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Can ACOs succeed? 6 key questions

It’s hard to build consensus on what “quality” means and to identify metrics that fairly and accurately measure it

If you ask healthcare leaders what they think about Accountable Care Organizations (ACOs), you won’t be short on answers. In a time when healthcare spending continues to rise, people are desperate to see something succeed in improving the quality and cost of care. ACOs are captivating because they contain elements of care delivery that most experts agree should improve healthcare: financial risk sharing, electronic health records, quality benchmarks, patient engagement, and care coordination, to name a few.

But the question remains: can ACOs pull it off? Emerging research from the Dartmouth Institute for Health Policy and Clinical Practice and the UC Berkeley School of Public Health will help uncover which ACOs are succeeding and why. To help put these early findings into perspective, the Kaiser Permanente Institute for Health Policy and The Commonwealth Fund asked a group of health care leaders their burning questions about ACOs. From their responses, six themes emerged.

1. What do ACOs look like today?

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Although ACOs share a common goal of improving care, a great deal of variation exists in how they’re organized. It will help to know the characteristics of different ACOs, such as how they differ insize, governance and organizational structure. “I think there’s more a continuum than sort of a one-size-fits-all,” said Aparna Higgins, Senior Vice President, America’s Health Insurance Plans. “Trying to understand that continuum and what are the different features in that continuum, I think would be important.”

2. What factors will lead to ACO success?

ACOs need information on best practices for achieving improved quality and efficiency. Researchers want to hear perspectives on factors that will help shape future studies. “Right now it's not what's working, it's what do you think is going to work that's most interesting,” said Carrie Colla, assistant professor, Dartmouth Institute for Health Policy and Clinical Practice.

3. Are current financial incentives strong enough to change provider behavior?

Rewarding high-value – versus high-volume – care is one of the strongest policy levers to transform the delivery system. But many participants questioned whether financial incentives for ACOs have enough muscle to change the practice of medicine. “How much profit is enough profit?” asked Sam Lin, medical affairs consultant, American Medical Group Association. Said Dana Safran, senior vice president, Blue Cross Blue Shield of Massachusetts, “physician organizations can reinvent themselves quite nimbly in some cases when the incentives are around total cost of care and quality. “It's harder for a hospital to reinvent its business model.”

4. Will ACOs integrate with other types of caregivers?

Healthcare systems are looking to work with other types of caregivers – such as social workers, behavioral health specialists and long-term care providers –to address the full range of patients’ needs. But many ACOs do not share financial risk with other caregivers, and barriers in exchanging patient health information make it difficult to coordinate. “I would like to know how ACOs are going to coordinate with infrastructure that is already in place like patient-centered medical homes, community-based health teams, behavioral health services, [and] long-term services and supports,” said Mary Takach, Senior Program Director, National Academy for State Health Policy.

5. Will ACOs successfully engage their patients?

ACOs must make patient engagement a priority. But will they fare any better than other health care organizations in making care patient-centered? “ACOs tout that they are the vanguard for [patient-centered care],” said Sam Lin, medical affairs consultant, American Medical Group Association. “That's a tall order, given we are very protective of our autonomy as providers and payers… [I]s this cultural shift  going to occur and actually become ingrained?”

How people are “enrolled” in ACOs may inhibit improving patient engagement. Patients may not know they are part of an ACO, and in many cases, there’s nothing stopping them from seeing outside providers. “[C]an ACOs create financial incentives, adjustment to premiums, and other sorts of mechanisms to get active patient buy-in into these arrangements?” asked Ross White, project manager, Brookings Institution.

6. What metrics will effectively measure quality?

Measuring the quality of healthcare is a thorny issue. It’s hard to build consensus on what “quality” means and to identify metrics that fairly and accurately measure it. The Centers for Medicare and Medicaid Services evaluates ACOs on 32 measures that are established in the field. Some wondered if future metrics would be tied to higher goals, such as improving population health.

In summary, there was energy and enthusiasm about the ACO movement. Whether ACOs prove to be a huge success, a huge failure, or somewhere in between, we will undoubtedly learn a lot about what it will take to transform health care in the United States.

Reprinted with permission of the Altarum Institute.