Sandra Yin

June 01, 2011

June 1, 2011 (Washington, DC) — Emergency physicians got a taste of the cultural changes accountable care organizations (ACOs) might demand, here at the American College of Emergency Physicians 2011 Leadership and Advocacy Conference (ACEP-LAC).

Because cost savings are important, "expect ACO management to assume patient admission is not the default," said Chester Speed, JD, LLM, vice president of public policy for the American Medical Group Association, a trade group that represents multispecialty medical groups.

The pressure to keep costs down will affect the 2 biggest decisions that emergency physicians make in the emergency department (ED), said Jay Kaplan, MD, FACEP, an ACEP board member, who moderated the panel. The big questions are: Do I admit or not? And, Do I image or not?

Under the fee-for-service model, a visit to the ED is a good thing, noted Steve Heilman, MD, system vice president and chief medical informatics officer of Norton Healthcare, which is part of an ACO pilot project sanctioned by Brookings/Dartmouth. In an ACO world, however, an ED admit might reflect a failure in another physician's care.

"Do you have something in place when someone comes in with bronchitis or [a urinary tract infection] so you don't inappropriately use the [ED]?" Dr. Heilman asked. "Can you move someone to a lower level of care?"

In the future, retail clinics headed by primary care physicians could materialize in the ED to care for nonemergency patients, Speed said.

"ED physicians will need to think of themselves as part of a team that works well with ACO managers, hospital administrators, ambulatory, care leaders, and a whole host of committees and commissions that you may not want to spend time with," he said.

Another change might be using caseworkers in the ED to help smooth transitions in care, such as discharge planning. The caseworkers might help explain medication directions to patients or schedule follow-up appointments with primary care providers, home health providers, or physical therapists, Speed added.

Emergency physicians can also expect to see financial incentives to shift. Meeting metrics in the future could bring in more pay, and tiered reimbursements would translate into more money for emergency care, and less for nonurgent care.

More consistent care that follows best practices will be expected. "If you have 15 different doctors, the old concept of 'I'm going to do it my own way' has to go away," Dr. Kaplan said. "Otherwise, there will be no cost savings."

During the question-and-answer session that followed the presentation, one burning question dominated the discussion: Should emergency physicians consider joining ACOs?

Both presenters seemed reluctant to commit to a firm answer. "I hate to go bipolar on you, but if you sit back and let things happen, you're going to end up accepting what's given to you later," said Dr. Heilman. "It's always important to be a little forward thinking and try to get involved. But without the financial resources and people to help you do that appropriately, you're facing a significant risk if you jump in and sign up."

"Speaking of bipolar, I would say 'yes and no,' " said Speed. He explained that it might be wise for contract ED doctors to hold off on jumping into an ACO. It may be worth it to wait and see how an ACO operates in real life, he told Medscape Medical News later. Because the program does not start until 2012, no formal ACO exists yet, nor has the final regulation come out yet. At this point, comments on the draft regulation are due back to CMS in June. In addition, the pilot projects have not drilled down to how ED will fit in.

"But Steve has a good point," he added. "If you don't join now, it may be foisted on you later."

Some questioned whether this was the best time for ACO reforms. One of the attendees, Bruce Auerbach, MD, FACEP, said he was convinced that ACOs and global budgeting were not needed to prod people into practicing better-quality medicine. "All we need to do is reward people for better quality and outcomes," he said, "whether it's in the fee-for-service model or any other type of payment model."

What really worries him, he said, is that the government payers that make up 50% or more of all the dollars physicians get when you aggregate Medicare and Medicaid are not carrying their weight. With states in dire straits cutting Medicaid rates, Dr. Auerbach expressed some pessimism about the future. Once the ACO takes a global budget, he noted, you are going to be cost shifting back to yourself when Medicare and Medicaid start to ratchet the rates down even more. "So it's really a great concern to me that we're pushing forward with reform in these economic times when we can't get the government payers to carry their weight," he said.

American College of Emergency Physicians 2011 Leadership and Advocacy Conference (ACEP-LAC). Presented May 23, 2011.