1. The Role Of ACOs in Emergency Medicine Ken Hanover For the Emergency Department Practice Management Association (EDPMA) Solutions Summit XVI 2013

2. What is an Accountable Care Organization (ACO)? 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. Source: Center for Medicaid and Medicare Services. Accountable Care Organizations. April 12, 2012. 2

3. And A More Refined Definition... Provider Groups that accept responsibility for the cost and quality of care delivered to a specific population of patients cared for by the groups. Source: S. Shortell et al. “How the Center for Medicare and Medicaid Innovation Should Test Accountable Care Organizations.” Health Affairs. July 2010. 3

4. The Goal of ACOs Aligning provider financial incentives with patient needs for better health and lower cost care. Providers earn more for achieving better care at a lower cost. Source: E. Fisher, M. McClellan, and S. Shortell. “The Real Promise of Accountable Care.” Wall Street Journal. March 4, 2013. 4

5. ACOs Come In Many Different Forms More than 423 ACOs across the USA Some are IDN/Hospital Sponsored (189) Steward Healthcare Partners Healthcare Cedars - Sinai 5

6. ACOs Come In Many Different Forms (Cont.) Some are physician sponsored (202) Atrius Health Optimus Healthcare Partners Physician Health Partners 6

7. ACOs Come In Many Different Forms (Cont.) Some are payor sponsored (32) Aetna Cigna Humana The “Blues” Source: M. Gamble. “Number of ACOs in the United States – A Quarterly Break-Down.” Becker’s Hospital Review. February 28, 2013. 7

8. Impact on Emergency Services 8

9. Emergency Care Utilization Researchers found a 4.1% increase in overall ED visits from 2006 to 2008 in the 11 hospitals studied versus a 4.6% increase in ED visits statewide. Researchers also found a 1.8% decrease in low severity visits by the groups most affected by the reform law. Source: P. Smulowitz, et al. “Emergency Department Utilization After the Implementation of MA Health Reform.” Annals of Emergency Medicine. 2011. 9

10. Emergency Care Utilization (Cont.) ACOs can try to direct patients to lower cost alternative sites of care However, many other factors will influence consumer behavior such as: Insurance product copays and deductibles; Patient patterns of prior access and usage; and Availability and convenience of alternative care delivery sites. 10

11. Care Coordination Triage centers, call centers, telemedicine and alternative sites of care will grow in numbers and prevalence. Information technology infrastructure and improving both access and flow of patient information will be key. Source: Emergency Medicine Practice Committee, “Accountable Care Organizations: What Do They Mean for mergency Medicine.” American College of Emergency Physicians. September 2012 11

12. Quality Indicators Most ACOs are still determining which metrics they will use to evaluate the quality of care provided in the Emergency Department. It is likely that a combination of service metrics and care delivery metrics will be utilized. 12

13. The National Quality Forum Endorsed Measures to Address Care Coordination And Efficiency In Hospital Emergency Departments Median time from ED arrival to ED departure for admitted ED patients. Median time from ED arrival to ED departure for discharged ED patients. Admit decision time to ED departure time for admitted patients. Door to provider. 13

14. The National Quality Forum Endorsed Measures to Address Care Coordination And Efficiency In Hospital Emergency Departments (Cont.) Left without being seen. Severe sepsis and septic shock management bundle. Confirmation of endotracheal tube placement. 14

15. The National Quality Forum Endorsed Measures to Address Care Coordination And Efficiency In Hospital Emergency Departments (Cont.) Pregnancy test for female abdominal pain patients. Anticoagulation for acute pulmonary embolus patients. Pediatric weight in kilograms. Source: National Quality Forum, NQF Endorses Measures to Address Care Coordination and Efficiency in Hospital Emergency Departments. October 29, 2008. 15

16. Financial Impact Key question will be how ACOs choose to allocate value-based bundled payments among provider participants. Under prepaid capitation all emergency services components were valued at 4% of premium cost. 16

17. Financial Impact (Cont.) Today, current utilization rates and emergency physician compensation must be adjusted for inflation. Also, ACOs will adjust for age, risk, and out of network utilization. Utilization and patient care acuity will eventually change and impact the financial structure of emergency services. 17

18. Financial Impact (Cont.) Will most emergency physicians become employees? Will size and scale become important factors to ensure financial vitality? Will emergency physicians increasingly diversify their service portfolio beyond the hospital? Source: Emergency Medicine Practice Committee. “Accountable Care Organizations: What Do They Mean For Emergency Medicine?” September 2012 18

19. Conclusions ACOs will bring a lot of changes to the delivery of health care services and the provision of emergency medicine. Emergency physicians must thoughtfully and effectively consider the potential impact on their practice and make adjustments accordingly. Engagement and involvement in ACO development and operation will ensure that your issues are understood and satisfactorily addressed. 19