Alan Eisman breaks down what’s at stake and what to do about it. He recently led a session at the EDPMA Solutions Summit.
The Problem Didn’t Start With ECAT, But ECAT Changes Everything
If you work in emergency medicine, you already know the story. ED boarding, prolonged wait times, and access bottlenecks have gotten measurably worse since the COVID-19 pandemic. Patients are waiting longer to be seen, longer to be admitted, and longer to be discharged. The clinical consequences are real. So are the operational and financial ones.
What’s changed is accountability.
The Emergency Care Access and Timeliness (ECAT) electronic clinical quality measure, finalized in the CMS 2026 OPPS Final Rule, elevates ED access and timeliness from an internal operational concern to a system-level performance priority, one with direct implications for STAR ratings, Value-Based Purchasing (VBP), and reimbursement.
For ED leaders, this is both a moment of urgency and a significant opportunity to lead meaningful change and address systemic issues that undermine performance and contribute to extraordinary levels of burnout. Emergency Medicine continues to report among the highest rates of physician burnout, with recent data estimating rates between 60%–65% driven in large part by operational and environmental factors that ECAT is specifically designed to to address many of which are largely outside of the direct control of the ED itself.
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What ECAT Actually Measures
ECAT is a digital quality measure that utilizes standard electronic health record data to track four access and timeliness gaps across the full ED visit: excessive wait times and lack of privacy, leaving without evaluation, extended boarding, and prolonged length of stay. If any one of those criteria is met during an encounter, that visit enters the numerator. That design matters. It means isolated fixes won’t move the needle. ECAT rewards end-to-end performance.
Voluntary reporting begins in 2027. Mandatory reporting follows in 2028. Payment implications could arrive as early as 2029. That runway sounds comfortable until you consider how long meaningful operational change actually takes.
The Stakes Are Higher Than Most Realize
Dr. Arjun Venkatesh, Chair of the Department of Emergency Medicine at Yale School of Medicine and a national expert in hospital and health system capacity can relate to the problem from the front lines of emergency medicine: “The ECAT measure isn’t just a set of technical or abstract metrics. The ECAT reflects the daily experience of ED physicians and their patients. Boarding isn’t just a throughput problem. It’s a patient safety problem. And now federal policy has elevated the reputations and potentially financial implications to meet the call for action.”
From Alan’s perspective supporting health systems through data and analytics, it’s not a question of whether ECAT will impact your organization, it’s knowing it does and will. The real question is whether your organization will address the operational drivers before financial and public reporting implications take hold, or react afterward trying to catch up once the consequences are visible.
Organizations that start this work early can realize meaningful financial, clinical, operational, and reputational benefits while improving patient flow, reducing burnout, and strengthening overall system performance.
Early ECAT benchmark data is beginning to emerge. A recent 2025 JAMA Health Forum study analyzing more than 148 million ED encounters across the U.S. found that emergency care access failures increased significantly between 2017 and 2024, rising from 18.5% of ED visits to 28.7%. The study also found prolonged ED length of stay (>8 hours) nearly doubled from 7.8% to 13.9%, while inpatient boarding delays (>4 hours) increased from 2.6% to 6.2%. Delays in placement into an ED treatment space (>1 hour) also worsened substantially, increasing from 11.4% to 16.7%.
Importantly, the data showed that performance varied meaningfully across patient populations and hospitals, with patients presenting with mental health conditions experiencing disproportionately higher rates of access failures. What the data makes clear is that operational performance varies widely, and the gap between top and bottom performers is significant. That gap represents both risk and opportunity.
Why This Requires More Than an ED Fix
Here’s the part that’s easy to underestimate: ECAT performance is largely determined by what happens outside the ED.
Boarding, one of the most heavily weighted ECAT drivers, is a downstream of hospital-wide bed capacity, inpatient throughput inefficiencies, and discharge delays.Similarly prolonged ED length of stay is often driven by factors such as delays in specialist consultation, diagnostic turnaround times, and admission workflows. These are not problems emergency medicine can solve alone.
Effective improvement requires a coordinated, system-wide approach. We describe that approach as the Integrated Acute Care Framework™. That means bringing together emergency medicine, hospital medicine, nursing leadership, hospital operations, and administration around shared data, shared metrics, and shared accountability. It requires conversations that challenge traditional silos and at times creates tension. But, these are precisely the conversations necessary that drive meaningful system-wide improvement.
It also means knowing where to start.
Where the Highest-Leverage Opportunities Are
Not every process improvement carries equal weight. In our EDPMA session, we reviewed the areas most likely to move ECAT performance, and where the clinical, operational, and financial returns are most meaningful:
- Patient handoffs and transitions of care — particularly the ED-to-inpatient handoff, where delays compound quickly
- Hospital crowding and patient throughput — addressing the systemic bottlenecks that extend both boarding and LOS
- Quality improvement and system efficiency — building the feedback loops that sustain change over time
- Staffing and resource allocation — ensuring the right capacity is available at the right time
- High-cost, high-utilization patients — a population where coordinated care pathways can reduce ED demand and improve outcomes
Making the Case and Making It Stick
One of the most practical parts of our EDPMA discussion focused on something that doesn’t always get enough attention: how to drive change when the solution requires buy-in from multiple departments and the financial case needs to land with hospital administration.
That includes knowing what data you need to benchmark current performance and identify the right opportunities, how to initiate productive conversations between emergency medicine and hospital medicine leadership, and how to build and present a business case that accounts for both clinical impact and cost when other departments are involved.
Getting the analysis right matters. So does knowing how to bring it into the room. And having the right conversations that are enabled by data and analysis.
If you’re focused on ED operations, quality performance, or the financial trajectory of your emergency program, we’d welcome a conversation.
If you want to get a head start on where your organization stands with ECAT, we’re glad to start that conversation.