Accountable Care Organizations: Characteristics, Challenges and Responses

As development of implementation strategies for the Patient Protection and Affordable Care Act of 2010 (PPACA) begin, establishment of accountable care organizations (ACOs) within the confines of Medicare and Medicaid and the Children’s Health Insurance Program (CHIP) continue to be discussed. As defined by the Centers for Medicare and Medicaid (CMS), an ACO is an organization of health care providers who are accountable for the quality, cost and overall care of beneficiaries. (CMS/Office of Legislation, 2010).

According to the Administrator of CMS, aside from the legal requirements such as number of required Medicare patients serviced, ACOs have several characteristics that, when combined, will uniquely define these organizations (CMS, 2010). A primary aspect of an ACO will be delivery of patient- and family-centered care. This includes the continuing effort to recognize patient and family values, preferences, resources and skills as important components of the “bundle of evidence” that healthcare practitioners use to guide the process of shared decision-making. Another characteristic of ACOs will be that of relieving patients and families of the burden of repeatedly relaying the same information related to their health to multiple healthcare professionals. For this to become a reality, the broad and deep realization of the electronic health record (EHR) will need to come to full fruition within ACOs. Coupled with EHR use will be the mining of aggregate data over time by ACOs to become “learning organisms” that continually identify what works best for the beneficiaries of their care. In addition, inter- and intra-professional communication within ACOs will need to be effective and efficient during patient handoffs across the continuum and teamwork will need to be apparent in all aspects of care. To this end, relevant strategies will need to continue to be used, evaluated and perfected from the field of crew resource management. Accountable Care Organizations will need to be proactive through early identification of potential health issues and swift in delivering effective evidence-based strategies when these are found. They will be able to coordinate and deliver appropriate resources throughout the care continuum in a manner that is cost-effective, and yet does not compromise patient care quality and safety.

Responses to the concept of ACOs, as well as to their development and implementation, were solicited by CMS. The American Nurses Association (ANA) was one organization that responded to the CMS with concerns related to the impact of ACOs on its specific profession. In the ANA response, several concerns were outlined that need to be addressed from the perspective of the nursing profession (ANA, 2010). These concerns included assuring that the measurement of patient care quality include nurse sensitive measures, that there is equity within ACO leadership structures, and that nurses be visible and recognized within the incentive structure.

Other responses focused not only on championing physicians as exclusive ACO leaders, but also on the possibility of specific patient populations being shortchanged. An example of this was seen in the document produced by Accountable Care Organization Workgroup of the American Academy of Pediatrics. This document addressed concerns about combining adult and pediatric healthcare delivery into the same ACO. One concern was that, as reducing costs is one of the driving factors in ACO evaluation, and that greater cost savings can be derived from managing adult care, emphasis on developing policies and protocols for children may be lessened. Also, because of the additional availability of Medicaid to a wider portion of adults through recent healthcare reform, it is more likely that resources would be shifted to this new stream of adult patients. In addition, families play a much more primary role in pediatric care; therefore, more costs for family resources may be entailed when caring for this population, thus reducing initial costs savings (AAP, 2011).

Implementation of the Pediatric Demonstration Project is scheduled to occur between 2012 and 2016. Although successful deployment of this project would avoid some of the issues listed in the AAP document, evaluation of cost savings based on adult parameters is still a concern. As the Pediatric Demonstration Project is rolled out, it is hoped that state Medicaid programs will be flexible enough to allow for the creativity and funds needed to deliver safe and effective healthcare and also the time needed to demonstrate eventual cost savings.

Jane Bliss-Holtz, DNSc, RN-BC

Editor