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.

Emergency medicine and ACO administrators will need to coordinate efforts to identify additional opportunities for improving the value of care provided. Another area in which emergency departments have begun to show dramatic ability to improve care management and control effective resource utilization is in the creation of care plans.

Many EDs have a small group of patients who constitute a disproportionate percentage of their ED visits and who could, through proper medical management in partnership with local community providers, be better managed with lower resource utilization. Many have begun developing care plan programs, often with noticeable success when measured by decreased utilization and costs.^2,3

Quality Indicators

As quality indicators for care delivery are being created, the measures that are used to evaluate care delivered within an ACO (including within the ED) have yet to be determined. For example, the role of emergency care in the acute management of chronic disease episode has not been clearly defined.

The exacerbation of chronic disease is often seen by payment policy makers as a “potentially avoidable complication,”¹ and the care delivered to these patients in the ED has yet to be valued appropriately.

In addition, as payment policies increase pressures to decrease hospital readmissions, there will likely be strong incentives to avoid hospital admissions. How will this affect ED operations, as emergency physicians are often the decision makers regarding hospital admission?

Furthermore, there may be different perceptions of risk among the physician groups that have a stake in the patient’s cycle of care.

Will the financial risk of failing to meet targets be spread evenly across groups within the ACO? What about the medico-legal liability for an inappropriate or adverse disposition decision – will this also be shared across the ACO? What role will patients themselves and their families have in disposition decisions?

These are critical questions that must be addressed. Another important consideration is the concept of ED “mission creep” and the potential expectation that the ED provides a wide range of mandated screening, counseling and education.

Inclusion of such targets in the ED visit may undermine the ability of EDs to carry out their core mission, and measured discussion regarding any such proposed requirements is essential.

Financial impact

There has long been a consensus that value-based and bundled purchasing of medical care holds much promise in controlling costs and delivering better quality care.⁴

However, important questions remain of how shared savings (and losses) will be distributed across ACOs, specifically with regard to the ED. The main body of experience with population-based, bundled-payment emergency care comes from the prepaid healthcare models of the late 1980s and 1990s.

Unfortunately, much of this experience is unlikely to be directly applicable to ACO design, as pre-paid care was based on a narrowly defined, risk-adjusted patient population, while an ACO’s patient population isn’t known until after the measurement period.

While the pre-paid capitation model is the closest example available to assist in defining the value of emergency care in a bundled payment model, given the potential variation and numerous unknown factors, accurately forecasting the financial impact on EM is difficult at best. Beyond calculating the value of EM within an ACO model, consideration must also be given to the impact of ACOs on ED utilization and revenue generation.

Emergency medicine is a flow-based business, and if decreasing ED utilization is a consequence of the ACO model, there are likely to be important financial repercussions. Will reduced volume necessarily lead to a decrease in revenues, or will the acuity mix shift towards sicker patients and perhaps result in higher average margins for the ED? If not, will shared savings from participation within an ACO make up some of this difference?

The possibility also remains that concomitant introduction of expanded insurance coverage through provisions of the ACA might actually lead to an increase in national ED volume.

The overall financial impact on emergency medicine therefore remains uncertain at this point.

Another challenge to consider will be how emergency groups will exist within the ownership and management structure of an ACO. Large hospital groups and integrated health systems are better organized and capitalized and therefore have a substantial advantage in forming and financing the transition to ACOs.

However, many EPs are not hospital employees but work for smaller, independent practice groups that contract with hospitals. They may have limited leverage, both financially and with regard to governance, to become full partners within an ACO.

Preserving the autonomy of these smaller practices as they attempt to integrate with larger, hospital-owned practices will prove to be a major challenge.

Recommendations

We believe that emergency medicine groups must be at the table with their hospital and healthcare system during the design and implementation of an ACO strategy.
Failure to participate actively as these programs are organized could have dire consequences for emergency medicine, as emergency department care is almost reflexively viewed as a high-cost service that should be limited. In addition, ACOs are uncharted territory, so there is ample opportunity for EPs to mold the program to suit the needs of their patients and their groups.

When considering participation in an ACO, emergency medicine groups should pay particular attention to the following:

• Patient diagnoses and clinical metrics that indicate the need for care.
• A complete picture of the patients’ total healthcare experience, including clinical records, claims data, and information gathered from and shared with other area providers.
• Comprehensive health plan and provider performance data.
• Payer analysis across various patient populations.
• Accounting and allocation of all revenue as directed by the ACO reimbursement model.

On a broader scale, as emergency medicine navigates through the development and implementation of ACOs, leaders must remain mindful of the myriad potential effects on the specialty, including alteration in the utilization of emergency services, creation of new opportunities for care coordination, introduction of new measures of quality, and the emergence of additional threats to revenue generation.

Whether ACOs will achieve their shared savings objectives or become the dominant medical services delivery model of the future remains to be seen.

The impact ACOs will have on EM is similarly difficult to predict. However, active participation in development projects helps to ensure that emergency care will be maximally valued within these new care delivery systems.

References

1. Wiler JL, et al. Episodes of Care: Is Emergency Medicine Ready? Ann Emerg Med. 2012; 59(5):351-357.
2. Michelen W, et al. Reducing frequent flyer ED visits. J Health Care Poor Underserved 2006; 17(1):S59-69.
3. Henry Ford Health System (2010, June 3). Social factors, ‘super users’ and urban EDs. ScienceDaily. (retrieved 6/5/12; www.sciencedaily.com/releases/2010/06/100603091637.htm)
4. Porter M and Teisberg E. Redefining Health Care: Creating Value Based Competition on Results, Harvard Business School Publishing, 2006

This article was written on behalf of the ACEP Emergency Medicine Practice Committee by Heather Farley, M.D., Andrew Nugent, M.D., Laurence DesRochers, M.D., Enrique Enguidanos, M.D., Ronald Hellstern, M.D., James Cusick, M.D., Howard Mell, M.D., Daniel Freess, M.D., Michael Lee, M.D., Michael Zappa, M.D., Azita Hamedani, M.D., Leslie Zun, M.D., Shkelzen Hoxhaj, M.D., Jennifer Wiler, M.D.