By virtue of its prominence at the beginning of the cycle of care, emergency medicine will likely play a key role in the success of Accountable Care Organizations (ACOs). However, the details of how emergency departments will operate within an ACO or in partnership with an ACO are speculative at this point.

Emergency medicine has thus far received scant attention in the initial guidelines for ACOs set forth in the Accountable Care Act as well as the final regulations released by the Department of Health and Human Services in October, 2011.¹

The effect ACOs could have on emergency care remains uncertain, but several broad areas should be considered: utilization of emergency services, coordination of care, implementation of and adherence to quality metrics, and the financial impact on EM.

Emergency Care Utilization

One important question to be addressed is whether the ascendancy of the ACO model will challenge the “prudent layperson” standard.

ACOs are often heralded as a delivery system in which purportedly unnecessary emergency department visits could be minimized.

The implication is that within an ACO’s bundled payment structure, financial incentives are such that patients may be directed towards alternative sites of care if their condition is deemed nonemergent. However, it remains unclear who will make this determination and what barriers patients who seek emergency care will face.

Care Coordination

Coordination of care with primary providers will be an important component of working with or within an ACO. On the front end, triage systems will take on greater importance.

Call centers and services such as telemedicine present opportunities for growth and a potential role for EM. There will likely continue to be growth in alternative sites of care such as urgent care, free-standing EDs, and retail clinics.

However, the challenge will be not only be to provide timely and consistent care (particularly during weekends and evenings), but also to ensure that these services are well-integrated and within the Accountable Care Organization.

Ultimately, in order to improve care coordination, emergency medicine might need to diversify the options available for management of patients evaluated in the emergency department who are not admitted as inpatients. Observation units are a promising area for growth, as are ED-run follow-up clinics and follow-up call centers staffed by physician extenders or nurses.

Additional resources will need to be devoted to case management to coordinate referrals to rehab and skilled nursing facilities, visiting nurse services, and other outpatient management tools.