204 “I’m Keeping Them Just in Case”: Patients Rationale for Retaining Unused Opioid Pills

Abstract

Methods: We are performing a qualitative study of ACOs using a purposive sampling strategy to identify early adopter organizations. We perform semi-structured interviews of key informants responsible for strategy, care redesign, and payment reform from each ACO (eg, Chief population health officer) and associated ED leadership (eg, Chair of emergency medicine). We analyze transcripts for key themes using a constant comparative method.Results: We present preliminary findings from 11 interviews across 4 sites. All sites were enrolled in the Medicare Shared Savings Program; however, sites varied in region and maturity with respect to population health initiatives. The Table describes care redesign examples by site. Nearly all sites were focused on reducing low-acuity ED visits and expanding alternate venues for acute unscheduled care (eg, urgent care). All sites were engaged in care redesign to reduce ED admission rates. All sites were expanding ED care coordination, although in different ways. All sites had programs to engage high-risk populations, older adults and frequent ED users were most frequently mentioned. All sites were engaged in initiatives to develop alternatives to inpatient hospitalization ranging from hospital at home to expanded use of direct transfer to skilled nursing facilities from the ED. Conversely, there has been no significant reform of payment for emergency medical care within these ACOs. All sites reported no change in fee-for-service reimbursement for ED services, while acknowledging that value-based payments for emergency care may require new payment methods and realignment of incentives. ED staffing models included independent contract groups, large national contract groups, and multispecialty faculty practices. ACO leaders at two sites indicated that future ED staffing contracts may incorporate value-based population health incentives. Respondents at two sites indicated fee-for-service EM payments are already tied to value. One site indicated that success in ACO value-based goals had led to decreased ED volume and revenue, raising significant challenges to the traditional academic mission of the ED. Nearly all informants expressed concern regarding reduced ED reimbursement given ACO efforts to reduce ED utilization and participation in alternative payment contracts, yet did not have a clear vision for reforming payment for ED services.Conclusions: Our preliminary findings suggest that care redesign within ACOs is generally impacting acute care delivery, particularly with respect to outpatient access and alternatives to hospitalization. Yet, to date, there has been little impact on methods of emergency medicine payment, which remain fee for service; further research is needed to determine how best to transition towards value-based payment for emergency medical care.