Editor’s Note: This article is the third in a series looking at how quality-improvement and performance-reporting programs are affecting emergency medicine and will affect emergency departments in the future.

In an optimistic future-state view of how care delivery might be transformed from the fragmented, who’s-on-first reality of discrete patient encounters and individual provider accountability, visionaries—and, increasingly, health care payers—are eyeing a new model: one predicated on integrating episodes of care (EOCs) for a single event or diagnosis, and reforming reimbursement to accommodate value-based purchasing.

In that scheme, care settings and providers—from the primary care office to the emergency department to the skilled nursing care facility—would be inextricably linked throughout the care continuum, not just for the purposes of improving handoffs and safety. Providers would also be on the hook, individually and collectively, for patients’ outcomes and would be allocated a portion of the total payment accordingly.

Even if emergency physicians have heard little or nothing about EOC methodology, value-based purchasing, or yet another take on provider measurement and accountability, they soon will. Hospital administrators are facing mounting pressure to improve care coordination across settings and demonstrate the value of care through medium-term outcomes. ACEP is moving proactively to define emergency medicine’s role in that future state.

“It’s like that much-used analogy, ‘skating to where the puck will be,’ and that’s what we’re doing,” explained Dr. Angela Gardner, ACEP president and associate professor of emergency medicine at the University of Texas Southwestern in Dallas.

“I think the desired effect of this [integrated] approach is to get patients taken care of and well, before they reach the point of having to go to the ED, saving the emergency department visit for true emergencies and things that can’t be handled in an office environment,” she said.

In anticipation of the steps that commercial payers and the Centers for Medicare and Medicaid Services, through its value-based purchasing (VBP) initiative and demonstration projects, are already taking, ACEP last year convened the Value Based Emergency Care (VBEC) Task Force. That group, in a white paper available on the ACEP Web site (www.acep.org/WorkArea/DownloadAsset.aspx?id=46846), evaluated the various VBP strategies being considered and recommended that ACEP consider pursuing several initiatives that relate VBP to emergency care.

This year, three different task forces are evaluating considerations for ACEP regarding specific VBP strategies. The Episodes Task Force is evaluating the impact of episodes of care on emergency medicine and is expected to make recommendations regarding the feasibility of a risk-adjusted presenting complaint–driven emergency department EOC model. The Integration Task Force is working to more tightly define emergency department care coordination and continuity support within the vertical and horizontal health care landscape, and is exploring a possible partnership with Federally Qualified Health Centers to improve how patients are cared for as they move between the two settings. In tandem with those activities, a Data Registry Task Force is evaluating the possibility of developing a comprehensive emergency medicine care data registry to facilitate benchmarking, quality improvement, and reporting.

“That data doesn’t exist at the moment, but if we had it, we could better tailor care to the populations emergency physicians serve,” Dr. Gardner said.

Of the myriad activities occurring nationally to improve care and reduce costs, Medicare’s VBP initiative is likely to have the most dramatic effect. VBP’s purpose is to effectively move Medicare from a passive payer of claims to an active purchaser of care by linking payments to results, including the extent to which emergency department care quality reduces unnecessary readmissions.

“Our members are busy practicing full time on day-to-day basis and probably aren’t leaving their shift thinking about their 30-day readmission rate. But for ACEP and emergency medicine to find a fit with health care reform and VBP, we need to be actively engaged at a policy level to demonstrate the real value of emergency care,” said Dr. Dennis Beck, a VBEC Task Force cochair who also chairs the Episodes task force and ACEP’s Quality and Performance Committee. “There has been considerable attention, nationally, on who provides value and how that value can be objectively measured and in turn drive payment policy.”

More generally, for the measures the CMS incorporates into VBP, hospitals will be ranked against national benchmarks. That will translate into increasing pressure on emergency departments to improve performance, Dr. Beck noted, in the longitudinal picture of care. “What ACEP is doing right now is try to prepare for how emergency medicine might fit into the equation,” Dr. Beck said.

The three task forces are expected to issue their initial recommendations this month, and with the recent passage of health care reform legislation, ACEP is refocusing efforts of these task forces accordingly.

“We’re taking a fresh look at these task forces because of the [Affordable Care Act’s] heavy focus on measuring patient outcomes over an episode and using health information technology to facilitate quality reporting,” said Angela Franklin, ACEP’s Director of Quality and Health IT. “We’re also looking at the payment implications for hospitals.”

ED Care Patterns, Costs Scrutinized

EOC methodology is nascent in its development, several demonstration projects are already underway. However, other than the initiating emergency department visit as the first step in an acute care episode, most methodologies consider an emergency department visit during an episode to be “inappropriate” or representing a failure of the system. And government and private sector demonstration projects are in development to qualify care and quantify total costs for episodes such as hip fracture, myocardial infarction, and pneumonia.

In the future, theoretically, if there’s a global or bundled payment for an episode, each provider who encountered the hip-fracture patient along the continuum may be commensurately compensated—or docked—depending on respective care quality, explained Dr. Michael Granovsky, course director of ACEP’s National Coding and Reimbursement Conference and a member of the VBEC task force.

“Ultimately, CMS is looking at paying us directly related to outcomes, and there is some concern in emergency medicine that we either might not receive our fair share or that emergency physicians might be penalized for things that are outside our control,” he said. “That’s one reason the VBEC Task Force is being so proactive.”

Medicare is also looking at individual provider costs, especially in high-cost areas like cardiac procedures, Dr. Granovsky said. Although emergency physician contributions to total care costs haven’t been a predominant focus, emergency physicians may already be feeling the resource-utilization pinch in their hospitals through various utilization measurements or even in the form of “withholds” that are written into group or payer contracts.

“The first area where this is coming, and fast, is imaging,” he said, adding that emergency physicians may already be facing pressure to reduce their utilization of MRI and CT scans.

A concurrent national development that will affect emergency physicians is the creation of what are called accountable care organizations (ACOs). Loosely described, ACOs are collectives—actual or virtual—that share responsibility for treating certain patient groups and for treatment outcomes over the medium to long term and may share in savings that accrue from reducing care fragmentation. The movement, which is gaining favor on Capitol Hill and already being tried out in pilots throughout the country, is a progressive attempt to reduce care fragmentation while incentivizing providers along the spectrum to coordinate their efforts.

Many in health care think that ACOs as a model hold promise for improving overall care and reducing costs. But given emergency departments’ sometimes precarious positioning on the care spectrum, Dr. Granovsky maintains, it behooves ACEP and individual members to ensure that emergency medicine is appropriately represented in the changing payment landscape.

“What we really want to ensure right now is that whatever model emerges is revenue neutral and recognizes the value inherent to emergency medicine—and that we’re not beholden to other third parties we have no say or influence over,” Dr. Granovsky said. “There’s no question that all of these things going on do and will have a big potential effect on the specialty and our physicians’ daily practice lives.”