Here’s how it would work. Imagine an ED has a fixed amount of money to hire emergency physicians to manage care for a population. Under this model, it is unlikely that we would choose to only sit in crowded EDs and deliver care only when available treatment spaces opened. We would move beyond the ED, where our patients could benefit from our skills in helping them decide where to seek care and ensuring continuity after their ED visit. Other elements of an ED physician global budget that would facilitate the move to population health would include additional payments for emergency telehealth to help guide patients to the ideal site of care, follow-up telehealth –or other digital connections—to ensure patients have recovered after their ED visit, and resources for programs that focus on ED frequent users. Other elements could include mandating specific staffing levels to allow for reserve capacity and working to align metrics with hospitals around ED flow, including addressing boarding.

Kaiser Permanente (KP), an integrated delivery system, works through capitation. It has focused efforts on population health through alignment of incentives across their health plan, hospital foundation, and medical group.⁴ Population-level ED utilization is about one-third lower than the rest of California in adults less younger than 65. For older adults, ED use is similar, but admission rates are one-third lower. KP has a demand management strategy, actively optimizing efficient use of health care resources through their on-call advice line, and access to same or next day outpatient appointments. A central feature is chronic disease management, focusing on treatment in the ED and coordination with outpatient specialists rather than hospital admission. While the KP model is not perfect, it aligns the incentives of acute care with providing the best value for a fixed budget.

Ultimately, how will value-based programs affect the day-to-day role of emergency physicians? That answer depends on whether these models take hold broadly, which is currently unknown, or how emergency medicine is integrated into other value-based care models that focus on primary care, hospitals, and specialists. But what is increasingly certain is that the role of the emergency physician in the health care continuum may change dramatically as these payment models evolve.

Dr. Leubitz is an innovation fellow at US Acute Care Solutions. He works as an emergency physician at Adventist Shady Grove Hospital in Rockville, MD.

Dr. Pines is the national director of clinical innovation at US Acute Care Solutions. and a professor of emergency medicine at Drexel University.