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.