In Name Only? The Accountability of ACOs

In the health care industry, there has been little escaping news and opinion surrounding accountable care organizations, or ACOs, as an innovative health care delivery model.  An undeniably "hot topic" in health care that has been viewed with both optimism and skepticism, ACOs are intended to address the cost and quality components of the "iron triangle," working to keep health care providers accountable to providing high quality care while minimizing health care costs for the populations they serve.  But are these providers truly held accountable by the ACO model?  In the recently published fall issue of Health Care Management Review (volume 39, issue 4), authors Rachael Addicott (King's Fund) and Stephen Shortell (University of California, Berkeley) address this question, examining "the governance structures and accountability mechanisms that have been established by provider networks" engaged in ACO initiatives "to achieve the shared aims of improving quality and containing costs" (p. 271).  In other words, do the collaborating parties in ACOs hold each other accountable in their pursuit of improved coordination and integration?

To explore this question, the authors conducted in-depth case studies of four commercial ACOs from across the United States in the early stages of their development.  Their findings revealed common characteristics across the ACO sites (e.g., commercial at risk contracts, existing or proposed Medicare ACO contracts, and medical group-centered with collaborating hospitals and health plans) as well as key differences in terms of "their level of integration, corresponding governance structures, and mechanisms of accountability" (p. 273).  Ultimately, Addicott and Shortell found little evidence of formal shared accountability among ACO partners, little experience among partners with measures of collaboration, and little evidence that incentives were effectively applied to influence behaviors.

The authors conclude the article with numerous recommendations.  These include reinforcing ACO goals by establishing clear performance measures and incentives, aligning performance thresholds across different payer contracts, promoting access to transparent data, and engaging patients in the design, governance, and accountability mechanisms of ACOs (p. 277).   They also call for each ACO to tailor accountability structures to their participants and development, bringing to mind contingency theorists' arguments that, rather than finding a single best structure that should be applied like a cookie cutter across all ACOs, organizational structures should be identified that provide the best fit with an individual ACO's task and environmental contingencies.

What do you think?  What are your experiences with ACOs and their level of accountability?  Is the ACO model one that should be applied like a cookie cutter, or is it true that if you've seen one ACO, you've seen one ACO?  Please share your comments; we'd love to hear your perspective.

Article citation

Addicott, R., & Shortell, S.M. (2014). "How 'accountable' are accountable care organizations?" Health Care Management Review, 39 (4), 270-278.