Kaiser Permanente has been following the Accountable Care movement since the concept was introduced
into MedPAC in 2009. As part of our work to promote the accountable care organization
model, we have been working with Steve Shortell at the University of California Berkeley School
of Public Health and Elliott Fisher with the Dartmouth Institute for Health Policy and
Clinical Practice. And Steve and Elliott have funding from the Commonwealth Fund to field
a survey of Accountable Care Organizations, and their goal is to try to get a sense of
the array of organizations out there that are holding themselves out as ACOs.
Steve Shortell and I had helped contribute to the development of the accountable care organization
model, and so we both thought, about five years ago, that it might be important to try
to understand how this model is emerging in the United States.
A year or two ago, our team and the Dartmouth team developed a framework, a common framework by which to evaluate ACOs.
So it starts with understanding the context, understanding the readiness for change and
the capabilities. What are the first implementation steps? What are the intermediate process and
outcome measures from all of this? Then, ultimately, what’s the final impact?
We’re always looking at new evolving models of care. ACOs was, obviously, a very important one.
We wanted to make sure that early on in the evolution, that we were there capturing what
was being learned, and also for not only seeing whether they impact quality but what we could
do to understand gaps to improve them over time.
There’s a huge appetite right now for information on how these organizations are doing, but there’s just not a lot of
experience yet. So we thought it would be important, and together with The Commonwealth
Fund, we brought together a group of stakeholders to look at some of the early findings from
the survey and to provide some feedback to the researchers to help them understand, what
do stakeholders most want to know about this information. And we asked people very pointedly,
“What is your burning question about the Accountable Care movement as it’s getting
off the ground." The first theme we heard was really what is an ACO. A lot of people hear
the expression, if you’ve seen one ACO, you’ve seen one ACO. So people really want
to try to get their arms around, what is this universe of organizations that are holding
themselves out as ACOs.
I think one thing is defining what an ACO is.
I think there’s more a continuum than sort of a one-size-fits-all, “This is an ACO, and this is not an ACO.”
It’s not black and white. I think there are shades of gray. Trying to understand that
continuum and what are the different features in that continuum, I think, would be important.
The second major theme we heard was, what are the factors that are going to lead to
ACO success.
We are a new organization in town. We started in January and 76 ACO members.
We're interested in the same thing, the question everybody is interested in, is
what factors leads to success?
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.
The third theme we heard was about financial incentives. People in the room wanted to know,
are the incentives structured correctly in the model to have an impact on provider behavior.
We think that we got into this problem, of course, because of a fee for service world.
But now that we're moving into a payment for value, there's two levels that we're concerned
about. One is how do the incentives get, how are they organized for the organization itself,
and then another deeper question is how are incentives structured for the end providers?
One, is the shared savings model with or without two-sided risks strong enough to cause the
cultural and organizational change that we all want? I have some doubts.
Speaking as a medical student, I wonder whether ACOs will motivate my classmates and I to change the
The fourth theme we heard was about medical care with other types of
culture of medicine.
The fourth theme we heard was about integration of medical care with other types of
care that are necessary to improve health.
We're very interested in exploring how to
strengthen primary care and also pertinent to the meeting today and the work at hand
is how we organize a system of delivery that can coordinate, integrate clinical care,
behavioral health, social support services for the high cost, high need, and vulnerable population.
I would like to know how are ACOs going to coordinate with infrastructure that is already
in place like patient-centered medical homes, community-based health teams, behavioral health
services, long-term services and supports, and what kinds of metrics can be used to,
or be developed to help drive this ACO formation in order that
these ACOs are focusing on population based or community based goals?
The next thing we heard was about patient engagement. People
in the room wondered whether, and how, accountable care organizations would be structured to
really bring patients into, and actively participating in their care.
I'm really interested in the patient engagement piece.
In particular, how are we going to get the accountability going both ways?
So most people are focusing on getting their providers and the payers accountable,
but obviously the patients have a very key role in this.
ACOs tout that they are the vanguard for the advent of true patient-centered care.
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?
The next big theme that came out of the meeting was about measurement.
And there was some concern that maybe the
quality measures that we have available to us now, wouldn’t really be adequate to capture
the kind of improvements that really are the goal of accountable care organizations.
The big challenge, I think, really is not the desire on the providers to improve quality
of care. A lot of it has to do with just the paucity of effective measures and, really,
measures that effectively capture whether quality is improving on a significant level,
moving beyond the traditional HEDIS diabetes, chronic care measures.
And we also measure ACOs on a core set of 32 quality measures that include patient experience of care,
outcome based measures, and preventive and chronic disease measures. And I'm interested in hearing
from you all as well about how should we refine that quality measure set and what measure
should we be looking at going forward as this program evolves?
We also heard some interesting questions that didn’t really fall neatly into these buckets.
For example, how should accountable care organizations be structured in light of anti-trust laws.
From an antitrust standpoint, the agencies have been focusing a lot on they're more comfortable if ACOs
are not a large market share and are non-exclusive. And one question I have is whether you can
really get ACO performance being a non-exclusive and what kind of scale or share you might need.
Overall, I thought the meeting was really helpful in helping to identify some of the
questions and concerns that researchers and others will need to address as the ACO movement
plays out. There were a lot more questions than there were answers in the room, but in
general it was really heartening to see that there was a great deal of hope and expectation
that ACOs were going to going to succeed.