Creating "turbo" accountable care organizations for time-critical diagnoses.

Accountable care organizations (ACOs) are scheduled for implementation in 2012 by the Center for Medicare and Medicaid Services (CMS), and this “standard” ACO model seeks to encourage hospitals and ambulatory care practitioners to come together as organized entities responsible clinically and financially for the health care of 5000 Medicare beneficiaries.1,2 However, significant barriers to implementation exist, including organizational complexity, informatics investments, legal issues, concerns about exacerbating healthcare disparities, and general uncertainty regarding the attainability of financial rewards based upon results from the CMS Physician Group Practice Demonstration.1–6 The standard-ACO model is also focused on primary care and chronic disease management in the ambulatory setting,7 thus ignoring essential emergency systems that provide sophisticated care for time-critical diagnoses that also affect overall public health. Thus, I propose that CMS considers the parallel initiation of a novel “Turbo” ACO model to promote efficient healthcare delivery systems for patients who suddenly experience an unplanned critical illness, including acute STelevation myocardial infarction (STEMI), stroke, or out-ofhospital cardiac arrest (OHCA). Moreover, instead of competition, the Turbo-ACO model would be designed to promote better collaboration between all hospitals and emergency medical services (EMS) providers within an organized region and improve clinical outcomes for time-critical diagnoses across entire populations. The 3 core attributes of the standard-ACO model include organized care, performance measurement, and payment reform, all aligned to promote value-based healthcare delivery.2 The proposed Turbo-ACO model would simply adapt these 3 core attributes to consistently promote the rapid treatment of time-critical diagnoses with specialized hospitalbased interventions. The Turboprefix provides a useful metaphor for these types of speed-oriented healthcare delivery systems because Turbo originates from engineers who modified a standard engine design to deliver more power and speed. My rationale for Turbo-ACOs within the context of the 3 core attributes is summarized next, with the goal of simultaneously optimizing intrahospital team-based care, interhospital collaboration, and prehospital systems. First, organized systems of care for STEMI, stroke, and cardiac arrest have already been successfully created in various early-adopter regions across the nation, and their implementation has translated into significant process-of-care improvements and real reductions in morbidity/mortality across entire regions.8–11 Regionalization for acute cardiovascular emergencies has been driven by a convergence of forces,12,13 including professional society quality improvement initiatives led by the American College of Cardiology14 and the American Heart Association (AHA).15–17 In addition, EMS providers generally transport anywhere from 50% to 100% of all STEMI, stroke, and OHCA to receiving hospitals, which positions EMS authorities as powerful advocates for quality health care at the local level. When these authorities implement destination protocols to designated hospitals with special capabilities, EMS systems can actively promote “the right care for the right patient in the right place at the right time (quickly)” for a cohort of critically ill patients identified by evidence-based prehospital triage criteria (eg, electrocardiogram [ECG] findings, focused neurological examination, or return of spontaneous circulation). The designated receiving hospitals are expected to participate in a quality assurance and improvement (QA/QI) registry to maintain their status within the regional network, accept all patients in their catchment area meeting prespecified triage criteria regardless of insurance status, and maintain 24/7 accessibility to time-critical specialty care regardless of emergency department diversion or overcrowding status.12 Lastly, recent findings from the North Carolina statewide STEMI network demonstrated that significant reductions in disparities can occur in organized networks.18 Thus, in contrast to standard-ACO concerns,4 disparities are likely minimized in Turbo-ACOs because rapid access to quality care would be much less dependent on a patient’s home zip code or usual hospital referral region. Second, existing registries already provide robust performance measurement nationally. Two American College of Cardiology registries (ACTION–Get With the Guidelines [GWTG] and Cath-PCI at www.ncdr.com) support QI efforts for acute coronary syndromes (with minor components for OHCA), and stroke is supported by the AHA’s GWTG Stroke registry. The primary strengths of these 3 registries include