The CMS Proposed Rule May Unintentionally Exclude Our Most Vulnerable Patients

Note: An earlier version of this article incorrectly stated that the ONC, not CMS, proposed the rule described below. We have since updated the story.

The eagerly anticipated Proposed Rule to Improve the Interoperability of Health Information was released two weeks ago by the Centers for Medicare & Medicaid Services (CMS). We see the potential for great benefit to patients and providers across the nation from the expansive framework for broader, patient-centered data sharing in the proposed rule.

But this progress may not be universal. As currently written, the proposed rule unintentionally excludes the safety net population. The proposed rule suggests that hospitals will be required to share admissions, discharge and transfer (ADT) notifications with other providers for inpatient stays — but notably excludes emergency departments (EDs), a place where so many vulnerable patients access care.

Chris Klomp, CEO, Collective Medical

There can be unintended consequences in particular when regulations make what may seem like sensible exclusions without considering the potential impact on underserved and vulnerable populations. Let’s take the HITECH Act and the well-intentioned EHR Incentive Program, or Meaningful Use, as an example. While most hospitals and ambulatory medical providers were offered incentives to adopt EHR technology, the post-acute and behavioral health community were notably left out. As a result, we see both groups disadvantaged and lagging in technology adoption and, in some cases, simply unable to meaningfully collaborate with a patient’s larger care team.

Similarly, by excluding EDs from the ADT sharing requirement, we may unintentionally ignore our nation’s most vulnerable patients.

The ED is the health system’s front door. Underserved patients, many of whom are un- or underinsured, or Medicaid beneficiaries, rely heavily on EDs across the country to access care. EDs contributed an average of 47.7 percent of the hospital associated medical care in the U.S. between 1996 and 2010. And, according to the National Ambulatory Medical Care Survey, only 8 percent of ED visits result in a hospital admission. After Medicaid Expansion in 2014, ED visits by the uninsured decreased by 5.3 percent, but visits covered by Medicaid increased by 8.8 percent. EDs can’t deny care under EMTALA rules, which only contributes to the ED’s importance to the safety net.

Excluding EDs from the framework being built by CMS to share ADT information and better coordinate care will also exclude the vulnerable and complex patients who rely on it — many of whom are never admitted to the hospital and thus may fall through the cracks.

Voluntary sharing of ADT to drive care coordination by EDs across the country has been growing organically for several years — in part due to the incredible success of Washington State’s “ER is for Emergencies” program and the efforts of the American College of Emergency Physicians (ACEP). To illustrate, hospital EDs in 22 states are already live and actively collaborating — and sharing ADT information — via the Collective Medical network. Of the nearly 240 million patient visits that have crossed our platform, 66 million originated in the ED. The benefits of this coordination have been well documented. For example, Washington’s “ER is for Emergencies” program reduced avoidable ED visits by 10 percent and saved the state $34 million in its first year of operation.

Because of their unique position in the continuum of care, ED providers have fostered some of the country’s most innovative approaches to collaborating on and caring for complex patients. In the San Francisco Bay Area, as an example, ED providers at disparate health systems collaborate regularly on complex patients with significant social determinants, many of whom are homeless. Through their coordination, ED physicians have identified at-risk patients and collaborate on their care across shared care plans with the local MCO, many FQHCs, behavioral health providers and community services. Similarly, in 2018, Virginia connected all 129 of its hospitals as a part of its Emergency Department Care Coordination program, in part to better support underserved patients.

With the ED as the anchor, other members of the care team, including behavioral health providers, post-acute facilities and physician practices, can more proactively care for patients.

EDs are also at the epicenter of the fight against the opioid epidemic. By voluntarily collaborating and sharing information with other EDs, St. Anthony Hospital, a critical access hospital in Pendleton, Oregon, was able to reduce narcotic prepack prescriptions coming out of the ED by 66 percent. Mat-Su Regional Medical Center in Palmer, Alaska, has seen a nearly 80% drop in opioid scripts given in the ED. And statewide in Washington, there was a 24 percent reduction in ED visits resulting in an opioid prescription.

Vulnerable populations have complex needs that aren’t, and can’t, be met at any single point of care. It’s critical to catch these patients and get them the help they need, starting in the ED. We believe that voluntary, provider-led initiatives to share data and collaborate are more effective and preferable as a general matter, and we have seen these initiatives focus particular attention on safety net populations across the nation. Any new regulations can have the unintended consequence of overburdening our country’s already stressed hospitals, among other potential challenges.

If CMS does adopt its proposal to require sharing of ADT by hospitals, it should also require that ED visits be shared. Excluding EDs from the final rule on ADT information sharing could result in uneven adoption across the nation and will disadvantage those complex patients that will benefit the most from full care team coordination.

Chris Klomp is CEO of Collective Medical, the nation’s largest network for care collaboration.

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