Development Of Accountable Care Organizations Research Articles

Accountable care organization reform: past challenges and future opportunities for public health

ObjectivesThis study aimed to analyze the regulatory landscape that governs accountable care organizations (ACOs) in the United States and the effects on organizational participation. Study designThis was a descriptive study of existing and prior regulations that govern ACOs in the United States. In addition, we analyze data on ACO participation over time. MethodsWe used content analysis methods to the regulatory framework governing ACOs. Authors read and analyzed all regulations since 2012. ResultsACO participation has been undermined by a shifting regulatory landscape. Under the Trump administration, ACOs have had to take on additional risk earlier and that has contributed to the lowest number of participating organizations in the program's history. ConclusionsThe Biden administration has the opportunity to remake regulations governing ACO development and support.

Utilization of High-Cost Interventions for Targeted Clinical Conditions During the Early Stages of ACO Development in a Commercially Insured Population.

This study compared utilization patterns of high-cost services and medications for patients receiving care from Accountable Care Organization (ACO)-participating physicians and those receiving care from non-ACO physicians during the initial phases of ACO development in a commercially insured environment. Patients ≥18 years (≥40 years for chronic obstructive pulmonary disease [COPD]) with prevalent rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis, type 2 diabetes, COPD, or chronic low back pain between January 1, 2012, and August 31, 2014 were identified in the HealthCore Integrated Research DatabaseSM. Patients were assigned to the ACO cohort if their primary treating physician was contracted to the health plan through an ACO agreement. Each clinical condition was stratified for severity of illness. Cohort utilization patterns were compared for the 12-month period following the index encounter. The primary outcome measures show that there was no statistically significant utilization difference between the ACO and non-ACO cohorts for 90% of the 82 comparisons made. It is expected that some measures will achieve significant difference simply because of having this many comparisons, but no clear pattern was identified. This study did not observe statistically significant differences in utilization of high-cost services and medications between ACO and non-ACO cohorts with limited experience in the ACO model. Future analyses with longer study durations, at later stages of ACO development, tracking a more granular level of physician organizational structure, and with designs that integrate clinical and administrative data are essential to better understand the impact of payment innovation strategies using an ACO structure.

Trust, Money, and Power: Life Cycle Dynamics in Alliances Between Management Partners and Accountable Care Organizations.

Accountable care organizations (ACOs) are a prominent payment and delivery model. Though ACOs are often described as groups of health care providers, nearly 4 in 10 ACOs partner with a management company for services such as financial investment, contracting, data analytics, and care management, according to recent research. However, we know little about how and why these partnerships form. This article aims to understand the reasons providers seek partners, the nature of these relationships, and factors critical to the success or failure of these alliances. We used qualitative data collected longitudinally from 2012 to 2017 at 2 ACOs to understand relationships between management partners and ACO providers. The data include 115 semistructured interviews and observational data from 7 site visits. Two coders applied 48 codes to the data. We reviewed coded data for emergent themes in the context of alliance life cycle theory. Qualitative data revealed that management partners brought specific skills and services and also gave providers confidence in pursuing an ACO. Over time, tension between providers and management partners arose around decision-making authority, distribution of shared savings, and conflicting goals and values. We observed 2 outcomes of partnerships: cemented partnerships and dissolution. Key factors distinguishing alliance outcome in these 2 cases include degree of trust between organizations in the alliance; approach to conflict resolution; distribution of power in the alliance; skills and confidence acquired by the ACO over the life of the alliance; continuity of management partner delivery on promised resources; and proportion of savings going to the management partner. The diverging paths for ACOs with management partners suggest 2 different roles that management partners may play in ACO development. In some cases, management partners may serve as trainers, with the partnership dissolving once the ACO gains skills and confidence to work alone. In other cases, the management partner is a central driver of the ACO and unlikely to break off.

Moving Organizational Culture from Volume to Value: A Qualitative Analysis of Private Sector Accountable Care Organization Development.

The concept of shifting from volume (i.e., billing for as many patients and services as possible) to value (i.e., reducing costs while improving quality) has been a key underpinning of the development of accountable care organizations (ACOs), yet the cultural change necessary to make this shift has been previously unexplored. Primary data collected through site visits to four private sector ACOs. Cross-sectional, semi-structured interview study with analysis done at the ACO level to learn about ACO development. One hundred and forty-eight interviews recorded and transcribed verbatim followed by rigorous qualitative analysis using a grounded theory approach. The importance of shifting organizational culture from volume to value was emphasized across sites and interviewees, particularly when defining an ACO; describing the shift in organizational focus to value; and discussing how to create value by emphasizing quality over volume. Value was viewed as more than cost-benefit, but rather encapsulated a paradigmatic cultural change in the way care is provided. We found that moving from volume to value is central to the culture change required of an ACO. Our findings can inform future efforts that aim to create a more effective value-based health care system.

A Direct Experience in a New Accountable Care Organization: Results, Challenges, and the Role of the Neurosurgeon.

The passage of the Affordable Care Act saw the creation of Accountable Care Organizations (ACOs), a new approach to healthcare delivery moving from fee-for-service toward population health. This paper presents a case study of the Memorial Hermann ACO (MHACO), launched in response to the Medicare Shared Savings Program, with goals to align physician and hospital incentives, practice evidence-based medicine, develop care coordination, and increase efficiency. Building blocks included an affiliated primary care network, a clinical integration program (involving shared electronic medical record platforms and quality data reporting), and significant investments in information technology. Presented is the approach taken to form MHACO; the management structure, technology developed, and a 2-year experience. Incorporated in July 2012, the MHACO involved 22 000 Medicare patients. In 2015, Centers for Medicare and Medicaid Services released data showing a composite quality score between 80 and 85 (from a maximum 100) and nearly $53 million in total savings (or 11% of expected expenditure), making MHACO one of the most successful nationally.1 In fewer than 5 years, almost 500 ACOs have developed, and by some estimates, a quarter of Medicare patients are currently enrolled in an ACO. Although ACOs to date have focused on primary care, the future will increasingly involve specialists. At Memorial Hermann, neurosurgeons took an early role in forming collaborative partnerships with the hospital, and started programs that served as precursors to the ACO model. This paper ends with an overview of ACO development, likely changes going forward, and a discussion of the role of specialists in general, and of neurosurgeons in particular.

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.

More Than Money: Motivating Physician Behavior Change in Accountable Care Organizations.

Policy Points: For accountable care organizations (ACOs) to be successful they need to change the behavior of their physicians. To stimulate this change, a broad range of motivators are being used, including ways to see a greater impact on patients (social purpose) and opportunities to be a more effective physician (mastery), in addition to personal financial incentives. From our analysis of case studies, it does not appear that the full range of motivators is being deployed by ACOs, which suggests an opportunity to develop more sophisticated and wider‐ranging portfolios of motivators for greater impact. ContextThere are approximately 800 accountable care organizations (ACOs) in the United States. In order to achieve the ACO goals of reduced cost, improved outcomes of care, and better population health, it is critical to change how physicians within ACOs deliver care. While knowledge of ACO development and evolution is growing, relatively little is known about the motivational drivers that are being used to effect change among participating physicians.MethodsWe synthesized 9 well‐established and empirically tested theories of motivation into an overarching framework of 6 motivator domains. This framework was then used to explore the types of motivators that leaders use to stimulate change within 4 case study ACOs. We explored the organizational characteristics, strategies, and motivators for changing physicians’ behaviors through in‐depth interviews and document review.FindingsThe case study ACOs more strongly emphasized nonfinancial motivators for changing physician behavior than financial incentives. These motivators included mastery and social purpose, which were used frequently across all case study sites. Overall, the ACO case studies illustrated variability across all motivational domains. While there was evidence of changing motivators as a result of the ACO, the case study ACOs found it difficult to comprehensively change the use of motivators, in part due to dispersed managerial attention and the complexity and diversity of programs and contracts that fragmented efforts to improve.ConclusionsMotivating behavior change within ACOs goes beyond financial incentives. ACOs are using a broad range of motivators, including creating ways to make a greater impact on patients and opportunities to be a more effective physician. Overall, it does not appear that ACOs are deploying the full range of available motivators. This suggests an opportunity to develop more sophisticated and wider‐ranging portfolios of motivators to drive behavior change.

Evaluating the Impact of an Accountable Care Organization on Population Health: The Quasi-Experimental Design of the German Gesundes Kinzigtal.

A central goal of accountable care organizations (ACOs) is to improve the health of their accountable population. No evidence currently links ACO development to improved population health. A major challenge to establishing the evidence base for the impact of ACOs on population health is the absence of a theoretically grounded, robust, operationally feasible, and meaningful research design. The authors present an evaluation study design, provide an empirical example, and discuss considerations for generating the evidence base for ACO implementation. A quasi-experimental study design using propensity score matching in combination with small-scale exact matching is implemented. Outcome indicators based on claims data were constructed and analyzed. Population health is measured by using a range of mortality indicators: mortality ratio, age at time of death, years of potential life lost/gained, and survival time. The application is assessed using longitudinal data from Gesundes Kinzigtal, one of the leading population-based ACOs in Germany. The proposed matching approach resulted in a balanced control of observable differences between the intervention (ACO) and control groups. The mortality indicators used indicate positive results. For example, 635.6 fewer years of potential life lost (2005.8 vs. 2641.4; t-test: sig. P < 0.05*) in the ACO intervention group (n = 5411) attributable to the ACO, also after controlling for a potential (indirect) immortal time bias by excluding the first half year after enrollment from the outcome measurement. This empirical example of the impact of a German ACO on population health can be extended to the evaluation of ACOs and other integrated delivery models of care.

Financial Performance of Rural Medicare ACOs.

The Centers for Medicare & Medicaid Services (CMS) has facilitated the development of Medicare accountable care organizations (ACOs), mostly through the Medicare Shared Savings Program (MSSP). To inform the operation of the Center for Medicare & Medicaid Innovation's (CMMI) ACO programs, we assess the financial performance of rural ACOs based on different levels of rural presence. We used the 2014 performance data for Medicare ACOs to examine the financial performance of rural ACOs with different levels of rural presence: exclusively rural, mostly rural, and mixed rural/metropolitan. Of the ACOs reporting performance data, we identified 97 ACOs with a measurable rural presence. We found that successful rural ACO financial performance is associated with the ACO's organizational type (eg, physician-based) and that 8 of the 11 rural ACOs participating in the Advanced Payment Program (APP) garnered savings for Medicare. Unlike previous work, we did not find an association between ACO size or experience and rural ACO financial performance. Our findings suggest that rural ACO financial success is likely associated with factors unique to rural environments. Given the emphasis CMS has placed on rural ACO development, further research to identify these factors is warranted.

Accountable Care Organizations and Transaction Cost Economics.

Using a Transaction Cost Economics (TCE) approach, this paper explores which organizational forms Accountable Care Organizations (ACOs) may take. A critical question about form is the amount of vertical integration that an ACO may have, a topic central to TCE. We posit that contextual factors outside and inside an ACO will produce variable transaction costs (the non-production costs of care) such that the decision to integrate vertically will derive from a comparison of these external versus internal costs, assuming reasonably rational management abilities. External costs include those arising from environmental uncertainty and complexity, small numbers bargaining, asset specificity, frequency of exchanges, and information "impactedness." Internal costs include those arising from human resource activities including hiring and staffing, training, evaluating (i.e., disciplining, appraising, or promoting), and otherwise administering programs. At the extreme, these different costs may produce either total vertical integration or little to no vertical integration with most ACOs falling in between. This essay demonstrates how TCE can be applied to the ACO organization form issue, explains TCE, considers ACO activity from the TCE perspective, and reflects on research directions that may inform TCE and facilitate ACO development.

Participation of Rural Health Care Providers in Accountable Care Organizations: Early Indications.

Recently, some rural health clinics (RHCs) throughout the country have chosen to join groups of health care providers in accountable care organizations (ACOs). Examined are characteristics of Southeastern RHCs and the counties they serve; it is shown how those characteristics compare with other regions across the country and suggested what role those differences might play in an RHC's decision to participate in an ACO. Rural health clinic-related data were collected and summarized for 2 time periods: 2007 and 2011: for 2007, data from RHCs throughout the United States; for 2011, summarized demographic data related to region 4 RHCs specifically. Several characteristics about region 4 RHCs indicate that they may be slow to participate in ACOs. However, other characteristics, including their perception that ACOs may improve the quality of care and health outcomes of their patients and communities, may facilitate the process of RHCs joining ACOs, should they choose to do so. Addressing the health care needs and health care quality of rural populations must be part of the design, development, and performance monitoring of ACOs of the future.

Accountable Care Organizations: The National Landscape

There are now more than seven hundred accountable care organizations (ACOs) in the United States. This article describes some of their most salient characteristics including the number and types of contracts involved, organizational structures, the scope of services offered, care management capabilities, and the development of a three-category taxonomy that can be used to target technical assistance efforts and to examine performance. The current evidence on the performance of ACOs is reviewed. Since California has the largest number of ACOs (N=67) and a history of providing care under risk-bearing contracts, some additional assessments of quality and patient experience are made between California ACOs and non-ACO provider organizations. Six key issues likely to affect future ACO growth and development are discussed, and some potential "diagnostic" indicators for assessing the likelihood of potential antitrust violations are presented.

Impact of ACA on the Dinner-for-Three Dynamic

The Patient Protection and Affordable Care Act (ACA) aims to expand coverage to the previously uninsured, improve the quality of coverage, and help eliminate inefficiencies in the health care market. We evaluated the implications of ACA on the drug industry by examining the impact on the “Dinner-for-Three” dynamic in our health care system. We can think of our system as an odd dinner party in which one person pays (the insurer), one orders the meal (the physician), and yet another eats the meal (the patient). This dynamic requires us to examine each stakeholder and how they interact with one another to assess the impact of the ACA. Of the 6.7 million initial exchange enrollees, ~3.8 million subjects were previously uninsured. A higher percentage of these enrollees are using their pharmacy benefit, and they are disproportionately filling prescriptions for specialty drugs relative to those covered in employer-sponsored plans. Formulary designs in exchange plans are passing on higher cost-sharing for prescription drugs to the patient. ACA has also resulted in the development of accountable care organizations (ACOs); these organizations may play a role going forward in the management of drug spending and the development of formularies and protocols that impact drug prescribing. Payers are tightening control over drug spending and are finding physicians and physician groups increasingly less reluctant allies in doing so. Patients are faced by more complexity than ever in the health care system and are expected to take a more active role in responsibly managing the cost of their care. It is increasingly critical that drug manufacturers develop robust value propositions and communicate that value to all stakeholders. They should re-evaluate trial investment decisions and consider changes in price setting, rebates (how much and to whom), copay programs, and physician and patient support programs in light of changing market needs.

Survey of twelve children’s hospital-based accountable care organizations

Accountable care organizations (ACOs) are a primary focus of value-based healthcare reform strategies, however research is lacking on pediatric-specific ACO development. To present the current landscape of children’s hospital-based pediatric ACOs, researchers conducted semi-structured telephone interviews with executive-level staff from twelve ACOs from November 2013 to February 2014. Interview questions spanned five topics: (1) pathway/strategy; (2) organizational structure; (3) shared savings; (4) provider network; (5) data and quality. Three qualitative frameworks were applied to assess the degree of similarity among pediatric ACO models and between these and promulgated adult ACO components: (1) operational diagrams; (2) spectrums of characteristics; (3) financial and organizational categorization. Organizational structures consisted of five Physician-Hospital Organizations, two System-Based Pediatric Contracts, three Provider-Sponsored Managed Care Organizations, and two Hospital Medical Staff Organizations. Oversight models developed for the ACOs included six separate boards, two board subcommittees, and one dispersed governance. Financial contracts between payers and participants included four shared savings only, one risk corridor, and seven full capitation. Eight participants had provider incentive programs primarily for cost reductions. Nine participants used National Committee for Quality Assurance (NCQA)’s Healthcare Effectiveness Data Information Set (HEDIS) metrics, emphasized utilization management, and invested in separate care coordination resources. Overall, marked variation in pediatric ACO models is developing nationally, and cost savings goals exceed the importance of quality improvement. National pediatric collaboration and state facilitation for ACO quality measures is crucial to improving health outcomes in the pediatric ACO.

Primary Care Clinics and Accountable Care Organizations

Background:The Accountable Care Organization (ACO) is one of the new models of health care delivery in the United States. To date, little is known about the characteristics of health care organizations that have joined ACOs. We report on the findings of a survey of primary care clinics, the objective of which was to investigate the opinions of clinic management about participation in ACOs and the characteristics of clinic organizational structure that may contribute to joining ACOs or be willing to do so.Methods:A 27-item survey questionnaire was developed and distributed by mail in 3 annual waves to all Rural Health Clinics (RHCs) in 9 states. Two dependent variables—participation in ACOs and willingness to join ACOs—were created and analyzed using a generalized estimating equation approach.Results:A total of 257 RHCs responded to the survey. A small percentage (5.2%) of the respondent clinics reported that they were participating in ACOs. Rural Health Clinics in isolated areas were 78% less likely to be in ACOs (odds ratio = 0.22, P = .059). Nonprofit RHCs indicated a higher willingness to join an ACO than for-profit RHCs (B = 1.271, P = .054). There is a positive relationship between RHC size and willingness to join an ACO (B = 0.402, P = .010).Conclusion:At this early stage of ACO development, many RHC personnel are unfamiliar with the ACO model. Rural providers’ limited technological and human resources, and the lack of ACO development in rural areas, may delay or prevent their participation in ACOs.

Challenges facing the United States of America in implementing universal coverage.

In 2010, immediately before the United States of America (USA) implemented key features of the Affordable Care Act (ACA), 18% of its residents younger than 65 years lacked health insurance. In the USA, gaps in health coverage and unhealthy lifestyles contribute to outcomes that often compare unfavourably with those observed in other high-income countries. By March 2014, the ACA had substantially changed health coverage in the USA but most of its main features – health insurance exchanges, Medicaid expansion, development of accountable care organizations and further oversight of insurance companies – remain works in progress. The ACA did not introduce the stringent spending controls found in many European health systems. It also explicitly prohibits the creation of institutes – for the assessment of the cost–effectiveness of pharmaceuticals, health services and technologies – comparable to the National Institute for Health and Care Excellence in the United Kingdom of Great Britain and Northern Ireland, the Haute Autorité de Santé in France or the Pharmaceutical Benefits Advisory Committee in Australia. The ACA was – and remains – weakened by a lack of cross-party political consensus. The ACA’s performance and its resulting acceptability to the general public will be critical to the Act’s future.

A taxonomy of accountable care organizations for policy and practice.

To develop an exploratory taxonomy of Accountable Care Organizations (ACOs) to describe and understand early ACO development and to provide a basis for technical assistance and future evaluation of performance. Data from the National Survey of Accountable Care Organizations, fielded between October 2012 and May 2013, of 173 Medicare, Medicaid, and commercial payer ACOs. Drawing on resource dependence and institutional theory, we develop measures of eight attributes of ACOs such as size, scope of services offered, and the use of performance accountability mechanisms. Data are analyzed using a two-step cluster analysis approach that accounts for both continuous and categorical data. We identified a reliable and internally valid three-cluster solution: larger, integrated systems that offer a broad scope of services and frequently include one or more postacute facilities; smaller, physician-led practices, centered in primary care, and that possess a relatively high degree of physician performance management; and moderately sized, joint hospital-physician and coalition-led groups that offer a moderately broad scope of services with some involvement of postacute facilities. ACOs can be characterized into three distinct clusters. The taxonomy provides a framework for assessing performance, for targeting technical assistance, and for diagnosing potential antitrust violations.

Quality of care and racial disparities in medicare among potential ACOs.

The Medicare Accountable Care Organization (ACO) programs encourage integration of providers into large groups and reward provider groups for improving quality, but not explicitly for reducing health care disparities. Larger group size and better overall quality may or may not be associated with smaller disparities. To examine differences in patient characteristics between provider groups sufficiently large to participate in ACO programs and smaller groups; the association between group size and racial disparities in quality; and the association between quality and disparities among larger groups. Using 2009 Medicare claims for 3.1 million beneficiaries with cardiovascular disease or diabetes and linked data on provider groups, we compared racial differences in quality by provider group size, adjusting for patient characteristics. Among larger groups, we used multilevel models to estimate correlations between group performance on quality measures for white beneficiaries and black-white disparities within groups. Four process measures of quality, hospitalization for ambulatory care-sensitive conditions (ACSCs) related to cardiovascular disease or diabetes, and hospitalization for any ACSC. Beneficiaries served by larger groups were more likely to be white and live in areas with less poverty and more education. Larger group size was associated with smaller disparities in low-density lipoprotein (LDL) cholesterol testing and retinal exams, but not in other process measures or hospitalization for ACSCs. Among larger groups, better quality for white beneficiaries in one measure (hospitalization for ACSCs related to cardiovascular disease or diabetes) was correlated with smaller racial disparities (r = 0.28; P = 0.02), but quality was not correlated with disparities in other measures. Larger provider group size and better performance on quality measures were not consistently associated with smaller racial disparities in care for Medicare beneficiaries with cardiovascular disease or diabetes. ACO incentives rewarding better quality for minority groups and payment arrangements supporting ACO development in disadvantaged communities may be required for ACOs to promote greater equity in care.

A Predictive Diagnostic Imaging Calculator as a Clinical Decision Support Tool

Table 1. Patient encounters versus charge counts from 2009 through 2013 annualized DESCRIPTION OF THE PROBLEM Augusta Health (AH), a 255-bed community hospital located in Virginia’s Shenandoah Valley, will transition into an accountable care organization (ACO) at the beginning of 2014. A quality improvement group, made up of primarily radiologists, was asked to monitor the hospital’s own imaging utilization.One ITmethodwas to develop a predictive imaging calculator on the basis of patient, physician, and department averages. AH has monitored its institutional imaging transactions since 2009. By closely monitoring imaging trends on the basis of patient demographics, physician, and department, AH expects to be able to create predictive calculators for orchestrating imaging utilization in the future, physician decision making, bundling payment models, and so on, in preparation for the ACO development. By looking at the hospital as a whole, alongside individual department, physician, and patient standards, radiologists will be able to work with physicians and specific departments to augment the costeffectiveness of the ACO in a nontraditional manner [1]. Electronic screening tools have proven successful in the prediction of hospital-induced infection and readmission rates and may be similarly useful in predicting the need for imaging utilization [2,3].

The Ephemeral Accountable Care Organization—An Unintended Consequence of the Medicare Shared Savings Program

A fundamental element of health care payment reform under the Affordable Care Act is the development of Accountable Care Organizations (ACOs). The ACO model employs shared-risk contracts to better align the interests of health care providers and payers with the intent of driving efficiency and quality in care. The Medicare Shared Savings Program is the most popular of the Medicare ACO programs, with over 200 health systems across the nation participating at this time. However, a pitfall in the way that the Medicare Shared Savings Program is structured, specifically the benchmarking and rebasing method, could make it difficult for even top-performing ACOs to achieve sustained success, thereby threatening the long-term viability of the program. In this paper, we present this pitfall to the radiology community as well as potential solutions that can be considered by CMS moving forward.