The health care landscape is shifting, and emergency physicians are at the forefront of change. Although the traditional fee-for-service (FFS) model has dominated health care reimbursement for years, value-based care is emerging. This transition, partly driven by the Center for Medicare and Medicaid Services (CMS), aims to reward clinicians for the quality of care they deliver rather than the quantity of services they provide.

Although this shift presents challenges, it also offers significant opportunities for emergency physicians. By embracing value-based care, emergency physicians can improve patient outcomes and secure their financial future in an evolving health care system.

Value-Based Care in Emergency Medicine

The transition to value-based care has been slower than anticipated, particularly for specialties like emergency medicine that need more predefined patient populations or well-defined episodes of care. However, emergency physicians have made significant strides in recent years.

A recent survey of emergency physicians revealed numerous examples of successful value-based models currently in place. These models primarily involve commercial payers, but there are also successful models with Medicaid and Medicare managed care carriers.

The structure of these models varies widely, but they generally fall into three categories:

FFS plus quality (pay for performance): This model combines traditional FFS reimbursement with additional payments to meet specific quality metrics. Because of its lower administrative burden and financial risk, it’s a good entry point for emergency physicians who are new to value-based care.

Shared savings: In this model, physicians receive additional payments if the total cost of care for a defined population is below a benchmark while maintaining or improving quality. Some models also include shared risk, meaning physicians may face financial penalties if costs exceed the benchmark.

Capitation: This model pays physicians a flat amount per patient in the population they manage, regardless of the services provided. It’s the most sustainable model but also requires the most administrative support.

Important Considerations

As emergency physicians navigate the transition to value-based care, several key considerations should guide their decisions:

Start with FFS plus quality: This model offers a low-risk way to gain experience with value-based care before progressing to more complex models.

Clear definitions: Ensuring that agreements with payers include clear definitions of desired outcomes and eligible populations is critical. For example, discharge risk stratification tools, such as the emergency department (ED) revisit algorithm or the SHOUT scoring system (see Table 1), provide structured approaches to identifying patient risk levels for readmission, follow-up failure, or adverse outcomes. When incorporated into payer agreements, these tools can standardize metrics and ensure that both parties align on patient stratification criteria, improving reimbursement accuracy, and care continuity.

Table 1: Discharge Risk Stratification and Assessment Tools

Data exchange: Focus on improving the ease and volume of data exchange between emergency physicians and other stakeholders, such as health plans and hospitals. Risk stratification tools often require integrating data on demographics, encounter history, clinical metrics, and social determinants of health. Standardized and transparent data sharing can enhance tool utility and payer–clinician alignment.

Proactive collaboration with payers: Proactive outreach to leaders of commercial or managed care insurance plans can be a productive way to create opportunities centered on value-based care. Meeting with key players, such as physicians or quality executives, can initiate discussions on shared pain points, a shared vision for patient care, and potential sources of funding for alternative payment models. This approach fosters alignment on objectives and paves the way for sustainable partnerships that benefit patients and providers alike.

Strategies to Increase Access to Alternative Payment Models (APMs)

To further accelerate the adoption of value-based care in emergency medicine, several strategies are recommended:

Essential building blocks: Advocate for financial support for transitions of care from the ED to outpatient settings, continued flexibility for telehealth services, and tools to help determine appropriate care settings for patients. Some specific recommended strategies include applying the Transitional Care Management (TCM) CPT codes to the post-ED space. TCM CPT codes are an ACEP-endorsed tool to support emergency physicians in identifying patients safe for discharge, along with reimbursement opportunities targeting health-related social need (HRSN) interventions in the ED.

Education: Provide ongoing education to emergency physicians and their practice groups about the benefits of APMs and the tools available to pursue them.

Collaboration: Promote the adoption of APMs with external stakeholders, including policymakers and payers.

The transition to value-based care has challenges, but the potential rewards are significant. By embracing this new model, emergency physicians can improve patient care and position themselves for success in a rapidly changing health care landscape. The future of emergency medicine lies in value-based care. Emergency physicians can remain leaders in delivering high-quality, cost-effective patient care by taking proactive steps to adapt to this new reality.

Dr. Rehman is an assistant medical director and assistant professor of emergency medicine at Mount Sinai Hospital.