Coordinating with PCPs Smooths the Rough Edges of Managed Care
Going the extra mile to develop close relationships with primary care physicians can head off potential access problems, and improve patient care and satisfaction.
Newsletters to PCPs outlining upcoming changes in an MCOs coverage of ED services; automatic routing of ED charts to the family physician and the health plan; and phone calls arranging and confirming follow-up care. These are just a few of the methods proactive EDs are using to improve communication between emergency physicians and primary care providers and eliminate some of the frustration and confusion experienced in the transition into a more "managed" environment.
Sound like too much of a hassle?
Think again.
As PCPs exert more control over how and when their patients are authorized for care in the ED, improving communication and coordination are essential.
"In the eight years that I have been here, managed care has risen from 10% of our payer mix to 40% of our payer mix," says Thom Mayer, MD, FACEP, Chairman of the Department of Emergency Medicine at Fairfax Hospital in Fairfax, VA. "So, we want to work closely with them to the extent that we can . . . I want those people to use our ED because we are a fee-for-service ED."
There is another reason improving communication between the ED and PCPs should be a primary goal, adds James Augustine, MD, FACEP, the CEO of Dayton, OH-based Premier Health Care Services and Chairman of the Department of Emergency Medicine at Miami Valley Hospital, also in Dayton.
"Primary care physicians and emergency physicians are really the two physician groups who work together in what we call first contact medicine, a point where the general public first touches the health care system," Augustine explains. "We share the responsibility for taking care of a whole lot of people, and the more effectively we do the communication, the more effectively we deliver care to the whole country."
Improving authorization procedures, easing the flow of information concerning a patient’s ongoing physical condition and acuity level, and ensuring adequate follow-up are key strategies for ED groups if they hope to capture more managed care dollars.
Step One: Dealing proactively with managed care
As the state of Washington prepared to put it’s Medicaid population into managed care just over two years ago, managers in the ED at Mary Bridge Children’s Hospital in Tacoma sat down with the primary care providers in their area to discuss how the changes would effect both the PCP’s office and the ED, says Ted Walkley, MD, Director of Pediatric Emergency Services.
"We set up a whole series of meetings with the PCPs," he says. "First, we set up a meeting with the [health] plans and came up with the rules, about authorization, about what a bona fide emergency was, that sort of thing. The we sat down with the PCPs to go over what the rules were."
The two groups have continued to meet periodically to go over problem areas or changes in the managed care regulations.
An example involves the "coordination of care" calls the plans began requiring in order for the ED visit to be covered, says Walkley. When the ED physicians began calling to coordinate care for emergency patients already seen in the department, the PCPs thought they were calling for authorization.
"And, they were mad," Walkley says. "Why are you calling me for a patient you’ve already seen?’ We said, We’re not, this is for coordination of care. Do you know what we’re talking about?’ They didn’t."
Since then, the ED leaders have been very careful to meet with them about any changes in the way things will be done, he says. "We’ve been very careful to sit down every time there is a rules change from our point of view and say, This is what we perceive the rule to be, and this is what it means in terms of what you are going to see from us, when you are going to get a call."
In instances where the changes did not warrant an actual, sit-down meeting with the PCPs, the department has even take the step of sending out a newsletter, updating the physicians on any changes and concerns the ED physicians had, Walkley says.
Because "the rules" usually differ from health plan to health plan, it is a good idea to meet with each plan in person and establish a working relationship, says Mayer.
"Some people do this by sending a letter and I think that is a mistake," he continues. "I think you have to meet with them and meet with someone in operations, not marketing, who is going to be responsible for making things work, and say to them, What do we need to do to make this work so that it looks good to the patient."
"We don’t want the managed care plan to look bad to the patient, because when re-enrollment occurs that is a problem."
And the main thing most plans want, is early notification of and coordination with the PCPs, he says.
Step Two: Making the right calls
Calls to the PCP for authorization, instead of being a time-consuming problem, can be a useful tool in providing care for the ED patient when performed correctly, says Augustine.
"First of all, we are not advocates, in our group, of the preauthorization communication wherein the primary care physicians have to hear from emergency physicians when the patient hits the door of the emergency room and the PCP has to authorize care," he emphasizes.
Augustine says the patient should be seen, evaluated, and a determination made of the ongoing medical problem, before the first option exists for contact with primary care. Once that has been accomplished, the patient’s PCP can be a valuable resource for the ED physician.
"It may be a complicated patient with a lot of medical problems and a lot of ongoing workup. If you’ll communicate with the primary care physician right then, you can avoid a whole lot of workup and time and expense," he says, adding that it is important that the emergency physician speak to the patient’s PCP and not just the plan’s physician-on-call. " Doctors will often say, "Oh, I have just done a complete workup of that problem, or, I have seen the patient recently.’"
The emergency physician can then proceed using the patient’s prior history and avoid repeating unnecessary workup and tests.
The earlier the ED physician can call the PCP, the better, says Mayer. Though he also agrees it should be after the ED doctor has seen the patient.
When a patient is identified, either in triage or registration, as a managed care patient, that area is highlighted on the chart for the physician, he explains. "We are very proactive about calling the PCP early and saying, "Look, we’ve got Mrs. Jones. She’s got some chest pain, looks like she’s going to have to come in, but we haven’t completed the workup and I will have to call back and let you know."
Then, the PCP knows early on that the ED is seeing his patient, what the situation is, and whether they are leaning toward admission or not admission.
"Frankly, one of the reasons we call them so early is for patient-flow reasons," Mayer adds. "If I work up a patient and then call the PCP, it may take 30 minutes to an hour for them to call back. Meanwhile, I’ve got a patient just sitting there in that bed. If I call them early, and say, Look, I think she may have to come in,’ they are expecting that call later and we get a decision quickly instead of having to wait. The second time you call, they know what you are calling about and they are going to call you back fairly quickly."
There are situations where this approach would not be appropriate, acknowledges Mayer.
"Obviously, I would not call the PCP at 3 a.m. and say, I am working Bessie up, I’ll call you back when I’m done," he says. "I’ll call him with the package and say, I have Mrs. Smith and I think she needs to come in."
In meetings with the PCPs and the health plans, Mary Bridge’s ED negotiated the arrangement that anyone in a PCP’s office could authorize care in the ED, but only a physician could deny it.
He is now careful to make sure that when a physician is required to be on the phone to deny authorization, he talks with a physician in the department, Walkley says.
"If we have a child with a fever and we call the office and the nurse says, No, send him home,’ then we say, Our physician will be calling you back once he’s done a screening exam if he thinks the child needs to be seen.’ Then we put the physician on the phone, they have a physician-to-physician conversation and [most of the time] it gets authorized."
Step Three: Sending the records
After the ED visit is finished, many EDs have taken steps to ensure that the PCP has an accurate record of the visit and that he gets it promptly.
"ER records have tended to arrive in the office a week later and the physician doesn’t know what the deal is," states Walkley. "He may have already seen the patient again."
One of the things Walkley is working on is a computerized discharge summary at the end of the visit that would summarize the salient points of the visit and would either be faxed or e-mailed to the PCP before the visit is transcribed, he says. "I think that is one of the most important information things. The ideal system would have it done electronically and the physician would come in the morning and his staff would log onto the computer and have an immediate list of all the patients seen that evening. It would make the issue of follow-up much easier, it would make the issue of paperwork that needs to be done with authorization much easier. I think it would go a long way to having the physicians understand the services that we do."
Premier works hard to encourage the hospitals where it has ED contracts to do automatic routing of the chart to the PCPs, says Augustine. "We consider it very important that the primary care physicians have a legible copy that is logical for them, so they understand what happened to the patient, and get all of the patient’s test results."
In some cases, the group has even modified their paperwork to make sure this takes place, he continues. "Our disposition paperwork that guides the patient though going home has a section about who the follow-up physician is going to be."
For example, a specialist following up the care, might not be the patient’s PCP, so the chart should go immediately to the specialist, with a copy eventually to the PCP.
Many of their hospitals also allow them to designate priority and list anyone who needs a copy when they are dictating the chart, he adds. "Here, I’ve dealt with the lady with the broken wrist. I’ve really made sure I’ve talked with the orthopedic surgeon, then when I dictate out the chart, I dictate out: Transcription, this is a priority chart to get done and you need to fax a copy to the orthopedic surgeon who will be seeing the patient in the office tomorrow.’"
It also helps that several of the hospitals’ transcription departments have automatic fax capabilities, he notes.
Augustine also encourages automatic copying of the chart to the managed care organization and the physician.
"Essentially, everyone gets notification that the patient was there or a copy of the chart," he says. In many instances, simple laceration repairs, for example, it is more expedient for the ED physician to treat the patient, then send a copy of the paperwork to the physician.
The patient just needs to be seen in seven days for suture removal, and, when he shows up in the PCPs office, the physician has a complete record of information, Augustine emphasizes. "Some of the managed care organizations we actually give [MCOs] daily logs of which patients of theirs we have seen. They know to expect a bill and what their log looks like."
Step Four: Continuing education
Increased communication with primary care providers has increased the PCPs’ knowledge about the scope of emergency medicine and how an ED works, says Walkley.
Because he and his staff make the effort to call for authorization when they are supposed to, and to send patients to the doctor’s office during the day, many of the primary care physicians are giving them more leeway about not calling after hours, and are even sending some patient’s to the ED.
"A doctor called me from his office and said, I have a lip laceration and it is through the border, is that something you do?’ Well, that’s something I do all the time," Walkley says. "By educating them [that] we do sedation, we do complex repairs, we can reduce fractures, we can take care of a child with abdominal pain for four or five hours and send them home. We can do those things that they can do, but don’t have the time or energy to do with a busy office."
Staying abreast of the needs of other physicians is key to working in managed care, adds Mayer.
"I think you have to go to department meetingsdepartment of family practice, department of medicine, section of cardiologyand talk about, if not practice guidelines, then at least general parameters of who’s going to get admitted and who is not going to get admitted."
As managed care gains more penetration in communities, it becomes vital to pay attention not just to the patients, but to the payer, says Mayer.
"In emergency medicine, you are always on the short end of the stick," he notes. "There are always more of them’more patients, more demands, more customers than there are of us.’ You have to make things work to your advantage."
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