Episode Overview

Each year, one in five Americans visit the emergency department (ED) at least once  – and these costly ED visits are on the rise. Are they a symptom of a larger issue in our health care system? Many of emergency visits are preventable – this may be a symptom for inefficient care management, inadequate patient access, or lack of patient knowledge. As hospitals and payers transition into value-based care, interpreting ED visits may be a symptom of a larger problem. 
In this episode of Value-Based Care Insights, Daniel J. Marino is joined by Dr. Nicholas Dodaro, Chief Medical Officer and co-founder of Medical Life Holdings, a portfolio of companies and practices founded in 2006 to improve the value of health care delivery. The two discuss common issues with emergency room visits, why they’re so costly, and what to do about them.

Key points include:

  • “Unmanaged” or “unengaged” patients seem to be a big contributor to unnecessary ED visits.
  • Understanding the financial impacts of ED visits on the performance of value-based contracts.
  • Reviewing ED visits can be insightful to future improvements with care delivery.


Lumina Headshots (6)
Daniel J. Marino

Managing Partner, Lumina Health Partners


Lumina Headshots (9)
Nicholas Dodaro

CMO & Co-Founder
Medical Life Holdings


Daniel J. Marino: Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. On past programs, we've discussed many times the challenges many hospitals and health systems physicians have had transitioning into value-based care. And many hospitals and health systems right now only have anywhere between 10% to 30% of their revenue tied to value-based care. Yet there continues to be a lot of pressure on the industry to focus care differently, to look at a lot of those outcomes, to manage costs, and again, to really transition fully into a value-based care model. When we think about emergency department visits, ED visits, I sort of think about it as a microcosm of the larger issue that we're experiencing as we're transitioning into value-based care. Many organizations have really struggled with getting their arms around ED visits, particularly those unnecessary visits. And I think there are a lot of reasons for that. I think in some cases patients need care that they can't always get within their community. They need to have support in one way or the other from either their primary care physicians and in some cases, they can't get it. So they're going to the ED. Yet, hospitals have had a tough time managing a lot of the costs, a lot of the referrals, a lot of the volume, some of which is because their fee for service contracts has promoted acceptance. Today on our show, I'm really pleased to have an industry leader in emergency medicine, Dr. Nicholas Dodaro. Dr. Dodaro is a Chief Medical Officer and co-founder of Medical Life Holdings. It's a portfolio of companies and practices founded in 2006 to improve the value of health care delivery. Dr. Dodaro is a board-certified physician with the American Board of Emergency Medicine and is a fellow in the American College of Emergency Physicians. Dr. Dodaro, welcome to the program.


Dr. Nicholas Dodaro: Thank you for having me, Dan. I'm excited to chat today and I feel honored to be here.


Daniel J. Marino: Well, thank you. We appreciate it. So Dr. Dodaro, a couple weeks ago I had a wonderful opportunity to participate in a conference. I heard you speak, you did a great job. You made an important comment that really resonated with me. “ER visits are an important symptom of a larger problem.” Can you expand on that? What did you mean by that comment?


Dr. Nicholas Dodaro: Absolutely, and thank you again. Thank you for having me and it's really fun to talk with you today. So we're in the business of taking care of patients that find solutions in emergency department and hospital settings. They wind up there as a result of a variety of different obstacles that have gotten in their way over the course of some amount of time, two days, five days, two weeks. One of the things I always say is every emergency department visit started about two weeks ago. It really becomes the symptom of all the events that transpire leading up to that visit. Whereas the visit is not the issue. The visit is the symptom of the larger system problem that we have in health care.


Daniel J. Marino: Yeah, it's an interesting perspective. That causes physicians particularly in primary care to be challenged, right? They're very busy, there's not enough primary care. I think physicians do a great job of delivering care in their office, but when the patient leaves, the quality of that care actually decreases. Do you think physicians really incorporate or use emergency visits as an extension of their practice?


Dr. Nicholas Dodaro: Well, I think they do rightly so. With all the good intentions, every physician that I know, primary care or anyone, cardiology or emergency medicine, they wanna take care of people. And certainly, the emergency department offers them a way to take care of them when the system isn't supporting the pieces of the journey and the puzzle the patient needs. You've made some mentioning comments, we can come back to it, but you think about comments like the division of necessary and unnecessary acute versus non-acute obstacles in the health care system, complicated health care journeys, all these challenges in the face of patients that are hard to solve, hard for the primary care provider or anyone to solve from their position of taking care of patients day in and day out. And with lack of solutions, the only solution that they often turn to or have as an option is the emergency department which has set itself up to be the solution fairly intentionally.


Daniel J. Marino: So some hospitals have provided alternatives to care than going through the emergency department. But I find right now that there are sort of competing objectives if you will, hospitals that still have a very strong fee-for-service contracts, frankly, they do well from emergency department visits. How does that come into play as you start to think about getting past that mindset, that paradigm shift where we think about the need for other alternative models if you will?


Dr. Nicholas Dodaro: The emergency department has become a really great resource for using hospital services. Hospitals have figured that out and this is not to say anyone's nefarious, it's just a business model. It is the emergency department has become an opportunity for hospitals to pull patients into their services, which in a lot of ways makes a lot of sense and often and to start to understand how to leverage an emergency department in a lesser front and center way for a population or a group of patients you care for is the challenge because those hospitals have certainly created great opportunities for patients to get around the clock care. So the industry has moved against a value-based or a population-based process through pursuit of the normal business practices you'd expect from a hospital.


Daniel J. Marino: And like you said, I think they focused on making things a lot more efficient, which is good. So it's a lot easier for the patients to get care out of the emergency department. I'm in the Chicago area and many of the hospitals and health systems post their wait time as a way of attracting patients, if you will. In your opinion, what percentage of the EF visits that occur are maybe unnecessary? Any ideas?


Dr. Nicholas Dodaro: Well, I do, let me give you a little context for a second. I spent a lot of years, spent almost two decades standing at the bedside in emergency departments, academic centers, large and small centers, whatever, a variety of different settings. And when you stand in an emergency department, you spent a lot of time watching ER on tv or for those of us who don't spend a lot of time there, you imagine patient patients show up a lot of times have life-threatening emergencies and that's very, very small percentage of patients. Certainly, there are those right who are having heart attacks or acute strokes and those sorts of things. But the majority of patients have challenges that aren't necessarily life-threatening. They have journey challenges, and they've got all kinds of obstacles in their health care solutions. They've got things that couldn't be solved in are the right setting, they've lost a prescription or they have just gotten frustrated by the lack of access to a physical therapist or wound care or something that caused the amount of frustration. At some point, they need some help or some answers and they're turning to a highly capable high acuity setting like an ER for those answers that then drive a lot of the acuity down on your day-to-day patients. So when you look at the population at large, you have really life-threatening emergencies. It's a very, very small percentage. In many places, it's below 20%.


Daniel J. Marino: That's interesting. Yeah. So really almost 80% of those visits can be managed differently I think is really what it comes down to. So when we had done we do quite a bit of managed care contracting, and I often say on behalf of the physician groups and the hospital, there are two types of risk. You have your insured risk or insurance risk and you have managed risk. Insurance risks are those things that you know don't really have much control over, they're gonna happen, it's catastrophic. We have to take care of the patients and so on and so forth. But you have the managed risk and those are the things that you should be held accountable to.


Dr. Nicholas Dodaro: Right. I agree. I think part of the challenge is patients are very poor as they should be at knowing what's necessary, unnecessary, and what's acute or non-acute. When you're anxious or unsure about something going on health care wise you need some guidance. And that's kind of why that's the job doctors provide. They understand health care. All of us have a lot of us in health care, myself, yourself, and probably a lot of the people who listen to this have a friend, neighbor, colleague, or someone they can text or call when they have a stress-provoking moment. My son got hurt or my wife is ill, or whatever the case may be. And that's how you relieve that anxiety. You're gonna ask for some guidance and some expertise. And so patients need that same access and if they don't have it, they're gonna go find it somewhere because a patient not cannot be expected to understand necessary from unnecessary. So when they have that anxiety-provoking moment they're gonna seek an outlet for some answers and if the best outlet they've seen, advertised or aware of is the ER, they'll go there for that assurance as they should. Providing a better outlet for that, providing better access to that is not something the system does well yet which is why ERs and urgent cares have thrived in the environment.


Daniel J. Marino: Right. I agree with you. Do you think that there's a differentiator there with maybe the level of engagement with patients?


Dr. Nicholas Dodaro: I do. We about talked to a number of groups of physicians. We've talked to a lot of groups who are shifting to a value based arrangement. These practices are taking great efforts to provide resources and services their patients, yet somehow they still have this expensive cohort of folks who are wandering around and using ERs and kinda leak into other networks, getting routed to places outside of the core kind of team of that position. The specialist that's surround them. They're trying to figure out what's going on there. And our experience is that some of the population are taking advantage of those resources and they're engaged with the primary, and then a group of them are not because they tend to seek care either when they need it or they want different venues or going to the office in two weeks doesn't seem to work for them, that sort of thing. So you have two groups of patients because many practices get frustrated. They say, we're doing all this stuff and we have a lot of people working with us and we have a lot of patients who come and do these things. Yet somehow I got this expensive group over here that doesn't seem to still respond to what I'm doing and I don't know how to solve for that. That's kind of what you're suggesting. 


Daniel J. Marino: If you just are tuning in, I'm Daniel Marino and you're listening to Value-Based Care Insights, I'm here today talking with Dr. Nicholas Dodaro, spending some time discussing impacts on ED visits, its relationship to value-based care and potentially changing the care delivery model. So Dr. Dodaro, when you think about some solutions on how hospitals, health systems or even physicians for that matter could start to put in different models of care, where do some of these organizations need to start?


Dr. Nicholas Dodaro: In our opinion, organizations need to start at extending the services the practice provides to the unengaged and unmanaged population that exists amongst the group they're working with, the patient group they're working with they've gotta approach that population from a different angle. They have different needs or expectations. And it seems in today's world when you have an acute concern, and again we tend to caution ourselves not to try to stratify concerns because the patients don't understand when something is serious or not. It's our job to sort that out. They've gotta access that practice in different ways and it's gotta be real-time access. A lot of times they wanna access that practice with a capable or credentialed provider, often a physician, which is not to say that any one provider is better than the other, but sometimes they want a physician-patient relationship to answer their question. And so you have to provide that access in a way that's more fluid and dynamic real-time. It's not a part of phone tree menus and callbacks and waits. You have to do that to get access to those folks who don't normally access the practice on a scheduled and routine basis.


Daniel J. Marino: When I heard you speak, you had talked about the fact that one solution to really being able to drive down the unnecessary, you have to provide these other alternatives in the care model through the physician practice. So you need to have a wraparound type of structure that gives the patients an alternative than just getting in their car and going to the emergency department. That was really interesting, I think in terms of being able to offer these different types of solutions. One, I think it's intuitive, right? I mean it's the right thing to do and if you're really going to establish that relationship, you almost have to provide that 24/7 level of care. But I think at the same time, it's challenging for physicians to be able to do that. How have some of the work that you've done helped to align what the physician does in their practice when trying to provide that alternative support after hours and almost a 24/7 model?


Dr. Nicholas Dodaro: What we've found is primary care physicians and even a lot of the specialty care physicians, their practice, they're hard-working, they're doing it a lot. Their practice is very busy and it's really difficult to shift gears and offer a whole other kind of style or capability of practice on top of that. Even your physicians still do it the old school way when we were now dating myself here when we were young and your doctor took all the phone calls around the clock, right? That's really difficult. It's not scalable, it's not sustainable, and it's hard to work 24/7. And we find the patients, when your doctor takes the phone, some doctors still say, “Hey, I answered my phone 24 hours a day.” The patients say, “I don't wanna bother them.” Do you know what I mean? Gosh, they work enough. So what do they do? They, hesitate and then they go back to solving it. They go back to the ERs or wherever they're going. So what we've done is we put together a group of emergency medicine physicians and we provide a virtual 24/7 emergency medicine practice that wraps around your existing practice because you want to keep that practice intact, right? You're doing a lot of great work. You want patients to learn to call that practice to become affiliated practice, but it should be that they get an expanded level of service at three o'clock in the morning on Thursday or on Thanksgiving day, that sort of stuff. They can still talk to a doctor real-time and get that level of interaction where they say, “Hey, I've got the comfort and in credible answer to your solution or kind of a sense of what's going on with me that I can trust that physician's relationship with me.” I trust that physician cuz they're a part of my doctor's practice. They're part of the practice I go to anyway. And so that all that changes the culture and dynamic and relationship between that the patient groups and that practice and then don't change the entire practice that already exists. It's doing a good job with the patients. They're working with them.


Daniel J. Marino: It becomes an extension of it. I love that. I think is on the surface, it sounds like it has so many benefits to it. So when you're focusing on that though, do you lead with the data or do you lead with the operations, so to speak? In other words, do you focus on looking at those patients from the data and really zero in on those patients that are creating those unnecessary visits? Or do you create the alternative in your operations in your practice and promote it that way to your patient population? Where do you start?


Dr. Nicholas Dodaro: We actually flip that upside down a little bit. I think we start with the patient relationship. We believe strongly that the only way you're going to get patients to work with you is to create a relationship physician-patient relationship with them. So we proactively go after patients at the primary care doctor and build a relationship with that patient. Now, we may stratify who we're going after first for a while. So granted, you may know there's a group, this kind of goes to the hospital a lot or you have some data on them. We may look at some data. You may have some data wherever the case may be. You may start with that group first. But the focus is the relationship with the entire population of that practice proactively. And again, we go back to, remember we talked about ER visits starting two or three weeks before the visit needs to be that you need to build that relationship. The patient says, “Hey, I have a relationship with my practice. I trust my doctors. The moment I have a question, I know now I can get an answer before this thing before this thing gets ahead of me.” They don't necessarily think that proactively, but you get my point the moment they have some anxiety, they're calling and saying, Help me out here. And that relationship then. So what happens is while you have some groups that are maybe a focus on, eventually a focus on the whole population, because the folks who've never used the ER eventually do at some point, and you wanna be in their lives before that decision happens.


Daniel J. Marino: I couldn't agree with you more. You have to give them an alternative. We know that business is going to occur, but as you said earlier, maybe 70 or 80% of those visits may not necessarily have to occur in the Ed. Right?


Dr. Nicholas Dodaro: Exactly right. Fee for service has provided kind of an event per click, per procedure, per diagnosis reimbursement model. And when you have to help a patient in a way that doesn't meet a checkbox for a fee-for-service arrangement, then how do you make that work? So if a lot of primary care practices haven't, of course, people haven't moved to the tipping point of 50%, 60% or 70% of value-based care where they can start to do whatever the patient needs and it all comes out. And in a value-based contract is the right work at the right time and a fee for serving environment, you can't make that switch very easily. So a lot of the things we help patients with on Saturday afternoon have no fee-for-service relationship. There's nothing you could write down that would get reimbursed. You're answering questions and solving problems. You're signing a document or talking to the daughter about the confusion they have over the discharge paperwork or any sorts of things that need to be done. It's hard to capture those on a fee-for-service basis. Sometimes people call us six times in two days or 10 times in one day. How do you ever capture that fee for service? But it needs to be done. And that's what the care of the patient needs. And when you get free from having to operate in a per-click basis you get to do a lot of fun things to help people out. And that's where the value, the total cost comes down, utilization goes down and the customer service component that the pleasure of being a part of that practice goes ways up. So patient retention goes up and compliance with your network goes up. All those things to factor into the challenges of managing a population successfully start to improve.


Daniel J. Marino: I would think patient satisfaction has to go up dramatically. Patients don't like sitting in the ED, there's no problem. Nobody wants to spend a couple of hours there. And if you can put some alternatives in place, and measure the impact of those alternatives, I think as you said, those are the fun things to do, right? Then you can really get some traction out of your provider community, out of your contract, out of the service that you're providing to your patients.


Dr. Nicholas Dodaro: It becomes a lot of fun. Actually, it's pretty funny because you're removed the barriers to access at the practice, lots of practices because they've had to for pragmatic reasons. Hey, if this happens, call 911. If we're not available, go here and go there. You get rid of all that. You culturally change the practice and say, Call us for everything. We're gonna help you out. And of course, there's the time someone calls and says, Hey, I've got chest pain. You go, that one actually has to go to the ER. Right? That's going to happen to you. You're not cutting corners. But the other conversations, you know, can solve so many problems. And boy I don't know from my experience, even if you've ever had a sick family member or a sick child, moving to the health care system is complicated. It can be very frustrating. There are a lot of obstacles there. Even when what you're doing, even for someone like myself, sometimes you just go, Oh hey, there's a lot of ways that they make it hard for me to get something done. And when we start to remove those, say, Hey, we'll take on that burden. Let us help you with that. That's fun stuff. And the patient starts to say, God, you made my life a whole lot easier. You solved the problem, the amount of thank yous, and I can't believe how much you've helped me. Sort of comments we get, which again becomes an extension of that practice we're working with. So it's not really about us, so to speak. It's about that, that practice, which is people tend to never wanna leave that practice.


Daniel J. Marino: Yeah. Boy, that's great. And spot on. Well, Dr. Dodaro, this has been fantastic, great conversation. I think you brought up some fantastic points. Any final insights or words of wisdom you share with our audience? I'm sure many people, many of our listeners have struggled with a lot of the elements that we brought up today. Any final pieces of advice?


Dr. Nicholas Dodaro: I think it's looking at your population with a fresh set of eyes is tough. It's hard to put yourself in patients' positions and unravel some of the barriers that any practice has by just doing what every other practice does. It's hard to do that. So we love kind of someone who's willing to step back and say, Let's just take a fresh look at how we have relationships with our patients. And I think that takes some discipline and some open-mindedness. And once we do that, we find that we really get to a better place. And I would challenge anyone to put themselves in the positions of their patients or any of their patients on a weekend who've had a challenge and that look like once it feel like, how can you make that better? And I think when you start there, you start there, the journey begins in earnest and it can be fun to solve it.


Daniel J. Marino: Yeah, and you may have to make little steps along the way, but I agree. I think if you start to put these things in place, that certainly will go a long way toward trying to manage some of these challenges that we often see through the ED. Well, this has been fantastic. If any of our listeners wanna get in touch with your website, email, or LinkedIn, any things that you can share with our audience?


Dr. Nicholas Dodaro: Yeah, absolutely. It’s Nicholas.Dodaro@crucialist.care. Always open to emails.


Daniel J. Marino: Well, Dr. Dodaro, this has been great. Kudos for you, to you and to your team for putting in these alternative methods of care delivery in support of the ED visits. You all have done some great work. Really appreciate your time.


Dr. Nicholas Dodaro: We're great. Thank you. It was a pleasure chatting with you. Look forward to doing it again sometime.


Daniel J. Marino: I wanna thank everyone for listening today Until the next insight. I am your host, Daniel Marino, bringing you 30 minutes of value to your day. Take care.


About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

Daniel J. Marino

Podcast episode by Daniel J. Marino

Daniel specializes in shaping strategic initiatives for health care organizations and senior health care leaders in key areas that include population health management, clinical integration, physician alignment, and health information technology.