As explained on the Intro page this is the first in a series that seeks to explore many of the “things” that are (or could) affect the future of emergency medicine. It is part of NJ-ACEPs year-long commitment to exploring the Confusing array of changes to healthcare and identify the Opportunities for our specialty. The goal is to give you three things:
The Opportunity (for our specialty)
ACCOUNTABLE CARE ORGANIZATIONS
According to the CMS website: Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of an ACO is to:
ensure that patients, especially the chronically ill, get the right care at the right time
avoid unnecessary duplication of services and preventing medical errors
deliver high-quality care and spending health care dollars more wisely
share in the savings it achieves for the Medicare program.
The essential component of this model is the transfer of financial risk AND responsibility for quality from the 3rd party entity (in this case medicare) to a “provider-led” organization. In some ways it is similar to the 1970s concept of Health Maintenance Organizations except that quality of care is supposed to be as important as cost reduction.
The financial incentive for an ACO is a substantial share of calculated savings in the care of medicare patients through better coordinated and (hoped for) reduced care. However in some cases the ACOs could also be liable for calculated increases in the cost of care provided. Currently there are also “33 quality reporting metrics” for physicians that effect payment under the Shared Savings Program.
Because of the size of beneficiaries required (> 5000 enrollees) and the complex network needed to provide care most ACOs have formed from large, already existing entities. In NJ many are based around hospital-centered health networks though others have formed as well. Currently there are 10 ACOs approved by CMS in our State:
Advocare Wallgreens Well Network
Atlantic Health System ACO
Atlanticare Health Solutions
Barnabas Health ACO – North
Central Jersey ACO
Hackensack Physician-Hospital Alliance
HNMC Hospital\Physician (Holy Name)
Meridian Accountable Care Organization
Optimus Healthcare Partners
Summit Health- Virtua
ACOs and EMERGENCY MEDICINE
As with so many things that will be written about in this series the future of ACOs and its impact on emergency medicine is unknown. Some emergency physicians (particularly those employed by hospitals) are already members of an ACO. Others may end up joining through their group practices or provide services to ACOs through other contracted relationships.
There are more questions than answers currently:
How will the ACOs goals of reducing the cost of care interact with our responsibilities under EMTALA and Prudent Layperson?
How would a group of emergency physicians negotiate fair payment based upon the incentives ACOs have?
And most importantly how do we show our value?
The opportunity I believe lies in that last question. We provide value now. We cost Just 2% of all US healthcare dollars. We provide acute care, safety-net care, and already straddle the link between hospital-based and out-patient care. We coordinate care for many of those same patients already.
But we need to better define that value and show that a trip to the ED is not an expense to be reduced but an important episode of care that can reduce other costs. Because this is a medicare program the patients involved are almost entirely elderly or disabled. Most of these patients present with either acute disease states complicated by chronic conditions or exacerbations of their chronic medical conditions.
So what value can we add beyond the acute episode of care? Clearly improving communication and coordination with their primary providers (most will have more than one) will be key. Others have also talked about the ED expanding its role as a hub that directs patients to the various spokes where the rest of their care is provided.