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To survive and prosper under healthcare reform emergency medicine (EM) must redefine and reinvent itself. EM will not be able to continue doing business as usual, standing on the Prudent Layperson dictum that “the patient defines the emergency.” As currently envisioned, Accountable Care Organizations (ACOs) could not possibly be accountable for their patient care and cost outcomes with such an unmanaged approach to emergency and unscheduled care. EM’s future will depend on emergency physicians taking an active role in defining the unscheduled patient care need and providing the most cost-effective intervention to meet it.

ACOs are heavily favored under the Patient Protection and Affordable Care (PPAC, otherwise known as reform) legislation. ACOs are envisioned to be vertically integrated healthcare delivery networks comprised of all healthcare goods and services providers necessary to care for a given patient over a given period for a fixed, pre-paid amount of money. As such these entities are intended to re-create the cost incentives of pre-paid managed care that looks something like the old staff model HMO where the emphasis shifts from maximizing to minimizing the goods and services necessary to achieve any given level of outcome performance. The money that would hopefully be saved in relationship to fee-for-service expenditures for comparable care would then be shared across the network in a CMS-endorsed gain-sharing arrangement. I use the word “hopefully” because the cost-savings realized by the ACO demonstration projects to date have been inconsistent at best.

Either a hospital or physician group can theoretically form and operate an ACO but most experts believe that it will be the hospital that will typically fill this role because of its superior business and administrative capabilities, and its ability to raise the capital necessary to fund the ACO’s formation. The hospital and physicians must share the same incentives and work closely together to achieve measurable patient outcome improvements. Current wisdom is that the simplest way to integrate professional services into an ACO is to buy the practices and move the physicians into a multi-specialty group that is tightly affiliated with (not to say ‘controlled by’) the hospital. It remains to be seen how effectively this structure can be led and managed, and until the verdict is in there will be many arrangements where the physician practices are contracted with the ACO rather than being employed by the hospital.

Based on prior managed care capitation rates it is likely that hospital-based emergency department professional services will command something less than $1 per member per month of the ACO professional services payment pie. In this situation there are only three ways to improve your EM group’s profitability: (1) reduce patient service utilization so you get paid for services you don’t have to deliver, (2) deliver the contracted services at less cost by utilizing physician extenders or less costly venues like fast tracks and freestanding urgent care centers or Federally Qualified Healthcare Centers (FQHCs), or (3) expand the size of the EM professional services pie.

Reducing utilization or channeling it to the most cost-effective alternative must be a major focus of the ACO if it is to produce cost savings. So called “Triage Out” programs will almost certainly become more prevalent. Near term (within 30 days of discharge) Readmission Reduction is currently receiving a lot of attention in this regard. The intervention that is most likely to keep chronic disease patients from being readmitted is intensive outpatient treatment. Both EM and hospitalist groups will have a role to play in creating and operating outpatient observation, clinical decision units or specialized, hospital-based chronic disease (CHF, COPD, etc.) management units to provide this intensive outpatient therapy. Call centers and other programs to identify which patients need these services soon enough to prevent a readmission are also at the forefront of interest.

There is already a significant movement within EM to maximize physician extender utilization in the ED. PAs and NPs are practicing in the majority of higher volume EDs around the country. Scribes, Personal Productivity Assistants and Patient Flow Assistants are increasingly being utilized to help the physician stay focused on clinical decision-making during a greater percentage of his on-shift time. Outside the ED urgent care or convenience care and nurse-staffed retail clinics are booming, but the question is how will these services be integrated with those of the ACO? Unscheduled care needs occur during twice as many hours as there are typically primary care office hours. Someone needs to be able to manage these needs.

And so we come to the opportunities for us to expand the size of the EM professional services pie. Operating 24/7 already, EM is uniquely situated to take charge of managing all of an ACO’s patients’ unscheduled care needs – of becoming Unscheduled Care, Incorporated – instead of just thinking of ourselves as ED-bound physicians. An EM group strategic plan to fill this need might include provisions for a nurse call center to triage patients to the most appropriate facility for their need or temporize and make next day office appointments. It might also include the staffing of smaller regional referral EDs or neighborhood-based urgent care centers. An affiliation with area retail clinics would be important as would a common electronic medical record platform around which to integrate all of these points of care. In the ED it might include a joint venture with the hospitalists to form and operate an observation unit that provides intensive outpatient therapy. Adjacent to the ED it might include the formation and staffing of an FQHC to obtain supplemented Medicaid visit funding for both your hospital and your practice.

I’m sure someone must have said it earlier, but Cary Grant in Operation Petticoat at one point says “In chaos there is opportunity.” We should grab this opportunity and run with it.



 

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