1. Accountable Care Organizations:
What are they ‘accountable’ for?
Dr Rachael Addicott
2011-12 Harkness Fellow
7 March 2013

2. Origins of ACO development
Why was reform necessary?
2010 Patient Protection and Affordable Care Act
– Payment and provision reform to encourage
cost savings and high quality care
– Care management for Medicare and Medicaid
populations

3. What is an ACO (in theory)?
Coordination of care across a network of providers
Interdependency: cost savings are more likely if
partners work together
Defined patient population
Shared governance structure (ie. ACO Board)
Shared accountability for quality and cost of care
Shared risk and savings: on condition of meeting
quality metrics

4. ACOs for Medicare patients
Centers for Medicare and Medicaid Innovation
(CMMI) testing the efficacy of the model
– SHARED SAVINGS PROGRAM: ACO develops from a one-
sided to a two-sided risk model
– PIONEER: providers with more experience move to an
accelerated population-based payment
– ADVANCE PAYMENT: additional upfront support to
developing ACOs, which is then recovered from any
future savings

5. What is an ACO (in practice)?
Origins in contracts for commercial populations
History of risk sharing with health plans
Driven by medical groups
Challenges in engaging hospital partners
Care management
Payment models
What do ACOs do with the savings?

6. Accountability for what?
Finance, mostly through process measures
Increasing focus on patient satisfaction
Quality measures as they relate to process
Measures “negotiated” with payer
– Medicare: single set of 33 quality measures
– More variation / overlap on commercial side
– ACO has variable influence in negotiations

7. Monitoring performance
Thresholds or targets are more contentious than
the measures themselves
– eg. keeping patients in the network
Collaborative accountability
– eg. patient satisfaction
Risk modelling

8. Sanctions and consequences
Reliance on informal influence
Appeals to professional competitiveness
Credibility of data
Development and coaching – “learning opportunity”
Financial penalties
Removal from ACO network

9. Conclusion: Culture of collaboration
Shared goals and incentives
– Reliance on data transparency and peer influence
Align measures and thresholds across payers
– Compatible matrix of accountabilities
Credibility and transparency of data
– Investment in IT infrastructure