The emergency department in an ACO world

In the era of accountable care, you’ll notice that many hospitals and health systems are already driving towards more collaborative workflow. The integrated delivery network (IDN) is changing significantly, and for the better. But in high-acuity care areas, like the emergency department (ED), the challenge of treating patients more holistically in what is already a fast-paced environment is concerning for physicians evaluating the pay-for-performance model.

In today’s ED, patients may enter with a chronic condition that could be better managed by a primary care physician (PCP), but because ED physicians are incented to treat sick people in a fee-for-service model, they continue to take these patients on instead of referring them outside the ED walls. If instead both ED and primary care physicians operate as part of a team of care givers that are incented to ensure patients stay healthy and avoid hospital admissions and readmissions, they are headed in the same direction in terms of focusing on better patient outcomes vs. reimbursement dollars.

ED physicians used to be among the few physicians employed by the hospital, but that’s changing dramatically as IDNs snap up physician groups. The larger group working together will help make sure the ball isn’t dropped anywhere throughout the spectrum of care. If a patient with a laceration comes into the ED with diabetes, and that ED doc doesn’t think to check blood sugar – because that’s more of a PCP issue – that oversight will be visible in an ACO environment and the physician might be under the microscope in terms of the role played in ensuring quality outcomes.

Part of this movement requires implementing integrated technology solutions that provide greater visibility into the types of care needed in your community, allowing the health system to build care facilities that are catered to the population it serves, ultimately enabling the sustainable health community. But the real lynchpin for success is the collaboration between people, not just IT systems. This means choosing metrics to support each constituency that has a stake in the game – providers, payers, physicians and patients – so that they buy into the new strategy and are empowered to make changes that support lower costs, increased efficiencies and higher quality care. It takes strong leadership demanding teamwork across clinical, administrative and even third-party vendors, along with a shared passion for making sure patients are cared for in the best possible way to make this happen.

Mark Crockett is SVP of Clinical Solutions at OptumInsight, CMO of Accountable Care Services at Optum and practices emergency medicine at Advocate Good Samaritan hospital in Downer’s Grove, Illinois.

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  • Rob Lindeman

    If ED docs and policy types (in this case, both) are writing articles describing how to incorporate emergency level of care into a “holistic” care model, then I’m afraid we’re all in severe trouble.  Emergency rooms never were designed to do anything except stabilize unstable patients.  They do a lousy job of doing anything beyond this core function (that they perform admirably).  Before we start “choosing metrics” or “increasing efficiencies”, let’s strap on a pair of cojones and start keeping non-emergently ill people out of emergency rooms.

    “Incent” is not (yet) a standard English word.  Incentivize still is.

  • Anonymous

    The ED is the most efficient delivery site in the system, already works in interdiciplinary team environment; communication during and after plays important role in continuity of care. Take advantage of what already works in the system we’re developing. ED care when combined into a regional EMS system is the basis of an ‘ACO for acute care’.

  • Anonymous

    Sounds like you’re saying every doc that has any contact with a patient will be responsible (both legally and economically) for every aspect of that patient’s health care. Opthamologists will be performing breast exams, psychiatrists will be giving tetanus boosters. Great. For the trial lawyers, that is.

  • Steven Reznick

    This article is more nirvana , fantasy pie in the sky horse manure propagated by administrative non care givers. Emergency departments are interested in determining if a patient requires admission and how to keep the patient stable until we pass them off to the next caregiver. Nothing more nothing less. They want the ED to be a referral profit center. Hospitals have purchased physician practices at least two times in the past in my thirty year career and mismanaged them each time except in rare instances like Kaiser Permanente. Technology in health care will need to assist and make patient care easier and safer. It should never be designed to replace human touch and contact. At the current time, despite being an advocate for computer health records and computer order entry, the field of vendors and EHR’s is a disastrous work in progress prolonging physician and health care providers patient visits and increasing not decreasing the work loads. Government mandated rules have been rolled out BEFORE the software is functional or the vendors have staff trained to teach doctors, nurses and staffs how it works. To think that computer systems will be interacting and communicating patient information within five years is the same type of dream we all had of landing on planets when we landed on the moon decades ago. I applaud Kevin including bloggers of all opinions on his board but if you notice there is a strong odor around the original piece its because the stench is representative of the fecal matter it contains.

  • Anonymous

    ACO = endless nightmare ER cases, angry patients in crisis from inadequate outpatient care =no compensation to the ER = an even bigger malpractice lawsuit risk than ever before.

    Have fun.

  • Anonymous

    What? The system we have today works well? We don’t have nightmare ER cases today? We don’t have angry patients in the current status quo system? We don’t have inadequate outpatient care today? We don’t have malpractice lawsuits today? Don’t try a new idea because it just might correct something, even if it has some bugs to work through? Are you saying that today’s health care system isn’t horse manure? Today’s health care system only works for those who make profit in chaos. That’s the doctors and other providers, that’s hospitals, that’s insurers and that’s the drug companies, these folks all make profit in chaos. The consumer does not profit in today’s chaotic model. The consumer keeps paying the bill while the industry rakes in the huge profits in today’s broken health care system. When I read the posts here, I’m reading the words of frightened professionals when they say that ACOs will not work. These corrupt doctors, hospitals, drug companies and insurers all see the handwriting on the wall. They are scared rats!  They are beginning to see that the cow has been milked dry. They are beginning to see that the goose that has been laying the golden eggs is dead. They are seeing that the game is coming to an end. You’ve had to your way for far too long. It’s now time to “Occupy Health Care”. It’s time to expose the corruption in the system. It’s time to end the game that only works for a certain connected few. It’s time for consumers to rise up and take control of the things they pay for. It’s time for consumers to make the system work better for them. It’s time to reward wellness and good outcomes. Huge profits from sick-care must end!

  • rah5408

    I strongly disagree with Dr. Crockett’s portrayal of EPs, the ED and its role in an ACO.  His piece is filled with misperceptions and misrepresentations, and I very much hope he doesn’t show up as a supposedly kncowledgeable consultant at my hospital.  In approximate order, (1) the idea that EM practice needs to be more “holistic” is nonsense.  We are already required to reconcile all of their meds, inquire as to smoking and high risk sexual behaviors, snoop out child and elder abuse, evalutate nutritional status, and assess their psycho-social environment, along with much else.  (2)  What, pray tell, does “…physicians evaluating the pay-for-performance model…” mean?  Everything is imposed on the ED and EPs – we don’t get to “evaluate” anything.  (3)  If Dr. Crockett knew anything about EMTALA he would know that we don’t have a choice other than to “take these (chronic disease) patients on” because we are obligated to see them.  And to insinuate we do it because of the FFS system is equally ignorant and offensive.  If Dr. Crockett were in fact an EP as he represents himself he would know that very one of these patients is referred “outside the ED walls” but primary care pays so little that they can’t find a physician to manage their chronic illness during office hours, much less outside of office hours.  (4) Dr. Crocket should know that EPs evaluate everything about every patient – that Dr. Crockett thinks they don’t is further evidence of his ignorance of EM practice.  (5)  EDs lead all other physicians in technology integration and the phrase “…build care facilities that are catered to the population it serves…” indicates Dr. Crockett knows little about the English language as well.

    I know needs copy but please try to spare us this kind of drivel.

    Ronald A. Hellstern, MD, FACEP
    Dallas, Texas

  • Ed Chory

    How can anyone talk about ER care and not acknowledge the role of defensive medicine??????  So much more is directed by fear of a lawsuit than financial incentives!!!!!!

  • MarkCrockett

    I appreciate all of the thought that readers have given to my post above and would love to continue the discussion. In an attempt to address as many comments as possible, I’ve posted a response on ( and welcome you all to read it. I find it encouraging that as ED physicians, we’re weighing in and not just letting this topic go by.
    Thanks, Dr. Mark Crockett.

  • WhiteCoat Rants

    First, I take issue with the statement “If a patient with a laceration comes into the ED with diabetes, and that ED doc doesn’t think to check blood sugar …” The term for this nonsense is called “mission creep.” Maybe the ED doc doesn’t think to check the INR or dilantin level or cholesterol or the date of the most recent PAP smear or the most recent colon screening, either. Are we going to be held “accountable” for those “oversights” as well? Heck, maybe we can be sued for failing to advise patients on their investments and how to potty train their grandchildren while we’re at it.
    Second, the notion that emergency physicians “continue to take these patients on instead of referring them outside the ED walls” also shows that Dr. Crockett is uninformed about the basic operation of emergency departments and EMTALA laws. Referring “them” to another physician without performing a screening examination is an EMTALA violation subjecting the actor and hospital to a $50,000 civil penalty.
    Come on, now. If you’re going to suggest solutions to the problems in our health care system, at least have a basic understanding of how the system works.

  • Anonymous

    The thousands of independent one-doc private practices across America are fighting to maintain the broken status quo of health care delivery and they continue to criticize the ACO model at every turn. They refuse to see the lack of efficiency of so many individual entities that never communicate, cooperate and collaborate with each other. Often, these small practices are still using paper records and can’t afford to upgrade to a EHR system. Will the new ACO model have problems as it develops? Of course it will. But one thing we know for sure. Consumers are paying top dollar (almost 18 percent of GDP) for a health care system that ranks 37th worldwide in performance. Every other industrialized nation in the world covers “all” of their citizens. America has over 50 million uninsured and another estimated 25 million more underinsured. Face it! It’s broken! Consumers have suffered enough! The ACO model ends fee-for-service health care. That, in and of itself, is a huge step in the right direction. The future of “big-box” health care looks very bright as long as we can stave off the neanderthals that keep promoting the status quo.

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