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.