Acute Unscheduled Care Model Financial Projections
The overall structure and mechanics of the Acute Unscheduled Care Model (AUCM) were described in the Spring 2019 issue of The EM Insider. Accurate financial modeling is essential for ED groups considering AUCM participation. Because the model is predicated on both rewards and penalties, it is critical that groups know the extent of potential financial risks and benefits.
In order for ED groups to make an informed decision on whether to proceed with the AUCM implementation, the following four data points must be evaluated:
Reconciliation payments and penalties;
Payments for new, waived services;
Costs for instituting and maintaining AUCM related resources;
MACRA-mandated 5% fee-for-service bonus if the threshold is achieved.
Reconciliation Payments and Penalties
Reconciliation payments and penalties are determined by whether the ED group has either decreased or increased Medicare costs as compared to a target price. The historic price is calculated at the facility level by measuring all Part A and Part B Medicare costs for the four initial presentations in the model – chest pain, abdominal pain, syncope, and altered mental status – for 30 days after ED presentation. Three years of data is included in the historic price calculation. Each of the four individual presentations has its own historic price. Medicare will then apply a 1.5% to 3% discount (depending on a quality score) to the historic price in order to determine the target price. On an annual basis, Medicare will measure the actual Part A and Part B costs for the four individual presentations using the same parameters as the target price, and will then determine whether the ED group reduced or exceeded the 3-year historic target price for the four presentations.
Groups can decide what degree of reward and risk to assume, and may choose either a 10% or 20% reward/risk level. An alternative, transitional option allows for smaller rewards with no downside risk. Table 1 illustrates the potential amount of reconciliation payments/penalties for a theoretic example of chest pain presentations.
Chest Pain with $10,000 Target Price and 1000 Annual Patients
Number of Patients
10% Reward or Risk
20% Reward or Risk
In order to make informed decisions regarding the actual target price calculation, ED groups will more than likely require assistance from consultants who have access to the Medicare claims database.
Payment for Previously Non-reimbursable Services
Current Medicare guidelines do not allow for reimbursement for certain CPT codes when those services are supplied by an emergency physician. Under the AUCM, participating ED physicians become eligible to provide telehealth services, receive care coordination payments, and supervise post-discharge visits (non-home health).
Financial modeling of additional revenue attributable to payment for previously non-reimbursable services is dependent on a host of variables. First, payment to the ED group for these services requires the ED group, or its paid representative, to provide the service. Some examples where reimbursement would be acceptable include services provided by the ED physician or by an employed nurse practitioner or physician assistant under the supervision of an ED physician. In those situations where a hospital employee provides the service, the ED group will be unable to submit claims for payment.
Second, the CPT code chosen will be dependent upon the complexity of the services rendered. As with emergency service evaluation and management codes, the newly reimbursable CPT codes require varying degrees of documentation. Different codes have different RVU values, which when multiplied times the conversion factor, determine the amount of payment.
In summary, in order to calculate the projected additional revenue generated by these newly reimbursable codes, ED groups will need to decide first whether they will be responsible for providing these services, and second what code distribution and volume are expected.
Additional Incurred Expenses
ED groups will need to determine what additional resources are required for successful implementation of the AUCM. Some ED groups may assume full responsibility, requiring hiring of additional personnel to assist in care coordination and home visits. Telehealth equipment and maintenance represent potential, additional costs. Administrative expenses to monitor patient interactions in the 30-day post ED discharge period would also be required. Budget consideration will need to take into account the full range of additional expenses that the ED group will assume.
Some ED groups may opt to partially or completely use other organizations to perform these services, such as hospital personnel, accountable care organization (ACO) personnel, or outside vendors. Each emergency department will have a unique set of circumstances that will determine infrastructure requirements.
MACRA Advanced APM Bonus
The 2015 MACRA legislation contained a provision that allows physicians who treat significant numbers of Medicare patients in advanced APMs to receive a 5% annual bonus for Medicare payments. The program expires in 2023. The AUCM qualifies as an advanced APM, as does a variety of other APMs including BPCI and some ACOs. In order to receive a bonus in 2019, an ED group would need to have 25% of treated Medicare patients receive care via an advanced APM. The threshold rises to 75% in the final year of 2023. Additionally, some non-Medicare APMs also qualify to be included in the threshold.
The ability of emergency groups to receive the 5% bonus is small. The earliest that the AUCM could be initiated is 2020, as the HHS Secretary has not yet approved the ACUM for implementation. Even those emergency groups that currently participate with certain advanced APMs will have difficulty meeting the increasing threshold requirements by the time that the bonus expires in 2023.
Developed by ACEP, the Acute Unscheduled Care Model (AUCM) allows emergency groups to extend their scope of practice into the post-ED discharge arena, while offering the financial infrastructure to support any additional, required resources. The Spring 2019 issue of The EM Insider outlined the general structure and mechanics of the AUCM. This issue outlines the basic financial questions that ED groups will need to answer as they make a decision regarding participation in the AUCM. ACEP remains hopeful that Secretary Azar will decide to allow full CMS implementation of the AUCM. Once implemented, ACEP envisions the incorporation of other clinical presentations into the AUCM, with an eventual goal of 90% of all Medicare ED patients.