The fee-for-service funding model for US emergency department (ED) clinician groups is increasingly fragile. Traditional fee-for-service payment systems offer no financial incentives to improve quality, address population health, or make value-based clinical decisions. Fee-for-service also does not support maintaining ED capacity to handle peak demand periods. In fee-for-service, clinicians rely heavily on cross-subsidization, where high reimbursement from commercial payors offsets low reimbursement from government payors and the uninsured. Although fee-for-service survived decades of steady cuts in government reimbursement rates, it is increasingly strained because of visit volatility and the effects of the No Surprises Act, which is driving down commercial reimbursement. Financial pressures on ED clinician groups and higher hospital boarding and clinical workloads are increasing workforce attrition. Here, we propose an alternative model to address some of these fundamental issues: an all-payer-funded, voluntary global budget for ED clinician services. If designed and implemented effectively, the model could support robust clinician staffing over the long term, ensure stability in clinical workload, and potentially improve equity in payments. The model could also be combined with population health programs (eg, pre-ED and post-ED telehealth, frequent ED use programs, and other innovations), offering significant payer returns and addressing quality and value. A linked program could also change hospital incentives that contribute to boarding. Strategies exist to test and refine ED clinician global budgets through existing government programs in Maryland and potentially through state-level legislation as a precursor to broader adoption.

中文翻译：

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紧急护理中的支付创新：全球临床医生预算案例


美国急诊科 (ED) 临床医生团体按服务收费的资助模式越来越脆弱。传统的按服务付费的支付系统不提供任何经济激励来提高质量、解决人口健康问题或做出基于价值的临床决策。按服务收费也不支持维持 ED 容量来处理高峰需求期。在按服务收费方面，临床医生严重依赖交叉补贴，商业付款人的高额报销抵消了政府付款人和未参保人群的低报销。尽管按服务收费在政府报销率数十年的稳步削减中幸存下来，但由于访问波动性和《无意外法案》的影响而日益紧张，该法案正在压低商业报销。急诊科临床医生群体面临的财务压力以及更高的医院寄宿和临床工作量正在增加劳动力流失。在这里，我们提出了一种替代模式来解决其中一些基本问题：为急诊临床医生服务提供由所有付款人资助的自愿全球预算。如果设计和实施有效，该模型可以长期支持强大的临床医生人员配置，确保临床工作量的稳定性，并有可能提高支付的公平性。该模型还可以与人口健康计划（例如，急诊科前和急诊后远程医疗、急诊室频繁使用计划和其他创新）相结合，为付款人提供可观的回报并解决质量和价值问题。相关计划还可能改变医院对寄宿的激励措施。现有策略可以通过马里兰州现有的政府计划以及可能通过州级立法来测试和完善急诊临床医生的全球预算，作为更广泛采用的先导。