نقش اقتصادی بخش اورژانس در زنجیره مراقبت های بهداشتی : استفاده از مدل نیروهای پنج گانه مایکل پورتر در فوریتهای پزشکی

Emergency Medicine plays a vital role in the health care continuum in the United States. Michael Porters’ five forces model of industry analysis provides an insight into the economics of emergency care by showing how the forces of supplier power, buyer power, threat of substitution, barriers to entry, and internal rivalry affect Emergency Medicine. Illustrating these relationships provides a view into the complexities of the emergency care industry and offers opportunities for Emergency Departments, groups of physicians, and the individual emergency physician to maximize the relationship with other market players.

Emergency Departments (ED) play a unique role in the health care system. Unlike any other health care resource, EDs provide continuous access to the health care system for both emergent and urgent medical needs. In addition, the Federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires EDs to provide a medical screening examination to all patients who seek care. A medical screening examination may include expensive diagnostic tests, treatment, and specialty consultation. EMTALA was passed to prevent hospitals from discriminating against indigent or uninsured patients by transferring, discharging, or refusing care (1). Because ED care is the only care that is required by law, it provides an important health safety net for the uninsured and underinsured. Although the ED plays a critical role in the health care system, it finds itself increasingly challenged in the face of rapid change. For many reasons, EDs have experienced a remarkable rise in patient volume over the last 50 years, with about 108 million visits in the United States in the year 2000, up 14% from 1997. At the same time, health care market forces have forced many EDs to close their doors to patients. Over the period of 1997–2000, the number of EDs in the United States decreased from 4005 to 3934 (2). The uninsured rate in the United States in 2001 was 16.7%, and it is well known that the uninsured, under-insured, and socioeconomically disadvantaged groups are more likely to seek care in EDs (3, 4 and 5). Staffing in EDs has shifted considerably, from a single room staffed by interns with no attending coverage, to departments staffed by trained emergency practitioners with access to the state-of-the-art in diagnostics and medical treatments [(6), p. 237]. The expanded role for Emergency Departments (EDs) in the health care system created the need for specialists in Emergency Medicine. The first EM training program was instituted at the University of Cincinnati in 1970 and today there are 132 accredited allopathic training programs and 30 osteopathic programs in the United States. At the same time, the economics of medicine and of emergency care have also changed. What was once a cottage industry now claims an ever-increasing portion of the US gross domestic product (GDP). As of 2002, US health care expenditures topped 14% of GDP (7). Due to the prominent role of the health care system in the economy and cost increases, government and market reforms have shifted to reduce provider payments and reorganize the way that care is delivered and reimbursed. Whereas the promise of managed health care has not met expectations, other entities such as physician practice management companies (contract management companies) have emerged in an attempt to centralize the administrative aspects of the health care business. Now, there are many players in the Emergency Medicine (EM) marketplace, from emergency physicians, nurses and contract management groups (CMG), to pharmaceutical companies, device manufacturers and insurance companies. Comprehending the role of EM in the health care marketplace is difficult due to the complex interactions among many forces. In this respect, using a model can provide insight into the emergency care industry and shed light on the myriad forces affecting Emergency Medicine. In 1980, Michael Porter introduced a model of competitive strategy to explain an industry’s position in a complex strategic environment (8). Porter’s five forces model provides one way to present the current position of EM or what will be called the industry for “emergency care” in a macroeconomic context. The five forces presented in this model are the degree of rivalry, the supplier power, the buyer power, barriers to entry, and the threat of substitution (8). Placing the industry of “emergency care” in a framework such as this offers unique insight into the bargaining position that we as emergency physicians have when negotiating with the different market players.

Analyzing the industry of emergency care using Porter’s five forces model makes it clear that EDs are in a precarious economic position in the current health care market. The suppliers to EDs, particularly the pharmaceutical companies and nurse staffing companies, exert a significant level of power over the individual ED due to the heavy reliance on drugs for ED treatments and the worsening nursing shortage. The industry does have significant barriers to entry, both in education and cost of starting an emergency care center. However, for-profit companies are effectively competing with EDs in the market and continue to expand. The buyers of ED care also have significant power over the individual ED, particularly due to the size and bargaining power of the buyers of care: MCOs, insurance companies, corporations, and the government. The threat of substitution for the board-certified emergency physician is also very high. Hospitals and CMGs often may hire physicians who are not board-certified and physician extenders such as PAs and NPs to staff EDs. In addition, due to the lack of individual patient relationships that are valuable in other medical specialties, CMGs may see the skills of an emergency physician as economically expendable and replaceable. There is a high amount of rivalry in EM among individuals, groups, and mega-groups for jobs and contracts. This is akin to trading patient care as a commodity, which often gives short shrift to the quality of care. Placing EM into the Porter’s five forces model paints a bleak picture for EDs and a bleaker picture for the individual practitioner. What can EM physicians do to improve the market position? Specialty organizations consisting of groups of ED physicians such as the American Academy of Emergency Medicine (AAEM) and the American College of Emergency Physicians (ACEP) can exert significant bargaining power by organizing to shift the power relationship with hospitals and CMGs through collective bargaining to improve contract provisions. Issues such as requirements for due process, eliminating restrictive covenants, and requiring open books are vital to place economic power back in the hands of individual doctors. Physicians can form democratic groups (with equal voting rights) and create longstanding relationships with hospitals to maintain group and career longevity for emergency physicians. In addition, emergency physicians and the public should assure quality by making sure that only EM-trained providers deliver emergency care. Despite the current market position for emergency care, ED visits continue to rise. Increasing demand for emergency care among patients is a significant opportunity for EDs to reconsider their role in the health care delivery system. Preventive care services have been explored as a potential addition to emergency care and may hold promise. Health care systems often use the ED as a front-loading of medical care and use EDs as 24-h access to specialty services, rapid diagnostic services, expedited workups for inpatient admissions, and as a holding bay for hospital overflow. Although these factors often contribute to ED overcrowding, recognition that the ED is providing these services and that capacity is often inadequate to provide expedient care may guide administrators to expand provider and space capacity for EDs. In addition, a valuable resource that is under-utilized in Emergency Medicine is the fact that we treat so many patients. This is a substantial opportunity for clinical research and for enrollment into clinical trials. Specifically, given the number, complexity, and severity of patients treated in ED, particularly academic EDs, there is an opportunity to tap into the vast research resources of pharmaceutical and medical device companies. EDs also provide the first line of defense in the case of bioterrorism. EDs provide a vital health care safety net, and the availability of emergency care is tremendously important to the citizens of the United States. However, EDs are in a position of weakness in comparison to many of the other competing forces in the market place. A unified stand among emergency physicians is needed to improve the overall position of EM as a specialty and to ensure the delivery of the highest quality emergency care.(Figure 1). Full-size image (47 K)