RM: Kaiser has an acute care strategy that actually sends more patients to the emergency department than it does to urgent care because it allows them to get a diagnosis quickly and put that patient in the right cost of care and the right place of care. Does CMMI have any programs that begin to follow patients across their continuum and that may help put a greater focus on that, or do you see that as something we need to do as a profession?

PC: That’s a great question. The vast majority of our models actually look at total cost of care as a metric, which I think is the right metric. We sometimes get pushback on this that physicians or clinicians only want to be responsible for their niche of care, but I think we’re trying to build a system with physicians, clinicians, and providers that is highest quality at lower cost for the total patient experience. Our focus is really on quality outcomes over time for patients and total cost of care for patients in the health care system.

Dr. Patrick Conway

ACOs are realizing emergency care, urgent care, and acute care are critical pieces of their success. I think you’ll see that grow in the bundled payment and episode-based payment arena. We certainly have inpatient bundles now, but I think you’re going to see even more outpatient bundles, and you should see bundles around emergency care as well. – Dr. Patrick Conway

RM: What do you see as the biggest changes in health care systems over the next five to eight years?

PC: I think we are seeing accountable care organizations (ACOs) continue to grow. We have over 500 now for over 12 million Medicare beneficiaries. Even more important, we have about 120 two-sided risk ACOs, whereas we had about 20 just a couple of years ago. Increasingly, those ACOs are realizing emergency care, urgent care, and acute care are critical pieces of their success. I think you’ll see that grow in the bundled payment and episode-based payment arena. We certainly have inpatient bundles now, but I think you’re going to see even more outpatient bundles, and you should see bundles around emergency care as well.

As for the state- and community-based programs, we’re seeing states like Vermont develop a program that is an all-payer ACO putting all of its patients, beneficiaries, and people into care systems often anchored with a hospital with its associated emergency network and clinics. In state-based innovation, you’ll see the critical role for emergency care grow. In the last year, I’d call out the telehealth, remote monitoring, and patient engagement technology arenas. Increasingly, we’re going to see a focus on consumer-driven care and how you manage the patients outside of the hospital, the clinic, etc. How do you manage them at home? How do you keep them healthy and avoid admissions? You’re going to see growth in emergency medicine using remote technology and other electronic means of communicating and interacting with patients, including telehealth.