Alternative Settings of Care: An Interview with Observation Leader and Pioneer Dr. Michael Ross

David Meguerdichian, MD, FACEP

Recently, I had the pleasure of sitting down with Dr. Mike Ross, chief of observation medicine, director of emergency medicine virtual care and professor of emergency medicine at Emory University School of Medicine. Dr. Ross, a pioneer and leader in our field, was this year’s recipient of the ACEP Lou Graff Award for Excellence in Observation Medicine. Through our discussion, he shared that he saw early on that he could transform observation care similar to how early visionaries did with emergency medicine stating, “observation medicine’s time had come.” Upon reflection, he characterized the theme of his career as identifying and building up “alternative settings of care”- an important skill given the challenges our specialty faces with high patient boarding and extreme volumes. As you will see from our Q&A below, Dr. Ross has been a pioneer, leader and advocate for observation medicine and continues to focus on improving patient care through his work with virtual medicine and his advocacy around observation unit accreditation.

1. How and when during the early stage of your career did observation medicine become your calling?

Dr. Ross: When I finished residency in 1987, the obs unit where I trained was unstructured and dysfunctional. It became a model of what I would later seek to avoid. In 1992, I was asked by my new chair, Dr. Andy Wilson, to convert a 15-bed scheduled procedure unit into a hybrid obs unit. I decided to learn from other’s mistakes and successes. First, I reached out to ACEP’s Observation Medicine Section for guidance. I then connected with Dr. Louis Graff, who shared his recent book which taught me the principles of observation medicine. I linked up with Dr. Rob Andelman at the Cleveland Clinic who shared with me their condition specific guidelines. Finally, I reached out to Riverside Methodist Hospital in Columbus, Ohio, which shared with me its metrics. I combined the collective knowledge of these three to develop a protocol and metric driven obs unit. I had my big “ah-ha” moment, though, when Louis and I published the CHEEPER study, where we showed that having an obs unit decreased the rate of missed myocardial infarction (MI) by ten-fold (from 5% to 0.4%). Our hospital had previously participated in the study, showing that in the ED, 5% of MIs were missed and subsequently sent home. I realized that there needed to be a third, middle pathway beyond the “admit - discharge” paradigm. It was like realizing that there needs to be a medium sized t-shirt, in addition to a large and small, in order to fit everybody. It was the quality improvement piece here that truly opened my eyes.

2. What were some of the challenges you faced as you helped build observation medicine into its current form? Did hospital leaders support or balk at the idea? What roadblocks did you encounter and how did you overcome them?

Dr. Ross: First, I had to convince the hospital that they should open an obs unit, which was counterintuitive at the time as they were still being paid a full DRG for these short stay admissions. I learned to understand their goals and fit my vision into that framework. I quickly understood that the “bottom line is the bottom line” and finally made my case by showing that through decreasing the missed MI rate, the hospital would essentially be increasing their admissions for ACS. This change would offset lost revenue for low risk chest pain cases that were not admitted. It worked, and they continued to support me as I learned to speak the language of hospital finance.

Second, I had to convince my colleagues that observation was the right thing to do. I learned the 80:20 principle and found that the 20% naysayers were not converted by me, but rather by their colleagues who understood. Almost to a person, over the course of a year, every naysayer came to me and thanked me for the “save”  that came from the obs unit. These “saves” included diagnoses like cerebellar bleeds to MIs and everything in between, which was truly gratifying.

Finally, I learned that Blue Cross Blue Shield of Michigan didn’t pay the physician observation codes - an ironic note because they had just awarded Dr. Rob Zalenski an award for his work in chest pain observation. Knowing this, I worked with the Michigan chapter of ACEP to convince them to change their policy. I learned that one of their biggest issues was the misuse of observation status for all scheduled outpatient procedure patients, that resulted in “double dipping” billing. After helping to remedy this issue, BC/BS of Michigan asked me to represent them at the annual UAW contract negotiations with General Motors. GM was allowed to write its own observation policies, and BC/BS tasked me to convince them to change it to be in line with observation standards. In a large meeting room at the top of the GM world headquarters in Detroit, I made my case and captured their buy in. GM changed their observation policy nationally, which triggered many other national unions to follow suit!

3. What was the most rewarding work you have done in the field over your distinguished career?

Dr. Ross: I would have to say co-founding the Society of Chest Pain Centers. While planning our second national observation medicine conference in Detroit, I realized our meeting would be competing with Dr. Ray Bahrs’ 3^rd conference of chest pain centers. So, I reached out to Ray, and we hosted our meetings together, selecting the best content matter experts that we could find. Following that meeting, Ray and I decided to form an organization that would become known as the Society of Chest Pain Centers. We held a meeting at ACEP, and the organization was formed. We modeled ourselves using ACEP bylaws. We went on to write criteria for what it meant to be a chest pain center, because there was significant variation at the time from hospital to hospital. We went on to start accrediting hospitals as chest pain centers, adding other conditions such as heart failure and afib along the way. We got to over 1,000 hospitals nationally. During the timeframe of this growth, there was a corresponding national decline in heart disease deaths in the U.S. that I believe was, in part, contributed to hospitals having a more organized approach to the management of ACS and other conditions. “The society” merged with ACC and is now called the ACC Accreditation Management Board.

I also found great reward in creating national Medicare and CPT policy. A couple years after the GM / BCBS meeting, Medicare stopped paying hospital observation services due to the same issue of double dipping and prolonged observation stays. I was able to pull together 10 specialty societies and meet with CMS leadership to convince them of their mistake. Following that meeting, I was appointed to the CMS APC Advisory Panel for three years, where I chaired the Visits and Observation Committee. We advised CMS on payment policy, impacting 25 million visits per year. During my tenure, we created the current payment structure for type A and type B emergency department visits and observation visits (with some modifications along the way). Separately, I worked with David McKenzie and others through ACEP to create the observation same day physician CPT codes (99234-99236) to address payment gaps that occurred when patients were observed and discharged on the same day. Those codes still exist and are employed to this day.

Third, I truly valued winning the best faculty research award for the SAEM annual meeting for our TIA randomized study. Realizing that TIA is to stroke what chest pain is to acute MI, we developed a TIA protocol and put it to use. We were funded by EMF/FERNE to do a randomized control trial of a TIA protocol in the EDOU vs. the hospital. We showed that the EDOU had a lower length of stay, lower cost, and comparable clinical outcomes. This study preceded a steady shift in TIA care from inpatient to outpatient settings.

Finally, I have great pride in having set up numerous observation units. I stopped counting at 50 hospitals and health systems across the U.S. that have reached out to me for help in designing and implementing a type 1 EDOU. Within our health system, we have six units, with plans to open two more.

4. What do you see as the biggest threats to the observation medicine in today's clinical landscape?

Dr. Ross: Apathy. Unfortunately, only about one quarter of hospitals in the U.S. have a type 1 observation unit. This is driven by the misconception that observation medicine is not part of emergency medicine, when in fact, the majority of the innovation, research, and advocacy in this area comes from emergency medicine. The ones who suffer the most for this are our patients, who will languish in the hospital for days when they could have been managed better in an EDOU. Hospitalists specialize in the management of inpatients, and observation patients are not inpatients - they are outpatients. Emergency physicians specialize in the care of outpatients, and it shows. This is also a missed opportunity for much needed clinical practice diversification for emergency physicians. Involvement in observation care can help mitigate emergency physician burnout.

5. Who were some of your mentors that had the most impact along your career?

Dr. Ross: Andy Wilson, my chair who supported me in getting started with observation. He saw my potential and developed it in my early career. I have strived to do the same for others.

Louis Graff, who served as my sounding board and mentor in the observation medicine space. He has been a good friend for years.

Rob Zalenski, who had an excellent mind for research and critical thinking. He helped me hone my research skills.

The ACEP staff, who guided me in my work in developing a state of the art obs unit and crafting national policy.

Finally, of course, my patients. They continue to keep me on my toes and humble me.

6. How have you seen ED observation units evolve?

Dr. Ross: I view the EDOU as a tool or a box. Over time and driven by innovations in healthcare, conditions move from the inpatient setting into the EDOU, and other conditions move out of the EDOU to direct discharge from the ED. Chest pain used to be managed by inpatient only, directed by ACEP policy decades ago. It has since moved into the EDOU, and now we see it in many instances moving out. Other conditions that we would have never considered managing are moving in, including TIA, small stroke, hemodialysis, pulmonary embolus, and psychiatric conditions.

Another evolution is in the use of telemedicine to staff EDOUs. It has the potential to close the gap for hospitals that do not have an observation unit.

Finally, the role of the EDOU in disaster planning is being better defined. Just as the ED is the safety net of the health system, the EDOU is the safety net of the ED. This becomes truer in the setting of a disaster, where the EDOU can be leveraged to manage the rapid inflow of disaster patients. Additionally, the EDOU can manage observation eligible disaster patients to preserve limited inpatient resources during a disaster.

7. At the annual ACEP Section meeting recently, it was announced that we are exploring OU accreditation. In thinking about the evolution and growth of observation units, what do you see as the importance of observation unit accreditation? 

Dr. Ross: Hospital management of observation patients is all over the place. Similar to chest pain center accreditation, there is a much-needed role that ACEP can play in identifying evidence-based best practices in the care of observation patients. With this in place, ACEP can help hospitals learn how to apply them. Additionally, unlike critical care units, there is currently no payer designation for the presence or use of an observation unit. This is a long-standing oversight that ACEP can help address through this process.

8. What is next up for your career?

Dr. Ross: Like any emergency physician, I will deal with problems and opportunities as they show up at my door. Developing telemedicine and disaster preparedness are currently my biggest challenges and opportunities.