Formation Of Accountable Care Organizations Research Articles

Understanding Medicare ACO Adoption in the Context of Market Factors

Medicare Accountable Care Organizations (ACOs) have achieved high-quality performance and recent cost savings, but little is known about how local market conditions influence provider adoption. The authors describe physician practice participation in Medicare ACOs at the county level and use adjusted logistic regression to assess the association between ACO presence and 3 characteristics hypothesized to influence ACO formation: physician market concentration, Medicare Advantage (MA) penetration, and commercial health insurance market concentration. Analyses are repeated on urban and rural county subgroups to examine geographic differences in ACO adoption. Practice participation in ACOs grew 19% nationally from 5.4% to 6.4% of practices between 2015 to 2017, but participation lagged in the West and rural counties, the latter of which had relatively concentrated physician markets and low MA penetration. After controlling for urban location, population density, and other covariates, ACO presence in a county was independently associated with less concentrated physician markets and moderate MA penetration but not commercial insurance concentration. The evidence suggests that Medicare ACO programs have continued appeal to physician practices, but additional engagement strategies may be needed to expand adoption in rural areas. In addition, greater practice competition and MA experience may facilitate ACO adoption. These insights into the relationship between market conditions and ACO participation have important implications for policy efforts to accelerate Medicare payment transformation.

Changes in the Use of Lumbar Arthrodesis Procedures Within Accountable Care Organizations

A retrospective review of Medicare claims data (2009-2014). The aim of this study was to evaluate changes in the use of lumbar fusion procedures following the formation of Accountable Care Organizations (ACOs). Within surgical care afforded by ACOs, savings are thought to be realized by improved care coordination as well as reductions in the use of preference-sensitive procedures such as lumbar fusion. We queried fee-for-service claims for patients enrolled in Medicare Part A and B, identifying patients who received lumbar spine fusion, discectomy, or decompression procedures. We performed a difference-in-differences analysis comparing the use of lumbar fusion in ACOs and non-ACOs in the period before (2009-2011) and after (2012-2014) ACO formation. Propensity score adjustment was used to address differences in case-mix. Multivariable logistic regression was used to compare the likelihood of receiving a lumbar fusion in ACOs and non-ACOs in the period before and after ACO formation. Within organizations that would form ACOs, the raw rate of lumbar fusion increased from 50% (n = 2183) in 2009 to 2011 to 54% (n = 2283) in 2012 to 2014. Among non-ACOs, the use of fusion increased from 52% (n = 110,160) to 59% (n = 109,917). Adjusted difference in differences in the use of lumbar fusion between ACOs and non-ACOs was -2.6 percentage points (P = 0.13). When limited to patients with spinal stenosis, ACOs significantly reduced the use of fusion (-5.8 percentage points; P = 0.03). Our results indicate that ACOs may effectively curtail the use of lumbar fusion procedures, particularly among patients with spinal stenosis. As these interventions are often associated with higher complications and need for reoperation, such practices might accrue additional health care savings for Medicare beyond those realized during the index surgical period. 3.

Disparities in Rates of Surgical Intervention Among Racial and Ethnic Minorities in Medicare Accountable Care Organizations.

To assess the effect of Accountable Care Organizations (ACOs) on the use of surgical services among racial and ethnic minorities. Health reform efforts were expected to reduce healthcare disparities. The impact of ACOs on existing disparities in access to surgical care remains unknown. We used national Medicare data (2009-2014) to compare rates of surgery among white, African American, Hispanic, and Asian Medicare beneficiaries for coronary artery bypass grafting, colectomy, total hip arthroplasty, hip fracture repair, and lumbar spine surgery. We performed a pre-post difference in differences analysis between African American, Hispanic, and Asian patients receiving surgical care in ACO and non-ACO organizations before and after the implementation of ACOs. The time period 2009 to 2011 was considered the pre-ACO period, and 2012 to 2014 the post-ACO period. Rates of surgical intervention in the ACO cohort were significantly lower (P < 0.001) as compared to non-ACOs for whites, African Americans, Hispanics, and Asians in both the pre- and post-ACO periods. There was no significant difference in the adjusted change in the rate of surgical interventions among minority patients as compared to whites in ACOs and non-ACOs between 2009 to 2011 and 2012 to 2014. The odds of receiving surgical intervention were lowest for minority patients in ACOs during the post-ACO period (P < 0.001). We found persistent differences in the use of surgery among racial and ethnic minorities between the time periods 2009 to 2011 and 2012 to 2014. These disparities were not impacted by the formation of ACOs. Programs that specifically incentivize ACOs to improve surgical access for minorities may be necessary.

Association of Physician Group Participation in Accountable Care Organizations With Patient Social and Clinical Characteristics

Accountable care organizations (ACOs) may increase health care disparities by excluding physician groups that care for socially and clinically vulnerable patients. To estimate the association between the patient characteristics of a physician group and the group's participation in a newly formed ACO. This retrospective cohort study investigated a 20% random sample of US Medicare fee-for-service beneficiaries attributed to physician groups identified in Medicare claims before ACO participation from January 1, 2010, through December 31, 2011. Physician groups that participated and did not participate in the Medicare Shared Savings Program (MSSP) from January 1, 2012, through December 31, 2014, were identified in the Medicare MSSP 2014 provider file. Data analyses were conducted from September 1, 2017, to March 30, 2018. Using multivariable regression, the association between physician group participation in the MSSP and the group's patients' characteristics before ACO formation was estimated focusing on measures of the vulnerability of the group's patients. All ACO-participating physician groups were compared with ACO-nonparticipating physician groups for reference, and estimates were made at the physician and patient level. Percentage of a physician group's patient panel that was socially vulnerable (based on race, dual Medicare and Medicaid enrollment, or living in high-poverty zip code) or clinically high risk. Among 67 891 physician groups caring for 5 394 181 patients, 7215 physician groups (10.6%) participated in an MSSP ACO by 2014. Comparing mean percentages across practices, the patients of non-ACO-participating physician groups, more patients of ACO-participating physician groups were black (mean percentage across practices, 12.1% vs 10.6%), dually enrolled in Medicare and Medicaid (23.0% vs 19.3%), living in poverty (10.7% vs 11.1%), and high risk (34.2% vs 30.2%). After adjustment, physician groups that participated in an ACO had 5.1 percentage points (95% CI, 0.1-10.0 percentage points; P = .05) more dually enrolled patients and 4.0 percentage points (95% CI, 1.9-6.1 percentage points; P < .001) more high-risk patients. At the patient level, patients who were at high risk were more likely to be attributed to a group that became part of an ACO, with 4.5 percentage points (95% CI, 0.5-8.5 percentage points; P = .03) more high-risk patients being attributed to an ACO, but other associations were not statistically different from zero. Accountable care organizations may be an effective approach to target care among high-risk patients. In this study, physician groups that participated in the MSSP ACO program cared for more clinically vulnerable patients than did nonparticipating groups, and ACO-participating physician groups cared for an equally large number of socially vulnerable patients compared with nonparticipating physician groups.

Alterations in 90-day morbidity, mortality, and readmission rates following spine surgery in Medicare Accountable Care Organizations (2009–2014)

BACKGROUND CONTEXTThe impact of Accountable Care Organizations (ACOs) on healthcare quality and outcomes, including morbidity, mortality, and readmissions, has not been substantially investigated, especially following spine surgery. PURPOSETo evaluate the impact of ACO formation on postoperative outcomes in the 90-day period following spine surgery. STUDY DESIGNRetrospective review of national Medicare claims data (2009–2014). PATIENT SAMPLEPatients who underwent one of four lumbar spine surgical procedures in an ACO or non-ACO. OUTCOME MEASURESThe development of in-hospital mortality, complications or hospital readmission within 90 days of the surgical procedure. METHODSThe primary outcome measures included postsurgical complications and readmissions at 90 days following surgery. In-hospital mortality and 30-day outcomes were considered secondarily. The primary predictor variable consisted of ACO enrollment designation. Multivariable logistic regression analysis was utilized to adjust for confounders and determine the independent effect of ACO enrollment on postsurgical outcomes. The multivariable model included a propensity score adjustment that accounted for factors associated with the preferential enrollment of patients in ACOs, namely, sociodemographic characteristics, medical co-morbidities, hospital teaching status, bed size, and location. RESULTSIn all, there were 344,813 patients identified for inclusion in this analysis with 97% (n = 332,890) treated in non-ACOs and 3% (n = 11,923) in an ACO. Although modest changes were apparent across both ACOs and non-ACOs over the time-period studied, improvements were slightly more dramatic in non-ACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012–2014, ACOs demonstrated an 18% increase in the odds of 90-day complications and a 14% elevation in the odds of 90-day readmissions when compared to non-ACOs. There was no difference in hospital mortality between ACOs and non-ACOs. CONCLUSIONSOur study of Medicare data from 2009 to 2014 failed to demonstrate superior reductions in postoperative morbidity, mortality, and readmissions for beneficiaries treated in ACOs as compared to non-ACOs. These results indicate that meaningful changes in postoperative outcomes should not be anticipated based on organizational participation in ACOs at present.

Thursday, September 27, 2018 1:05 PM–2:05 PM The Spine Journal Outstanding Paper Awards

BACKGROUND CONTEXT The impact of Accountable Care Organizations (ACOs) on healthcare quality and outcomes, including morbidity, mortality and readmissions, has not been substantially investigated, especially following spine surgery. PURPOSE To evaluate the impact of ACO formation on post-operative outcomes in the 90-day period following spine surgery. STUDY DESIGN Retrospective review of national Medicare claims data (2009-2014). PATIENT SAMPLE Patients who underwent one of four lumbar spine surgical procedures in an ACO or non-ACO. OUTCOME MEASURES The development of in-hospital mortality, complications or hospital readmission within 90-days of the surgical procedure. METHODS The primary outcome measures included post-surgical complications and readmissions at 90-days following surgery. In-hospital mortality and 30- day outcomes considered secondarily. The primary predictor variable consisted of ACO enrollment designation. Multivariable logistic regression analysis was utilized to adjust for confounders and determine the independent effect of ACO-enrollment on post-surgical outcomes. The multivariable model included a propensity score adjustment that accounted for factors associated with the preferential enrollment of patients in ACOs; namely socio-demographic characteristics, medical co-morbidities, hospital teaching status, bed size and location. RESULTS In all, there were 344,813 patients identified for inclusion in this analysis with 97% (n=332,890) treated in non-ACOs and 3% (n=11,923) in an ACO. Although modest changes were apparent across both ACOs and non-ACOs over the time-period studied, improvements were slightly more dramatic in non-ACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012-2014, ACOs demonstrated an 18% increase in the odds of 90-day complications and a 14% elevation in the odds of 90-day readmissions when compared to non- ACOs. There was no difference in hospital mortality between ACOs and non-ACOs. CONCLUSIONS Our study of Medicare data from 2009-2014 failed to demonstrate superior reductions in postoperative morbidity, mortality and readmissions for beneficiaries treated in ACOs as compared to non-ACOs. These results indicate that meaningful changes in post-operative outcomes should not be anticipated based on organizational participation in ACOs at present. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P68. Alterations in 90-day morbidity, mortality and readmission rates following spine surgery in Medicare accountable care organizations (2009–2014)

BACKGROUND CONTEXT The impact of accountable care organizations (ACOs) on health care quality and outcomes, including morbidity, mortality and readmissions, has not been substantially investigated, especially following spine surgery. PURPOSE To evaluate the impact of ACO formation on postoperative outcomes in the 90-day period following spine surgery STUDY DESIGN/SETTING Retrospective review of a 100% sample of Medicare claims (2009–2014). PATIENT SAMPLE Patients who underwent one of four lumbar spine surgical procedures in an ACO or nonACO. OUTCOME MEASURES The development of in-hospital mortality, complications or hospital readmission within 90-days of the surgical procedure. METHODS The primary outcome measures included post-surgical complications and readmissions at 90-days following surgery. In-hospital mortality and 30-day outcomes considered secondarily. The primary predictor variable consisted of ACO enrollment designation. Multivariable logistic regression analysis was utilized to adjust for confounders and determine the independent effect of ACO-enrollment on postsurgical outcomes. The multivariable model included a propensity score adjustment that accounted for factors associated with the preferential enrollment of patients in ACOs; namely socio-demographic characteristics, medical co-morbidities, hospital teaching status, bed size and location. RESULTS In all, there were 344,813 patients identified for inclusion in this analysis with 97% (n=332,890) treated in nonACOs and 3% (n=11,923) in an ACO. Although modest changes were apparent across both ACOs and nonACOs over the time-period studied, improvements were slightly more dramatic in nonACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012-2014, ACOs demonstrated an 18% increase in the likelihood of 90-day complications and a 14% elevation in the likelihood of 90-day readmissions when compared to nonACOs. There was no difference in hospital mortality between ACOs and nonACOs. CONCLUSIONS Our study of Medicare data from 2009 to 2014 failed to demonstrate superior reductions in postoperative morbidity, mortality and readmissions for beneficiaries treated in ACOs as compared to nonACOs. These results indicate that meaningful changes in postoperative outcomes should not be anticipated based on organizational participation in ACOs at present.

Control Versus Administrative Discretion in Negotiating Voluntary P4P Networks: The Case of Medicaid Accountable Care Organizations

Government sponsored pay-for-performance systems (P4P) have emerged in many contexts, including those featuring third-party federalism such as Medicaid. In this vein, voluntary networks called Medicaid accountable care organizations (ACOs) seek to achieve health care savings while boosting the quality of care. Drawing on evidence from four states, this study probes how collaborative governance strategies that downplay formal democratic controls and enhance administrative flexibility shaped the response to two implementation problems. We find that administrative flexibility, combined with signals of support from political principals, helped galvanize ACO formation but undermined efforts to tailor performance metrics to the needs of Medicaid enrollees.

Pediatric Accountable Care Organizations: Insight From Early Adopters.

Partly in response to incentives in the Affordable Care Act, there has been major growth in accountable care organizations (ACO) in both the private and public sectors. For several reasons, growth of ACOs in pediatric care has been more modest than for older populations. The American Academy of Pediatrics collaborated with Leavitt Partners, LLC, to carry out a study of pediatric ACOs, including a series of 5 case studies of diverse pediatric models, a scan of Medicaid ACOs, and a summit of leaders in pediatric ACO development. These collaborative activities identified several issues in ACO formation and sustainability in pediatric settings and outlined a number of opportunities for the pediatric community in areas of organization, model change, and market dynamics; payment, financing, and contracting; quality and value; and use of new technologies. These insights can guide future work in pediatric ACO development.

A New Healthcare Alliance: Consumer Engagement in the New Healthcare Economy

A New Healthcare Alliance: Consumer Engagement in the New Healthcare Economy

Trends in cancer care with the Affordable Care Act.

46 Background: Accountable Care Organizations (ACO), as proposed by the Affordable Care Act, will change the delivery of health care in the United States. ACO serve as a network of providers with primary care providers (PCP) set up as gate-keepers for referrals to specialists. Within the next several years, many trends will emerge and drive progress of change, requiring oncologist to take a lead role to adapt to the evolving landscape of health care. Methods: Literature search of internet-based and academic sources for oncology and the Affordable Care, with a focus on ACO formation. Results: Four main expected trends and strategies to adapt to changes were formulated. Trend 1: Changes in referral patterns towards oncologists. Referral will be based on outcome data and ACO membership. Strategy: Increase communication and education to PCP and other providers. Endorse multidisciplinary clinics, which have shown to improve guideline compliance, coordination, and communication. Trend 2: Formation of large scale oncology provider groups collaborating with PCP/ACO. Physicians will be able to provide around the clock care to patients with the goal of reducing hospital visits. Strategy: Establish oncology homes with goal of reducing inpatient and ED visits by providing telephone symptom management, daily questionnaires and opportunities for end of life discussions. Trend 3: Reimbursement reform to oncologists based on quality measures. ACO can bill fee for service basis and eligibility for bonus payments based on outcomes. Strategy:Adherence to evidence based guidelines chosen by evaluating efficacy, toxicity and cost have been proven to increase quality of patient care. Trend 4: Development to pathway driven medicine.ACO structure lends to a centralized governance committee responsible in choosing guidelines for treatment within an ACO. Strategy: Oncologists should provide a voice for the field and patients when different guidelines are chosen. Conclusions: In the context of the Affordable Care Act, oncology specialists are encouraged to participate in the new organization model to ensure best outcomes for both physicians and patients. Awareness of future trends and ways to contribute will be the first step in adapting to implementation of the Affordable Care Act.

Economics of Team-based Care in Controlling Blood Pressure: A Community Guide Systematic Review.

High blood pressure is an important risk factor for cardiovascular disease and stroke, the leading cause of death in the U.S., and a substantial national burden through lost productivity and medical care. A recent Community Guide systematic review found strong evidence of effectiveness of team-based care in improving blood pressure control. The objective of the present review is to determine from the economic literature whether team-based care for blood pressure control is cost beneficial or cost effective. Electronic databases of papers published January 1980-May 2012 were searched to find economic evaluations of team-based care interventions to improve blood pressure outcomes, yielding 31 studies for inclusion. In analyses conducted in 2012, intervention cost, healthcare cost averted, benefit-to-cost ratios, and cost effectiveness were abstracted from the studies. The quality of estimates for intervention and healthcare cost from each study were assessed using three elements: intervention focus on blood pressure control, incremental estimates in the intervention group relative to a control group, and inclusion of major cost-driving elements in estimates. Intervention cost per unit reduction in systolic blood pressure was converted to lifetime intervention cost per quality-adjusted life-year (QALY) saved using algorithms from published trials. Team-based care to improve blood pressure control is cost effective based on evidence that 26 of 28 estimates of $/QALY gained from ten studies were below a conservative threshold of $50,000. This finding is salient to recent U.S. healthcare reforms and coordinated patient-centered care through formation of Accountable Care Organizations.

CORR Insights(®): Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis.

H ip fractures are common, and treating patients with them is challenging because the patients often are older and medically complicated. New payment models initiated by the Patient Protection and Affordable Care Act (which encourages bundled payments and the formation of accountable care organizations) focuses on high-cost procedures [2, 7]. The systems used to provide care for patients with diverse diagnoses, including hip fracture, also vary; this would appear to offer a meaningful opportunity to improve both outcomes and costs [5]. With total treatment costs estimated at more than USD 12 billion, hip fracture care in the United States certainly represents a worthwhile topic for further evaluation. Swart and colleagues performed an economic analysis to determine the cost-effectiveness of a comanaged model of care for geriatric patients with hip fracture. The prevalent ‘‘traditional’’ model of hip fracture care in the United States is one in which the medical physician provides preoperative clearance with variable postoperative followup care for the patient with a hip fracture on the orthopaedic surgical service [5, 9]. A small percentage of hospitals have adopted an organized medical comanagement model to improve both patient reported outcomes and process measures for patients with a hip fracture. Although the topic has been reasonably well-studied, most reports to this point involve retrospective analyses that may be subject to various types of bias [1–4]. While some studies have looked at the economics of these models, and although these reports generally suggest the models are cost-effective, these analyses only represent the study of program performance at individual hospitals [2, 7, 8]. As such, the value of the comanaged hip fracture programs remains controversial. This CORR Insights is a commentary on the article ‘‘Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis’’ by Swart and colleagues available at: DOI: 10.1007/s11999-015-4494-4. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or the Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999-0154494-4. S. L. Kates MD (&) Department of Orthopaedics, University of Rochester, 601 Elmwood Ave., Box 665, Rochester, NY 14620, USA e-mail: stephen_kates@urmc.rochester.edu CORR Insights Published online: 1 September 2015 The Association of Bone and Joint Surgeons1 2015

Moving From Patient Care to Population Health: A New Competency for the Executive Nurse Leader

There are many social, political, and economic influences shaping healthcare delivery today that are expanding the scope of responsibility for the executive nurse leader. The focal point of change is the passing of the Patient Protection and Affordability Care Act (ACA), where there is a clear strategic shift to provide patient care in the right setting with the formation of Accountable Care Organizations (ACOs). Financial reimbursement strategies are being aligned to facilitate these changes. Executive nurse leaders are trying to navigate through these healthcare changes by developing cost-effective care delivery models, supporting the role of the professional and advanced practice nurse, and advocating for the patient. In healthcare reform, this translates to healthcare being delivered in community venues and the executive nurse leader being the advocate for the healthcare needs of the population in the community. There are many social, political, and economic influences shaping healthcare delivery today that are expanding the scope of responsibility for the executive nurse leader. The focal point of change is the passing of the Patient Protection and Affordability Care Act (ACA), where there is a clear strategic shift to provide patient care in the right setting with the formation of Accountable Care Organizations (ACOs). Financial reimbursement strategies are being aligned to facilitate these changes. Executive nurse leaders are trying to navigate through these healthcare changes by developing cost-effective care delivery models, supporting the role of the professional and advanced practice nurse, and advocating for the patient. In healthcare reform, this translates to healthcare being delivered in community venues and the executive nurse leader being the advocate for the healthcare needs of the population in the community.

Shared Savings Models for ACOs-Incentivizing Primary Care Physicians

Increasing numbers of health systems and physician practices are considering formation of accountable care organizations (ACOs) to promote clinical integration and to create a potential revenue stream through shared savings. In large part, the ACO triple aim of improved experience of care, better population health and decreased cost is to be achieved by empowering primary care physicians who will be the “quarterbacks” for preventive care and care coordination and will serve as the main source of attribution for patients to an ACO. As competing ACOs are established within overlapping markets, an ACO’s success will be determined in large part by its ability to attract and retain a vibrant and effective primary care workforce, currently experiencing a national shortage. Although the potential for financial incentives through shared savings is one way in which ACOs can attract primary care providers, there is currently no agreed upon taxonomy for categorizing or evaluating shared savings distribution methodologies and their impact on primary care providers and organizational success. Herein we propose a taxonomy of shared savings decision-making and discuss four models for shared savings distribution that recognize the increasing importance of primary care within ACOs.

Accountable Care Organization Formation Is Associated With Integrated Systems But Not High Medical Spending

Medicare's approximately 250 accountable care organizations (ACOs) care for a growing portion of all fee-for-service beneficiaries across the United States. We examined where ACOs have formed and what regional factors are predictive of ACO formation. Understanding these factors could help policy makers foster growth in areas with limited ACO development. We found wide variation in ACO formation, with large areas, such as the Northwest, essentially empty of ACOs, and others, such as the Northeast and Midwest, dense with the organizations. Key regional factors associated with ACO formation include a greater fraction of hospital risk sharing (capitation), larger integrated hospital systems, and primary care physicians practicing in large groups. Area income, Medicare per capita spending, Medicare Advantage enrollment rates, and physician density were not associated with ACO formation. Together, these results imply that underlying provider integration in a region may help drive the formation of ACOs.

Mental Health Care in the Accountable Care Organization

The Centers for Medicare and Medicaid Services (CMS) is promoting formation of accountable care organizations (ACOs). In these population-based models, CMS aligns a Medicare beneficiary population to an ACO with associated expenditure and quality targets, transitioning away from purely volume-based revenue of fee-for-service Medicare. Patients with mental illness are among high-cost Medicare beneficiaries, but this population has received little attention in ACO implementation. Although the ACO goals of providing chronic and preventive care in a coordinated, patient-centered manner are consistent with what some mental health providers have long advocated, the population-based orientation may be unfamiliar. In addressing the needs of high-cost, high-risk patients to meet quality and expenditure targets, an ACO should examine the quality of mental health care it provides as well as medical quality for patients with mental illness. In addition, federal agencies should invest to ensure understanding of the impact of population-based initiatives on patients with mental illness.

ACCOUNTABLE CARE ORGANIZATIONS: AN OPPORTUNITY FOR SYNERGY

With the reelection of President Obama, full enactment of the Patient Protection and Affordable Care Act is all but certain. Part of that legislation is the establishment of Accountable Care Organizations (ACOs). These large networks require a minimum of 5,000 Medicare patients, and will assume the total costs for their care in many cases. Over 140 ACOs are already established with over 130,000 physicians and 2.2 million beneficiaries.1 Much of the broad legislation governing ACOs has yet to be converted to specific regulations, which will vary between states. Because so much of this change has yet to be decided, and large systems will have to rapidly adapt, ACOs may become a sudden order of business for family medicine program directors. ACOs are a model of shared risk for costs and savings of a defined population. The more patients a network has, the more easily they can spread the costs of expensive care of the relatively few. In the ACO model, hospitals will shift from revenue centers to cost centers. ACOs have the potential to shift systems to embrace wellness rather than reactive illness care. In the future, we may get reports on how much our patients cost the system, rather than how much revenue we generated with our level-4 visits, inpatient billing, and procedures. Many systems will need to increase their primary care workforce as more patients have health coverage, and systems shift their emphasis to outpatient and preventive care. Insurance and payment reforms are the first 2 steps in health care reform. The third phase is delivery system reform.1 A need to educate those making ACO formation decisions will exist, regarding the value of family medicine residency programs to ACO networks. One of the fundamental objectives of the National Institute of Program Director Development (NIPDD) training is to understand the worth of your program; in the world of ACOs, our 2 principal strengths to promote will be cost-effective care and workforce generation. To truly provide population health care (rather than just those who come to see us) will require a fundamental shift in perspective for our systems, and most of us as well. Many of us will need to learn new skills; we will need to strongly advocate for resources such as case managers, chronic disease registries, and searchable electronic health records to provide high quality, cost-effective health care to a population. We also need to advocate for payment reforms that truly reflect our value to our systems. If we are not involved in the early formation and leadership of ACOs, we risk maintaining the status quo of huge payment disparities between procedure-based specialists and diverse primary care practices. These disparities discourage future medical students from entering primary care, which eventually will hurt all of our patients. Residency education about cost-effective care is optimized if the system can provide each resident with clinical quality and cost data on their own panel of patients, rather than having them subsumed under the faculty patient panel. We need to advocate for not just teaching about quality improvement, but doing it in our residency practices. Family medicine has a long and celebrated history of advocating for our patients. With the formation of ACOs, there is a moral imperative that we advocate for systems that reflect our values as a specialty. In the next few months, many decisions will be made that will affect both process values (the rules that govern decision-making processes such as transparency, accountability, and participation) and content values (clinical effectiveness, cost-effectiveness, justice/equality, and autonomy).2 We all need to ensure that family medicine has a voice at the table, and that we are proud of the end result. After all, the ACOs created in the next few months will be the ones our graduates will be practicing in for the foreseeable future.

Are you ready for health care teams?

As I look towards the future to identify opportunities for myself and other pharmacists, I see a health care system that embraces a team approach to patient care and gives pharmacists an important role on the team to ensure safe and effective medication use. As I look towards the future to identify opportunities for myself and other pharmacists, I see a health care system that embraces a team approach to patient care and gives pharmacists an important role on the team to ensure safe and effective medication use. As pharmacists, we encounter drug therapy problems every day, from medication nonadherence and the need for additional therapy to problems related to dosing and adverse drug reactions. We also are aware of the consequences of improper medication use for our patients, including hospitalizations, institutionalizations, and death. Our health care system is changing, and pharmacists have to be ready. Part of that change is the formation of accountable care organizations (ACOs), patient-centered medical homes, and payment systems that reward positive patient outcomes. is the time for pharmacists to step up, define their role as medication experts, and become sought out and integrated within the team. ■The time is coming when pharmacists will be integrated in health care teams.■Pharmacists must be proactive and engage in discussions about joining these teams. ■The time is coming when pharmacists will be integrated in health care teams.■Pharmacists must be proactive and engage in discussions about joining these teams. Recently, I came across an article about integrated pharmacists within a health care system that demonstrated positive results.1.Isetts B.J. Brummel A.R. de Oliveira D.R. Moen D.W. Managing drug-related morbidity and mortality in the patient-centered medical home.Med Care. 2012; 50: 997-1001Crossref PubMed Scopus (41) Google Scholar ■The health care system studied is Fairview Health Services of Minneapolis-St. Paul.■A team approach is used in the care of patients, all team members have responsibilities in comprehensive medication therapy management (MTM), and patients are engaged participants within their own care.■Pharmacists within the system provide comprehensive MTM consultations, home and telephonic visits, and joint visits with other health care team members. They also engage in collaborative practice agreements for patients with chronic conditions.■The authors looked at the results over a 15-month period, comparing 4 Fairview clinics to 38 other clinics within the state.•Spending growth was 11% less in the Fairview clinics.•Median per member per month health care costs were significantly lower in the Fairview clinics.•More of Fairview's patients with diabetes (40%) achieved all five performance benchmark treatment goals than did patients at the other statewide clinics (17.5%).•More than 4,000 drug therapy problems were resolved in the Fairview clinics. Throughout my career, I have always supported the notion of the health care team, the role of pharmacists as medication managers, and a fair reimbursement system that rewards the efforts of all team members. Although movement towards these goals has been slow in past years, I am beginning to think that the time is coming when pharmacists will be more integrated within the team. The difficulty for all of us is trying to determine what the final system will look like, how pharmacists will be integrated within the system (i.e., employed or contracted), and how pharmacists and other team members will be paid. I know that health care systems within my community are part of a statewide effort to develop and implement ACOs, but pharmacy has not had a strong presence yet in this process. This is not the time for pharmacists to sit back and wait to see what happens. This is the time for us to be proactive and to engage in the discussions that local health systems are having regarding health care reform and the formation of ACOs. Pharmacists should prepare themselves to provide patient care services important to ACOs, including comprehensive medication management, medication adherence programs, medication reconciliation services, management and monitoring of patients on high-risk medications, and identification and resolution of drug therapy problems. I believe that pharmacists will be sought out for their clinical expertise relating to drug therapy within America's new health care system. It will not be enough to make sure that the right drug is in the right bottle with the right directions; health professionals will also have to ensure that patients achieve their therapeutic goals. This requires a new set of skills, including critical thinking, problem solving, and interpersonal communication. Pharmacists will need to become interventionists by recognizing drug therapy problems, communicating therapeutic recommendations, and regularly documenting their activities. This can be an intimidating frightening time for us more seasoned pharmacists, but I also recognize the wonderful opportunity for our profession. The time has come for our profession to step it up another notch. Are you ready? Column coordinator [email protected] Co-owner and Director of Clinical Services, Towncrest and Medical Plaza Pharmacies Iowa City

A Framework For Evaluating The Formation, Implementation, And Performance Of Accountable Care Organizations

The implementation of accountable care organizations (ACOs), a new health care payment and delivery model designed to improve care and lower costs, is proceeding rapidly. We build on our experience tracking early ACOs to identify the major factors-such as contract characteristics; structure, capabilities, and activities; and local context-that would be likely to influence ACO formation, implementation, and performance. We then propose how an ACO evaluation program could be structured to guide policy makers and payers in improving the design of ACO contracts, while providing insights for providers on approaches to care transformation that are most likely to be successful in different contexts. We also propose key activities to support evaluation of ACOs in the near term, including tracking their formation, developing a set of performance measures across all ACOs and payers, aggregating those performance data, conducting qualitative and quantitative research, and coordinating different evaluation activities.