The healthcare landscape is ever changing, and because of this, the role that Emergency Department (ED) providers play is also in a state of constant change. Originally seen as a provider of 24/7 care, EDs are now also being viewed as centers of cost containment and drivers of quality improvement, especially with the increasing popularity of accountable care organizations (ACOs) and other value-based care models.
ED physicians and case managers are finding themselves being asked to work with ACO care management staff, such as nurses and social workers, and to engage with primary care providers. This is especially true in recent weeks as the battle against coronavirus continues and many ACO resources are being deployed to focus on infected or at-risk patients. Although ACOs and EDs share a common goal of effectively managing patient care (and now, responding to an unprecedented disaster), there are multiple pain points that get in the way of optimal care collaboration—sometimes contributing to disharmony and tension between the two groups.
The ED has often been described as the “safety net” of the healthcare system. Three crucial roles the ED plays in this include: fulfilling the Emergency Medical Treatment and Labor Act (EMTALA), providing 24/7 unscheduled services, and consistently being ready for disasters and/or population health emergencies.
ACOs provide care coordination for a defined population, identify and manage high-risk patients within that population, and assume collective responsibility for the cost and quality of care of their members, with the potential to receive financial savings and/or incur losses.
Taking a closer look at both sides reveals significant areas of misalignment, most notably reimbursement methods. ED providers are paid under a “fee-for-service” (FFS) system based on relative value units (RVU). In very simplified terms, EDs have financial incentives to increase revenue for the hospital by increasing volume while providing efficient and complex evaluations. ACOs, on the other hand, have alternative payment arrangements with payers in which the ACO is rewarded for decreasing admissions and ED visits.
ACOs view ED providers as critical to their success or failure in value-based care arrangements because ED physicians often have control over the decision to admit. The majority of inpatient admissions occur through the ED and community primary care physicians rely heavily on the ED to provide acute care services for their patients.
Additionally, EDs order testing (which may be seen as unnecessary or duplicative), make decisions about a patient’s discharge disposition (was it the most appropriate, low-cost care setting for that patient?), and influence transitions of care (thus contribute to positive or negative outcomes such as readmissions). In these and other ways, ED providers can either help or hinder an ACO’s efforts to manage total cost of care. ACOs who do not effectively engage EDs will struggle to achieve savings.
Scenario: Dr. Adams is a community primary care physician (PCP) and a member of a physician-led ACO. He receives a call from Betty, a long-time patient of his, that she is in the hospital for abdominal pain. Since Dr. Adams does not have privileges at Collective Regional, the ED provider admitted her to the hospitalist group. Betty has undergone multiple tests, including x-rays, CT Scans, lab work, and multiple pharmaceutical treatments. She was “wondering if he knew she was there and if he could come by to see her.” Dr. Adams calls Collective Regional’s ED and is upset, demanding to speak to the medical director. Dr. Wiley is pulled from patient care to talk to Dr. Adams, who is furious that “nobody called me to let me know Betty was being admitted. I could have managed her on an outpatient basis. My ACO is going to ding me on this!”
Dr. Adams, like many PCPs, may not fully understand the workflow of ED providers. Some EDs see over 200 patients per day and admit about 30-40 percent of those patients. Communities can have over 1,000 PCPs, and most may not have privileges at a given hospital. Therefore, in the spirit of efficiency, the ED provider admits to the covering hospitalist and continues with their day. Dr. Adams is expecting the ED providers to know which PCP belongs to which group, which ACO the patient is aligned with, who is covering them this week for admissions, etc. However, ED providers have been trained to focus primarily on addressing the emergency at hand and either admitting or discharging the patient.
Scenarios like this do not mean that ED providers don’t care about providing quality care and lowering healthcare costs. In reality, they lack the tools and infrastructure to assist them to do so—potentially leading to frustration for both the ED providers and ACO.
If you ever visit an ED provider workroom, you will see mountains of papers taped to the wall, pinned to a corkboard, or strewn about the room. These are “lists” that ACO care managers, community providers, organizations, and specialists bring down to the department for the ED providers to sift through to find who is covering for who or what group they belong to. As one could imagine, this is not an ideal way to manage patient care or effectively contribute to care coordination.
ACO providers and care managers also suffer from manual and fragmented communication systems. They do not enjoy calling the ED the day following a preventable admission to inquire about why the ACO was not contacted prior to the decision to admit, only to have the ED provider explain apologetically “we had no way of knowing that it was an ACO patient and that there was a resource to assist with a home discharge.” ACO clinical staff take on significant manual work as well—scouring census reports and logging into different EMRs and IT systems—in an effort to stay on top of where their members are seeking care. Without real-time visibility into patient activity, ACOs end up “Monday morning quarterbacking” ED clinicians, which only fuels animosity and does not contribute to desirable outcomes.
Using a technology platform such as Collective Medical that is uniquely designed to support real-time care collaboration can help ACOs and EDs address these challenges and work more effectively together for the good of the patient. Collective’s solution brings together ACOs, EDs, hospitals, post-acutes, PCPs, and other providers across the continuum, bridging information gaps and enabling more coordinated patient care. For example, ED providers using Collective can:
- Easily identify ACO patients
- Be alerted to patients with frequent utilization or complex needs
- Access an ACO’s care recommendations for individual patients, including insights about patient’s medical, behavioral, and social needs
- Know who is on a patient’s care team and how to contact them
Instead of living on various paper lists in the ED provider workroom, this information is embedded directly into ED provider workflows. Actionable clinical insights are surfaced at the right time, without requiring busy ED clinicians to log into a separate tool or search a phone directory.
The Collective platform further supports care collaboration by allowing ACOs to follow their members as they move throughout the care continuum. ACOs are notified in real time of patient presentations to the ED, including admissions and discharges—empowering care teams to reach out and engage treating clinicians in real time, as well as to perform post-discharge follow-up.
Through a common technology platform, EDs and ACOs can transform their relationship into a collaborative partnership focused on a common goal: doing what is best and most appropriate for the patient.
Jody Rain, MBA-HM, BSN RN CEN, is a Senior Clinical Solutions Lead at Collective Medical. Jody has been a nurse for over 21 years and recently was a Director of a large Emergency Care Center in Florida for six years. Jody’s work continues to focus on quality, efficient, and effective care for patients seeking medical treatment.
Nikki Starrett, MS, is the Director of Accountable Care and Population Health at Collective Medical. Prior to this, Nikki spent many years working for accountable care organizations, helping lead initiatives focused on value-based care and system transformation.