If you ask healthcare leaders what they think about Accountable Care Organizations (ACOs), you won’t be short on answers. From high hopes to cautious optimism to worry and skepticism, the full gamut of feelings is there.
The amount of buzz is not surprising: 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 particularly 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.
And yet the question remains: can ACOs pull it off? Because the ACO movement is in its infancy, it’s hard to predict whether or not these organizations will be successful. However, emerging research will help us understand which ACOs are succeeding and why. With support from The Commonwealth Fund, the Dartmouth Institute for Health Policy and Clinical Practice and the University of California at Berkeley School of Public Health are fielding a survey of ACOs, identifying which characteristics lead to success or failure.
In November 2013, the Kaiser Permanente Institute for Health Policy and The Commonwealth Fund brought together a diverse group of healthcare leaders to discuss early findings of this research. A goal of this meeting was to hear directly what these leaders want to know about ACOs as the movement plays out. We asked them: what are your burning questions about ACOs? From their responses, six major themes emerged.
What do ACOs look like today?
There’s a saying in the health policy community that, “if you’ve seen one ACO, you’ve seen one ACO.” Although ACOs share a common goal of improving care, a great deal of variation exists in how they’re organized. Many of the meeting participants wanted to know what the characteristics of different ACOs are and how they differ in terms of size, 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.”
What factors will lead to ACO success?
ACOs need information on best practices for achieving improved quality and better efficiency. Beyond wanting to know about the organizational characteristics of ACOs, participants were interested to know more generally what factors are likely to lead to their success. Researchers wanted to hear perspectives on what these factors are, which will help shape future studies. “We all want to know what works, so 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.
Hear from the health care leaders themselves in the video below:
Are current financial incentives strong enough to change provider behavior?
Aligning financial incentives towards high-value care – versus high-volume care – is one of the strongest policy levers to transform the delivery system. But many participants questioned whether the current financial incentives for ACOs would have enough muscle to change the culture and practice of medicine. “What I want to know is: How much profit is enough profit?” asked Sam Lin, medical affairs consultant, American Medical Group Association. Dana Safran, senior vice president, Blue Cross Blue Shield of Massachusetts, was optimistic that physician organizations could restructure themselves, but wondered whether hospital systems could do the same. “[P]hysician 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.”
Others wondered whether shared savings would trickle down to doctors in a way that would induce behavior change. “There’s two levels that we’re concerned about,” said Dave Krueger, Executive Director, Bellin-Thedacare Healthcare Partners. “How are the [incentives] organized for the organization itself, and then another deeper question is how are incentives structured for the end providers?”
Will ACOs integrate with other types of providers, such as social services, behavioral health and long-term care workers?
Personal behavior and social and environmental factors – rather than medical care – are known to have the greatest impact on health outcomes. Health care systems are thus looking to integrate other types of caregivers – such as social workers, behavioral health specialists and long-term care providers – into care teams to address the full range of patients’ needs. For ACOs, this might be easier said than done. Most ACOs are not structured to share financial risk with other types of caregivers, and barriers in exchanging patient health information make it difficult to coordinate and communicate. “How do we shift the emphasis from the ‘O’ in accountable care organizations, which a lot of the emphasis has been on, to the ‘AC’, the accountable care at a community level,” asked Stu Guterman, vice president, The Commonwealth Fund. “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.
Will ACOs successfully engage their patients?
Given that health outcomes rest so much in patients’ hands, ACOs must make patient engagement a priority if they want to hit quality benchmarks. But many participants were skeptical that ACOs will fare any better than other health care organizations in changing the culture of medicine to be more patient-centered. “ACOs tout that they are the vanguard for the advent of true patient-centered care,” said Sam Lin, medical affairs consultant, American Medical Group Association. “That is providing patients with greater access, relevant knowledge, active participation, and coordinated care. Now that’s a tall order, given we are very protective of our autonomy as providers and payers… So this cultural shift, is this also going to occur and actually become ingrained?”
How people are “enrolled” in Medicare ACOs also may inhibit improving patient engagement. By and large, patients are unaware that they are part of an ACO, and in most cases, there’s nothing stopping them from seeing providers outside the ACO. Ross White, project manager, Brookings Institution, elaborated on this, saying “most people are focusing on getting their providers and the payers accountable, but obviously the patients have a very key role in this. And so to what extent can ACOs actually create financial incentives, adjustment to premiums, and other sorts of mechanisms to actually get active patient buy-in into these arrangements?”
What metrics will effectively measure quality?
Measuring the quality of healthcare has long been a thorny issue. It’s hard to build consensus on what “quality” means and perhaps even harder to identify metrics that fairly and accurately measure it. Today, the Centers for Medicare and Medicaid Services is evaluating ACOs on 32 measures that are established in the field and which cover aspects of care such as patient experience, safety, care coordination, preventive care and chronic disease management. Many roundtable participants were eager to find out what other measures will be added, and wondered if they would be tied to higher goals, such as improving community and population health. “The big challenge…is not the desire [of] providers to improve quality of care,” said Tricia McGinnis, director of delivery system reform, Center for Healthcare Strategies. “A lot of it has to do with just the paucity of effective measures … that effectively capture whether quality is improving on a significant level, moving beyond the traditional HEDIS diabetes, chronic care measures, to measures that really, again, are targeted to more highly vulnerable populations and whether the care for those populations is truly improving.”
Although there were many more questions than answers at the meeting, it was heartening to see the energy and enthusiasm people have towards the ACO movement. Whether ACOs prove to be a huge success, a huge failure, or somewhere in between, we will undoubtedly learn a lot along the way about what it will take to transform health care in the United States.