers (PCPs), but some would argue that emergency medicine is primary care, as no one refers patients to the ED.<ref>{{Cite web|url=https://www.aamc.org/download/100598/data/|title=Recent Studies and Reports on Physician Shortages in the US: Emergency Medicine (2009) – "Emergency Care System Remains in Serious Condition"|date=October 2012|pages=13|archive-url=https://web.archive.org/web/20161021204254/https://www.aamc.org/download/100598/data/|archive-date=21 October 2016|url-status=dead}}</ref><ref name="ReferenceA"/> In one such program, two specific conditions listed were directly tied to patients frequently seen by emergency medical providers: acute myocardial infarction and pneumonia.<ref>{{cite journal |doi=10.1016/j.annemergmed.2006.06.032 |pmid=16979264 |title=Pay for Performance in Emergency Medicine |journal=Annals of Emergency Medicine |volume=49 |issue=6 |pages=756–61 |year=2007 |last1=Sikka |first1=Rishi}}</ref> (See: [[Hospital Quality Incentive Demonstration]].)

There are some challenges with implementing these quality-based incentives in emergency medicine in that patients are often not given a definitive diagnosis in the ED, making it challenging to allocate payments through [https://www.aapc.com/medical-coding/medical-coding.aspx coding].  Additionally, adjustments based on patient risk-level and multiple co-morbidities for complex patients further complicate attribution of positive or negative health outcomes. It is not easy to assess whether much of the costs directly result from the emergent condition treated in acutely care settings.<ref>{{Cite web|url=https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Emergency-Medicine-and-Payment-Reform/|title=Emergency Medicine and Payment Reform // ACEP|website=acep.org|access-date=2016-11-28|archive-url=https://web.archive.org/web/20161129021328/https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Emergency-Medicine-and-Payment-Reform/|archive-date=29 November 2016|url-status=dead}}</ref> It is also difficult to quantify the savings due to preventive care during emergency treatment (i.e. workup, stabilizing treatments, coordination of care and discharge, rather than a hospital admission). Thus, ED providers tend to support a modified fee-for-service model over other payment systems.<ref>{{Cite web|url=https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Emergency-Medicine-and-Payment-Reform/|title=Ibid|website=acep.org|access-date=2016-11-28|archive-url=https://web.archive.org/web/20161129021328/https://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Emergency-Medicine-and-Payment-Reform/|archive-date=29 November 2016|url-status=dead}}</ref>

==== Overutilization ====

Some patients without health insurance utilize EDs as their primary form of medical care, as their financial status limits their access to consistent care. Because these patients cannot utilize insurance or primary care systems, emergency medical providers often increased volumes of lower acuity patients and risk of financial loss, especially since many patients cannot pay for their care (see below). ED overuse produces $38 billion in spending each year (i.e. care delivery and coordination failures, over-treatment, administrative complexity, pricing failures, and fraud),<ref name=":7">{{Cite web|url=http://www.nehi.net/writable/publication_files/file/nehi_ed_overuse_issue_brief_032610finaledits.pdf|title=A Matter of Urgency: Reducing Emergency Department Overuse|date=March 2010|website=NEHI Research Brief|publisher=New England Healthcare Institute|access-date=16 November 2016|archive-date=23 November 2016|archive-url=https://web.archive.org/web/20161123064444/http://www.nehi.net/writable/publication_files/file/nehi_ed_overuse_issue_brief_032610finaledits.pdf|url-status=dead}}</ref><ref>{{Cite web|url=http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82|title=Reducing Waste in Health Care|website=Health Affairs – Health Policy Briefs|access-date=2016-11-28}}</ref> Moreover, it unnecessarily drains departmental resources, reducing the quality of care across all patients. While overuse is not limited to the uninsured, the uninsured constitute a growing proportion of non-urgent ED visits.<ref>{{cite journal |doi=10.1016/j.annemergmed.2008.01.327 |pmid=18407374 |title=Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States? |journal=Annals of Emergency Medicine |volume=52 |issue=2 |pages=108–15 |year=2008 |last1=Weber |first1=Ellen J. |last2=Showstack |first2=Jonathan A. |last3=Hunt |first3=Kelly A. |last4=Colby |first4=David C. |last5=Grimes |first5=Barbara |last6=Bacchetti |first6=Peter |last7=Callaham |first7=Michael L.}}</ref> Insurance coverage can help mitigate overutilization by improving access to alternative forms of care and lowering the need for emergency visits.<ref name=":6" /><ref>{{cite journal |doi=10.1007/s10900-016-0293-4 |pmid=27837359 |title=Emergency Department Visits and Hospitalizations for the Uninsured in Illinois Before and After Affordable Care Act Insurance Expansion |journal=Journal of Community Health |volume=42 |issue=3 |pages=591–597 |year=2016 |last1=Sharma |first1=Aabha I. |last2=Dresden |first2=Scott M. |last3=Powell |first3=Emilie S. |last4=Kang |first4=Raymond |last5=Feinglass |first5=Joe |s2cid=25647447}}</ref>

A common misconception identifies frequent ED visitors as a significant factor in excess spending. However, frequent ED users make up a small portion of those contributing to overutilization and are often insured.<ref>{{Cite web |url=https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7696.pdf |title=Characteristics of Frequent Emergency Department Users |date=October 2007 |publisher=The Henry J. Kaiser Family Foundation |access-date=16 November 2016 |archive-url=https://web.archive.org/web/20161128200549/https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7696.pdf |archive-date=28 November 2016 |url-status=dead}}</ref>