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The author declare no conflicts of interest, in relation to this article.
Program (EPRP) is staffed 24/7 by emergency physicians
and ED nurses, coordinating KP patient care by non-KP
providers in community EDs. When medically indicated,
EPRP providers also assist with inter-facility transfers of
KP patients back to KP facilities, including physician-level
critical care transport. Thus, thousands of high-risk KP
patients each year are safely repatriated without delete-
rious clinical outcomes (26).
Urgenciaas Hub for Complex Conditions
In the RAND study on the role of ED’s in the US system,
the single largest cost center for most health insurance
programs was noted to be hospital care (27). Most of KP
competitors in the private insurance market, as well as
MA contracting with Medicare for senior populations,
attempt to control hospital costs by viewing ED visits as
a negative metric; a failure of primary care and disease
management. The RAND study also noted, however, that
an ED visit is only one tenth of the cost of an inpatient
hospital stay.
KP is somewhat unique among ACO’s in its preferential use
of the ED over primary clinics to rapidly evaluate more
complex or high-risk conditions, as well as acute exac-
erbations of many chronic diseases. KP programs direct
members with lower-acuity conditions to other points
of care, preserving ED capacity and resources for emer-
gency physicians and related specialists to collaborate on
more intensive, prolonged ED related care for complex or
high-acuity KP patients, often preventing the need for
hospitalization, and delivering post-acute care in other
settings. Selevan et al reported ED use of the KP disease
management protocol for congestive heart failure resulted
in lower rates of readmission, return ED visits and 90-day
mortality rates in their 2011 outcomes study.
Alignment of Incentives
KP programs are pre-paid fixed amounts of insurance
premiums for its private members, and larger amounts
by Medicare for elderly members in their MA program. KP
also intends to keep members enrolled in their programs
for many years by delivering high-value care; the Triple
Aim. Most emergency physicians in California are paid by
the number of patients they treat and how many proce-
dures they perform. Emergency physicians in KP are more
likely to be paid a flat salary, with rewards for optimizing
hospital care. This is reflected in lower admission rates at
KP hospitals than non-KP hospitals than patients treated in
other ED settings in California or across the US. A complex
set of checks and balances in the contracts between KP
entities protect patient safety or discourage cost-shifting.
Evidence based medical practices in KP also help control
costs without negatively impacting outcomes (28).
CONCLUSION
California, along with neighboring Oregon and Wash-
ington, has the fewest number of hospital beds per capita
of any US state (29). Now that RAND has affirmed the ED
has become the primary portal of entry for hospital admis-
sions, it is also the last if not best place to safely manage
demand for inpatient care. The non-partisan Congres-
sional Budget Office has predicted that the trust fund for
hospital services in the Medicare program will be unable to
pay the full cost of projected care by 2028 (30). States face
similar challenges for Medicaid programs (31). Most states
are seeing rapid rise in the price of coverage through ACA
exchanges, with fewer private insurance companies partic-
ipating (32). Acute care stakeholders need to aim higher
than saving individual lives. They must align to save essen-
tial systems of acute care.
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