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Background Accountable care organizations (ACOs) aim to improve health care quality and reduce costs, including among patients with heart failure (HF). However, variation across ACOs in admission rates for patients with HF and associated factors are not well described. Methods and Results We identified Medicare fee-for-service beneficiaries with HF who were assigned to a Medicare Shared Savings Program ACO in 2017 and survived ≥30 days into 2018. We calculated risk-standardized acute admission rates across ACOs, assigned ACOs to 1 of 3 performance categories, and examined associations between ACO characteristics and performance categories. Among 1 232 222 beneficiaries with HF, 283 795 (mean age, 81 years; 54% women; 86% White; 78% urban) were assigned to 1 of 467 Medicare Shared Savings Program ACOs. Across ACOs, the median risk-standardized acute admission rate was 87 admissions per 100 people, ranging from 61 (minimum) to 109 (maximum) admissions per 100 beneficiaries. Compared to the overall average, 13% of ACOs performed better on risk-standardized acute admission rates, 72% were no different, and 14% performed worse. Most ACOs with better performance had fewer Black beneficiaries and were not hospital affiliated. Most ACOs that performed worse than average were large, located in the Northeast, had a hospital affiliation, and had a lower proportion of primary care providers. Conclusions Admissions are common among beneficiaries with HF in ACOs, and there is variation in risk-standardized acute admission rates across ACOs. ACO performance was associated with certain ACO characteristics. Future studies should attempt to elucidate the relationship between ACO structure and characteristics and admission risk.

Importance: Although Medicare accountable care organizations (ACOs) account for half of program expenditures, whether ACOs are associated with surgical spending warrants further study., Objective: To assess whether greater beneficiary-hospital ACO alignment was associated with lower surgical episode costs., Design, Setting, and Participants: This retrospective cohort study was conducted between 2020 and 2022 using US Medicare data from a 20% random sample of beneficiaries. Individuals 18 years of age and older and without kidney failure who had a surgical admission between 2008 and 2015 were included. For each study year, distinction was made between beneficiaries assigned to an ACO and those who were not, as well as between admissions to ACO-participating and nonparticipating hospitals., Exposures: Time-varying binary indicators for beneficiary ACO assignment and hospital ACO participation and an interaction between them., Main Outcomes and Measures: Ninety-day, price-standardized total episode payments. Multivariable 2-way fixed-effects models were estimated., Results: During the study period, 2 797 337 surgical admissions (6% of which involved ACO-assigned beneficiaries) occurred at 3427 hospitals (17% ACO participating). Total Medicare payments for 90-day surgical episodes were lowest when ACO-assigned beneficiaries underwent surgery at a hospital participating in the same ACO as the beneficiary ($26 635 [95% CI, $26 426-$26 844]). The highest payments were for unassigned beneficiaries treated at participating hospitals ($27 373 [95% CI, $27 232-$27 514]) or nonparticipating hospitals ($27 303 [95% CI, $27 291-$27 314]). Assigned beneficiaries treated at hospitals participating in a different ACO and assigned beneficiaries treated at nonparticipating hospitals had similar payments (for participating hospitals, $27 003 [95% CI, $26 739-$27 267] and for nonparticipating hospitals, $26 928 [95% CI, $26 796-$27 059]). A notable factor in the observed differences in surgical episode costs was lower spending on postacute care services., Conclusions and Relevance: In this cohort study evaluating hospital and beneficiary ACO alignment and surgical spending, savings were noted for beneficiaries treated at hospitals in the same ACO. Allowing ACOs to encourage or require surgical procedures in their own hospitals could lower Medicare spending on surgery.

The Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) Model was the first Medicare specialty-oriented accountable care organization (ACO) model. We examined whether this model provided better results for beneficiaries with ESRD than primary care-based ACO models. We found significant decreases in Medicare payments ($126 per beneficiary per month), hospitalizations (5 percent), and likelihood of readmissions (8 percent) among beneficiaries with ESRD during the first year of alignment with the CEC Model and no impacts on these measures among beneficiaries with ESRD who were aligned with primary care-based ACOs, relative to fee-for-service Medicare beneficiaries. Neither the CEC nor primary care-based ACO models significantly reduced the likelihood of catheter use, but fistula use increased for CEC Model beneficiaries to levels just above statistical significance. Other populations with chronic conditions may benefit from the testing of a specialty-oriented ACO model. In addition, primary care-based ACOs may benefit from applying CEC Model strategies to high-need subpopulations. Last, the strategies that enabled ESRD Seamless Care Organizations to achieve reductions in hospitalizations and readmissions even without hospital participation as owners could inform physician-led ACOs' efforts to coordinate with hospitals in their areas.

Importance: Thirty percent of Medicare accountable care organizations (ACOs) in the Shared Savings Program (SSP) have exited within five years of joining. Absent the potential for shared savings, exiting ACOs may choose to divest from costly resources needed to support population health, worsening clinical quality for beneficiaries aligned to these organizations., Objective: To examine the associations of SSP exit with clinical quality., Design Setting and Participants: Between 2019 and 2020 we conducted a retrospective cohort study with national Medicare claims from a 20% random sample of beneficiaries. We identified 1,713,237 beneficiaries aligned with an SSP ACO at some point between 2012 and 2016. We distinguished between those for whom the ACO to which they were aligned exited the SSP and those whose ACO stayed in the program. Comparing exiting ACOs with those who stayed in the SSP, we evaluated changes in the quality of care that a beneficiary received before and after the aligned ACO exited the SSP. We also examined whether findings associated with exit varied with respect to the number of years after exit., Exposures: SSP exit and the number of years after exit., Main Outcomes and Measures: Annual preventive care services receipt and hospital utilization., Results: The cohort of 1,713,237 individuals (mean [standard deviation] age at enrollment: 75.20 [7.96] years) included 998,511 (58.3%) female, 126,123 (7.4%) Black, and 1,482,823 white (86.6%) beneficiaries. SSP exit was associated with significantly lower rates of annual glycated hemoglobin testing (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.68 to 0.81), low-density lipoprotein cholesterol testing (OR, 0.86; 95% CI, 0.76 to 0.97), and all diabetes complication screening (OR, 0.90; 95% CI, 0.81 to 0.97), for beneficiaries with diabetes. The exit was not related to rates of hospital utilization, in terms of emergency department utilization and 30-day readmission after SSP exit. The associations with exit depended on the length of time since contracts end. For example, the baseline rate of annual glycated hemoglobin testing was 89.8% (95% CI, 89.5% to 90.1%) but fell to 86.9% (95% CI, 85.9% to 88.0%) and 86.8% (95% CI, 85.0% to 88.5%) in years 1 and 2 after exit, respectively, but it then rose to 91.9% (95% CI, 85.3% to 98.5%) in year 3., Conclusions and Relevance: In this cohort study of Medicare beneficiaries, SSP exit was associated with modest declines in clinical quality. These findings were timely given recent SSP changes that could accelerate program exit., Competing Interests: Conflict of Interest Disclosures: None reported.

Background: Pediatric accountable health communities (AHCs) are emerging collaborative models that integrate care across health and social service sectors. We aimed to identify needed capabilities and potential solutions for implementing pediatric AHCs., Methods: We conducted a directed content analysis of responses to a Request for Information (RFI) from the Center for Medicare & Medicaid Innovation on the Integrated Care for Kids Model (n = 1550 pages from 202 respondents). We then interviewed pediatric health policy stakeholders (n = 18) to further investigate responses from the RFI. All responses were coded using a consensual qualitative research approach in 2019., Results: To facilitate service integration, respondents emphasized the need for cross-sector organizational alignment and data sharing. Recommended solutions included designating "Bridge Organizations" to operationalize service integration across sectors and developing integrated data sharing systems. Respondents called for improved validation and collection methods for data relating to school performance, social drivers of health, family well-being, and patient experience. Recommended solutions included aligning health and education data privacy regulations and utilizing metrics with cross-sector relevance. Respondents identified that mechanisms are needed to blend health and social service funding in alternative payment models (APMs). Recommended solutions included guidance on cross-sector care coordination payments, shared savings arrangements, and capitation to maximize spending flexibility., Conclusions: Pediatric AHCs could provide more integrated, high-value care for children. Respondents highlighted the need for shared infrastructure and cross-sector alignment of measures and financing., Implications: Insights and solutions from this study can inform policymakers planning or implementing innovative, child-centered AHC models., Level of Evidence: Level V., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Health care spending in the United States continues to grow. Mental health and substance use disorders (MH/SUDs) are prevalent and associated with worse health outcomes and higher health care spending; alternative payment and delivery models (APMs) have the potential to facilitate higher quality, integrated, and more cost-effective MH/SUD care., Objective: To systematically review and summarize the published literature on populations and MH/SUD conditions examined by APM evaluations and the associations of APMs with MH/SUD outcomes., Evidence Review: A literature search of MEDLINE, PsychInfo, Scopus, and Business Source was conducted from January 1, 1997, to May 17, 2019, for publications examining APMs for MH/SUD services, assessing at least 1 MH/SUD outcome, and having a comparison group. A total of 27 articles met these criteria, and each was classified according to the Health Care Payment Learning and Action Network's APM framework. Strength of evidence was graded using a modified Oxford Centre for Evidence-Based Medicine framework., Findings: The 27 included articles evaluated 17 APM implementations that spanned 3 Health Care Payment Learning and Action Network categories and 6 subcategories, with no single category predominating the literature. APMs varied with regard to their assessed outcomes, funding sources, target populations, and diagnostic focuses. The APMs were primarily evaluated on their associations with process-of-care measures (15 [88.2%]), followed by utilization (11 [64.7%]), spending (9 [52.9%]), and clinical outcomes (5 [29.4%]). Medicaid and publicly funded SUD programs were most common, with each representing 7 APMs (41.2%). Most APMs focused on adults (11 [64.7%]), while fewer (2 [11.8%]) targeted children or adolescents. More than half of the APMs (9 [52.9%]) targeted populations with SUD, while 4 (23.5%) targeted MH populations, and the rest targeted MH/SUD broadly defined. APMs were most commonly associated with improvements in MH/SUD process-of-care outcomes (12 of 15 [80.0%]), although they were also associated with lower spending (4 of 8 [50.0%]) and utilization (5 of 11 [45.5%]) outcomes, suggesting gains in value from APMs. However, clinical outcomes were rarely measured (5 APMs [29.4%]). A total of 8 APMs (47.1%) assessed for gaming (ie, falsification of outcomes because of APM incentives) and adverse selection, with 1 (12.5%) showing evidence of gaming and 3 (37.5%) showing evidence of adverse selection. Other than those assessing accountable care organizations, few studies included qualitative evaluations., Conclusions and Relevance: In this study, APMs were associated with improvements in process-of-care outcomes, reductions in MH/SUD utilization, and decreases in spending. However, these findings cannot fully substitute for assessments of clinical outcomes, which have rarely been evaluated in this context. Additionally, this systematic review identified some noteworthy evidence for gaming and adverse selection, although these outcomes have not always been duly measured or analyzed. Future research is needed to better understand the varied qualitative experiences across APMs, their successful components, and their associations with clinical outcomes among diverse populations and settings.

Organisations can have a significant impact (positive or negative) on society through their actions and decisions. Given this reality, it is important that they are held responsible and accountable for the consequences of their actions. This concept is often referred to as 'social responsibility'. However, 'social responsibility', as currently conceived in the literature, neglects a specific focus on health as a social goal. Additionally, there are no practical tools to capture this concept in a holistic way to facilitate implementation and monitoring of organisational improvement. This paper reports on the process of developing a more holistic conceptual framework and tool for assessing organisational social responsibility and accountability for health (OSRAH). We conducted a review of the published and grey literature and engaged in expert consultation and focus group discussions. The initial OSRAH framework and the self-assessment tool were finalised for implementation and used by 95 organisations at a national event in Iran in February 2017. The results of the assessment data collected at the event showed organisations scored lowest in the domain of community health and highest in the domain of employee health. The OSRAH framework and assessment tool represents a new understanding of health and its determinants in organisations outside the health sector. It integrates health within the existing Corporate Social Responsibility (CSR) culture of organisations. The process of creating the tool and implementing it at the national festival of OSRAH in Iran created momentum for intersectoral action. This experience can inspire researchers and practitioners in other countries, especially in developing countries, to develop their own local definition and practical assessment framework for responsibility and accountability.

This study aimed to assess the efficacy of two cartoons which depict autistic characters in improving attitudes towards autistic peers in two separate studies. Forty-six children participated in study 1 (4-7 years), and 47 children participated in study 2 (8-11 years). Both the conative (behavioural) component of attitudes and knowledge about autism were measured before and after the cartoon interventions. Knowledge of autism increased after watching the cartoons in both studies but attitudes to autism only improved in study 1. Knowledge was shown to correlate with change in some but not all attitude measures. The findings suggest that cartoons can improve attitudes to autism, but this may depend on how information is presented.

The purpose of this research paper is to explore variations in online accountability practices in US hospitals and determine the factors that are associated with higher levels of online accountability practices. This project employed a quantitative content analysis of 240 US hospital websites. Additionally, secondary data were obtained from the American Hospital Association and the American Hospital Directory. The results show that the external environment somewhat impacted hospitals' online accountability practices, with hospital volume (measured through the number of annual admissions) as an unquestionable predictor. Another key finding is that some of the governance forms impacted online accountability practices. Particularly, hospitals with private ownership structures tended to disclose less accountability information in an online environment, compared with their public and nonprofit counterparts. The financial situation of hospitals did not have any significant impact on overall online accountability practices but was influencing performance disclosure practices. Online accountability studies have not been conducted in a health care setting. This research theoretically relates online accountability practices to organizational characteristics (such as size, volume, financial performance, system affiliation, ownership, and rurality). Knowledge of the online accountability landscape might benefit future policy decisions on accountability models., (© 2019 John Wiley & Sons, Ltd.)

The medical profession is steeped in traditions that guide its practice. These traditions were developed to preserve the well-being of patients. Transformations in science, technology, and society, while maintaining a self-governance structure that drives the goal of care provision, have remained hallmarks of the profession. The purpose of this paper is to examine ethical challenges in health care as it relates to Big Data, Accountable Care Organizations, and Health Care Predictive Analytics using the principles of biomedical ethics laid out by Beauchamp and Childress (autonomy, beneficence, non-maleficence, and justice). Among these are the use of Electronic Health Records within stipulations of the Health Insurance Portability and Accountability Act. Clinicians are well-positioned to impact health policy development to address ethical issues associated with the use of Big Data, Accountable Care, and Health Care Predictive Analytics as we work to transform the doctor-patient relationship towards improving population health outcomes and creating a healthier society.

Value-based payment initiatives, such as the Medicare Shared Savings Program (MSSP), offer the possibility of using financial incentives to drive improvements in mental health and substance use outcomes. In the past 2 years, Accountable Care Organizations (ACOs) participating in the MSSP began to publicly report on one behavioral health outcome-Depression Remission at Twelve Months, which may indicate how value-based payment incentives have impacted mental health and substance use, and if reforms are needed. For ACOs that meaningfully reported performance on the depression remission measure in 2017, the median rate of depression remission at 12 months was 8.33%. A recent meta-analysis found that the average rate of spontaneous depression remission at 12 months absent treatment was approximately 53%. Although a number of factors likely explain these results, the current ACO design does not appear to incentivize improved behavioral health outcomes. Four changes in value-based payment incentive design may help to drive better outcomes: (1) making data collection easier, (2) increasing the salience of incentives, (3) building capacity to implement new interventions, and (4) creating safeguards for inappropriate treatment or reporting.

Importance: Social needs, including food, housing, utilities, transportation, and experience with interpersonal violence, are linked to health outcomes. Identifying patients with unmet social needs is a necessary first step to addressing these needs, yet little is known about the prevalence of screening., Objective: To characterize screening for social needs by physician practices and hospitals., Design, Setting, and Participants: Cross-sectional survey analyses of responses by physician practices and hospitals to the 2017-2018 National Survey of Healthcare Organizations and Systems. Responses were collected from survey participants from June 16, 2017, to August 17, 2018., Exposures: Organizational characteristics, including participation in delivery and payment reform., Main Outcomes and Measures: Self-report of screening patients for food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence., Results: Among 4976 physician practices, 2333 responded, a response rate of 46.9%. Among hospitals, 757 of 1628 (46.5%) responded. After eliminating responses because of ineligibility, 2190 physician practices and 739 hospitals remained. Screening for all 5 social needs was reported by 24.4% (95% CI, 20.0%-28.7%) of hospitals and 15.6% (95% CI, 13.4%-17.9%) of practices, whereas 33.3% (95% CI, 30.5%-36.2%) of practices and 8.0% (95% CI, 5.8%-11.0%) of hospitals reported no screening. Screening for interpersonal violence was most common (practices: 56.4%; 95% CI, 53.3%-2 59.4%; hospitals: 75.0%; 95% CI, 70.1%-79.3%), and screening for utility needs was least common (practices: 23.1%; 95% CI, 20.6%-26.0%; hospitals: 35.5%; 95% CI, 30.0%-41.0%) among both hospitals and practices. Among practices, federally qualified health centers (yes: 29.7%; 95% CI, 21.5%-37.8% vs no: 9.4%; 95% CI, 7.2%-11.6%; P < .001), bundled payment participants (yes: 21.4%; 95% CI, 17.1%-25.8% vs no: 10.7%; 95% CI, 7.9%-13.4%; P < .001), primary care improvement models (yes: 19.6%; 95% CI, 16.5%-22.6% vs no: 9.6%; 95% CI, 6.0%-13.1%; P < .001), and Medicaid accountable care organizations (yes: 21.8%; 95% CI, 17.4%-26.2% vs no: 11.2%; 95% CI, 8.6%-13.7%; P < .001) had higher rates of screening for all needs. Practices in Medicaid expansion states (yes: 17.7%; 95% CI, 14.8%-20.7% vs no: 11.4%; 95% CI, 8.1%-14.6%; P = .007) and those with more Medicaid revenue (highest tertile: 17.1%; 95% CI, 11.4%-22.7% vs lowest tertile: 9.0%; 95% CI, 6.1%-11.8%; P = .02) were more likely to screen. Academic medical centers were more likely than other hospitals to screen (49.5%; 95% CI, 34.6%-64.4% vs 23.0%; 95% CI, 18.5%-27.5%; P < .001)., Conclusions and Relevance: This study's findings suggest that few US physician practices and hospitals screen patients for all 5 key social needs associated with health outcomes. Practices that serve disadvantaged patients report higher screening rates. The role of physicians and hospitals in meeting patients' social needs is likely to increase as more take on accountability for cost under payment reform. Physicians and hospitals may need additional resources to screen for or address patients' social needs.

Purpose: Accountable Care Organizations (ACOs) are implementing interventions to achieve triple-aim objectives of improved quality and experience of care while maintaining costs. Partnering across organizational boundaries is perceived as critical to ACO success., Methods: We conducted a comparative case study of 14 Medicaid ACOs in Oregon and their contracted primary care clinics using public performance data, key informant interviews, and consultation field notes. We focused on how ACOs work with clinics to improve colorectal cancer (CRC) screening - one incentivized performance metric., Results: ACOs implemented a broad spectrum of multi-component interventions designed to increase CRC screening. The most common interventions focused on reducing structural barriers (n = 12 ACOs), delivering provider assessment and feedback (n = 11), and providing patient reminders (n = 7). ACOs developed their processes and infrastructure for working with clinics over time. Facilitators of successful collaboration included a history of and commitment to collaboration (partnership); the ability to provide accurate data to prioritize action and monitor improvement (performance data), and supporting clinics' reflective learning through facilitation, learning collaboratives; and support of ACO as well as clinic-based staffing (quality improvement infrastructure). Two unintended consequences of ACO-clinic partnership emerged: potential exclusion of smaller clinics and metric focus and fatigue., Conclusion: Our findings identified partnership, performance data, and quality improvement infrastructure as critical dimensions when Medicaid ACOs work with primary care to improve CRC screening. Findings may extend to other metric targets.

Accountable Care Organizations (ACOs) are exemplars of so-called value-based care in the US. In this model, healthcare providers bear the financial risk of their patients' health outcomes: ACOs are rewarded for meeting specific quality and cost-efficiency benchmarks, or penalized if improvements are not demonstrated. While the aim is to make providers more accountable to payers and patients, this is a sea-change in payment and delivery systems, requiring new infrastructures and practices. To manage risk, ACOs employ data-intensive sourcing and big data analytics to identify individuals within their populations and sort them using novel categories, which are then utilized to tailor interventions. The article uses an STS lens to analyze the assemblage involved in the enactment of population health management through practices of data collection, the creation of new metrics and tools for analysis, and novel ways of sorting individuals within populations. The processes and practices of implementing accountability technologies thus produce particular kinds of knowledge and reshape concepts of accountability and care. In the process, account-giving becomes as much a procedural ritual of verification as an accounting for health outcomes.

Importance: Accountable care organizations (ACOs) aim to control health expenditures while improving quality of care. Primary care has been emphasized as a means to reduce spending, but little is known about the implications of using specialists for achieving this ACO objective., Objective: To examine the association between ACO-beneficiary office visits conducted by specialists and the cost and utilization outcomes of those visits., Design, Setting, and Participants: This cross-sectional study obtained data on 620 distinct ACOs from the Centers for Medicare & Medicaid Services Shared Savings Program Accountable Care Organizations Public-Use Files from April 1, 2012, to September 30, 2017. Generalized estimating equation models were used for analysis of ACOs, adjusting for ACO-beneficiary health status, Medicare enrollment groups, ACO size, and proportion of participating specialists., Exposures: Specialist encounter proportion, the percentage of office visits provided by a specialist, was categorized into 7 discrete groups: less than 35%, 35% to less than 40%, 40% to less than 45% (reference group), 45% to less than 50%, 50% to less than 55%, 55% to less than 60%, and 60% or greater., Main Outcomes and Measures: The primary outcome was total expenditures (given in US dollars) per assigned beneficiary person-year. The secondary outcomes were total numbers of emergency department visits, hospital discharges, skilled nursing facility discharges, and magnetic resonance imaging orders., Results: In total, the data set included 1836 ACO-year (number of participation years per ACO) observations for 620 distinct ACOs. Those ACOs with a specialist encounter proportion of 40% to less than 45% had $1129 (95% CI, $445-$1814) lower per-beneficiary person-year spending than did ACOs in the lowest specialist encounter proportion group and had $752 (95% CI, $115-$1389) lower per-beneficiary person-year spending compared with ACOs in the highest specialist encounter proportion group. Monotonic decreases in emergency department visits, hospital discharges, and skilled nursing facility discharges were observed with increasing specialist encounter proportion. Conversely, monotonic increases in magnetic resonance imaging volume discharges were observed with increasing specialist encounter proportion., Conclusions and Relevance: These findings suggest that an ACO's ability to reduce spending may require sufficient involvement in care processes from specialists, who seem to complement the intrinsic primary care approach in ACOs.

Objectives: To compare aggressiveness of end-of-life (EoL) care for older cancer patients attributed to Medicare Shared Savings Programs with that for similar fee for service (FFS) beneficiaries not in an accountable care organization (ACO) and examine whether observed differences in EoL care utilization vary across markets that differ in ACO penetration., Design: Cross-sectional observational study comparing ACO-attributed beneficiaries with propensity score-matched beneficiaries not attributed to an ACO., Setting: A total of 21 hospital referral regions (HRRs) in the United States., Participants: Medicare FFS beneficiaries with a cancer diagnosis who were 66 years or older and died in 2013-2014., Measurements: Outcome measures were claims-based quality measures of aggressive EoL care: (1) one or more intensive care unit (ICU) admissions in the last month of life, (2) two or more hospitalizations in the last month of life, (3) two or more emergency department visits in the last month of life, (4) chemotherapy 2 weeks or less before death, and (5) no hospice enrollment or hospice enrollment within 3 days of death. Analyses were adjusted for demographic and clinical characteristics of beneficiaries and practice characteristics., Results: Compared with beneficiaries not in an ACO, ACO-attributed beneficiaries had a higher rate of ICU admission during the last month of life (37.7% vs 34.0%; adjusted difference = +2.8 percentage points; 95% confidence interval (CI) = 1.0-4.6) but fewer repeated hospitalizations (14.5% vs 15.2%; adjusted difference = -1.7 percentage points; CI = -3.1 to -.3). Other measures did not differ for the two groups. Although the ICU admission rates tended to decrease as ACO-penetration rates increased (P < .01), ACO patients had higher rates of ICU admission than non-ACO patients in both medium and high ACO-penetration HRRs., Conclusion: Cancer patients attributed to ACOs had fewer repeated hospitalizations but more ICU admissions in the last month of life than non-ACO patients; they had similar rates of other measures of aggressive care at the EoL. This suggests opportunities for ACOs to improve EoL care for cancer patients. J Am Geriatr Soc 67:961-968, 2019., (© 2019 The American Geriatrics Society.)

Issue: New payment and care delivery models such as accountable care organizations (ACOs) have prompted health care delivery systems to better meet the requirements of their high-need, high-cost (HNHC) patients., Goal: To explore how a group of mature ACOs are seeking to match patients with appropriate interventions by segmenting HNHC populations with similar needs into smaller subgroups., Methods: Semistructured telephone interviews with 34 leaders from 18 mature ACOs and 10 national experts knowledgeable about risk stratification and segmentation., Key Findings and Conclusions: ACOs use a range of approaches to segment their HNHC patients. Although there was no consistent set of subgroups for HNHC patients across ACOs, there were some common ones. Respondents noted that when primary care clinicians were engaged in refining segmentation approaches, there was an increase in both the clinical relevance of the results as well as the willingness of frontline providers to use them. Population segmentation results informed ACOs’ understanding of program needs, for example, by helping them better understand what skill sets and staff were needed to deliver enhanced care management. Findings on how mature ACOs are segmenting their HNHC population can improve the future development of more systematic approaches.

As the cost of health care continues to escalate, payers are adapting by moving away from models based on traditional fee-for-service reimbursement to models focused on rewarding care delivery that reduces costs and improves quality. These alternative payment models (APMs) are being introduced by government and commercial payers and will likely become the norm over time. Recent changes in sleep medicine related to advances in technology and approaches by payers for the management of OSA make this an appropriate time to incorporate the delivery of sleep medicine services into APMs. For OSA, the approaches that should lead to success include the appropriate use of home sleep apnea testing and automatic positive airway pressure; lower cost providers to manage less complex patients; evolving technologies including cloud-based positive airway pressure adherence monitoring, telemedicine, and Internet-based coaching to improve adherence with treatments; data analytics to better identify high-risk populations and to more appropriately allocate resources; and appropriate referrals of more complex cases to sleep specialists for management. All of these approaches should improve the value of care for payers, providers, and patients while allowing sleep specialists to more appropriately allocate their efforts to overseeing APM program development and administration and allowing them to focus on the management of more complicated patients., (Copyright © 2018 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Falls are a serious and common problem among older adults. Low-tech, inexpensive, community-based fall prevention programs have been shown to be both effective and cost effective, however, these programs are not well-integrated into clinical practice., Research Design: We surveyed primary care providers at a convenience sample of two accountable care organizations in Massachusetts to assess their beliefs, attitudes, knowledge, and practices relative to fall risk assessment and intervention for their older patients., Results: Response rate was 71%. Providers' beliefs about the efficacy of fall risk assessment and intervention were mixed. Eighty-seven percent believed that they could be effective in reducing fall risk among their older adult patients. Ninety-six percent believed that all older adults should be assessed for fall risk; and, 85% believed that this assessment would identify fall risk factors that could be modified. Nonetheless, only 52% believed that they had the expertise to conduct fall risk assessment and only 68% believed that assessing older adult patients for fall risk was the prevailing standard of practice among their peer providers. Although most providers believed it likely that an evidence-based program could reduce fall risk among their patients, only 14% were aware of the Centers for Disease Control and Prevention's fall risk assessment algorithm (STEADI Toolkit), and only 15% were familiar with Matter of Balance, the most widely disseminated community fall risk prevention program in Massachusetts., Discussion: New strategies that more directly target providers are needed to accelerate integration of fall risk assessment and intervention into primary care practice., Competing Interests: The authors have declared that no competing interests exist.

End-of-life care is often overly aggressive and inconsistent with patients' preferences. Although end-of-life care could therefore be a natural target for accountable care organizations (ACOs) in their efforts to reduce spending, identifying and curbing wasteful care for patients at high risk of death may be challenging. To date, the impact of ACOs on end-of-life care has not been quantified. Using fee-for-service Medicare claims through 2015 and a difference-in-differences approach, we found evidence of some changes in end-of-life care associated with providers' participation in the Medicare Shared Savings Program among both decedents and patients at high risk of death. Although generally suggestive of less aggressive care, most effects were small and inconsistent across cohorts of ACOs entering the program in different years. This suggests that ACOs have not yet substantially altered end-of-life care patterns and that additional incentives, time, or both may be needed. Alternatively, curbing wasteful end-of-life care might not be a viable source of substantial savings under population-based payment models.

Addressing healthcare costs requires incenting providers to address both physical and behavioral health conditions, as well as social determinants of health. The most complex, and expensive, patients are often those with comorbid mental illness and/or addiction, who are at higher risk for exposure to violence, food insecurity, unstable housing and other adversities that negatively affect health. Yet today's value-based payment models and associated quality measures do not incent providers to address patients' behavioral and social needs. We propose a state-led framework for moving towards fully integrated accountability through improved value-based payment and measurement., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Massachusetts' community hospitals face the challenge of achieving accountable care readiness with fewer financial and operational resources and a higher share of publicly-insured patients than their academic medical center counterparts. They are thus doubly constrained to make the investments necessary to perform in a value-based payment environment. Hallmark Health System and Lowell General Hospital are among 25 community hospital awardees engaged with the Massachusetts Health Policy Commission's Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program to implement clinical transformation programs to reduce unnecessary hospital utilization; enhance care for individuals with social, behavioral, and medical complexity; and improve post-acute community-based care, as means to advance accountable care readiness. The programs are payer-blind and designed to operate at-scale based on clinical and/or utilization criteria. Using examples from Hallmark Health System and Lowell General Hospital, we report on early lessons learned, representative of experiences from across the Phase 2 cohort: 1) locally-derived data enables hospitals to plan and implement action-oriented initiatives that are tailored to their communities; 2) investments in appropriate technologies facilitate near real-time patient engagement upon presentation to the acute care setting and/or immediately post-discharge; 3) non-medical providers are a cost-effective and high-value addition to complex care teams serving individuals with complex needs; and 4) collaboration with community partners improves care continuity and promotes stability outside the hospital-a promising approach to cost-effective population health management., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Failed diffusion of innovations may be linked to an inability to use and apply data, information, and knowledge to change perceptions of current practice and motivate change. Using qualitative and quantitative data from three large-scale health care delivery innovations-accountable care organizations, advanced primary care practice, and EvidenceNOW-we assessed where data-driven innovation is occurring and where challenges lie. We found that implementation of some technological components of innovation (for example, electronic health records) has occurred among health care organizations, but core functions needed to use data to drive innovation are lacking. Deficits include the inability to extract and aggregate data from the records; gaps in sharing data; and challenges in adopting advanced data functions, particularly those related to timely reporting of performance data. The unexpectedly high costs and burden incurred during implementation of the innovations have limited organizations' ability to address these and other deficits. Solutions that could help speed progress in data-driven innovation include facilitating peer-to-peer technical assistance, providing tailored feedback reports to providers from data aggregators, and using practice facilitators skilled in using data technology for quality improvement to help practices transform. Policy efforts that promote these solutions may enable more rapid uptake of and successful participation in innovative delivery system reforms.

Aims: A third of the patients with Type 2 diabetes have an advance disease that requires complex pharmacotherapies and advanced expertise, dependent on multiple clinical interactions. Unfortunately, limited providers availability enables only sporadic interactions. Additionally, the expanding Accountable Care Organization (ACO) concept enhances providers' compensation when clinical performance is improving while limiting face-to-face clinic visits., Methods: We developed an advanced type 2 specialty clinic model, geared toward frequent remote clinical interventions while limiting face-to-face clinic visits. The model was tested in a 1-year, prospective, randomized controlled clinical trial. N=60, patients were randomized 1:1, to the experimental or standard endocrinology clinics., Results: Average A1c in the experimental arm decreased from 9.6±0.9% to 7.9±1.3%(p<0.0001). Whereas in the control it decreased from 8.9±0.8% to 8.6±1.9%(non-significant). More patients were treated with statins in the experimental arm compared to the control (93.3% vs. 66.7%; p=0.01). Face-to-face clinic visits occurred 1.5±0.7 times per year in the experimental arm compared to 3.6±4.0 in the control (p<0.0001)., Conclusions: We believe that the presented model for a modified type 2 diabetes specialty clinic may enhance providers accessibility and patients' outcomes while improving reimbursement in the ACO model., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Care coordinators may help manage care for children with chronic illness. Their role in pediatric epilepsy care is understudied. We aimed to qualitatively describe the content of a care coordination intervention for children with epilepsy., Methods: We conducted nine semi-structured interviews and one focus group with care coordinators at a pediatric accountable care organization (ACO) in Ohio. The care coordinators used a modified version of a published care coordination checklist for children with epilepsy (Patel AD, 2014). We analyzed transcripts using thematic analysis. We focused on (1) the content of the intervention; and (2) perceptions of facilitators and barriers to improve outcomes, with an emphasis on epilepsy specific facilitators and barriers., Results: Care coordinators interacted with children and families in multiple contexts (phone calls, physician visits, home visits), and included relationship building (developing rapport and trust between families and the health system), communication (transmission of information between the child, family, physician, and other care providers), and service (help with housing, transportation, scheduling, liaison with community resources, etc.). Facilitators and barriers of care coordination included factors related to parents, physicians, health system, payers, and community. Epilepsy-specific barriers included stigma (felt & enacted) and the anxiety associated with clinical uncertainty. Epilepsy related facilitators included a seizure action plan, written educational materials, and an epilepsy specific care coordination checklist., Conclusion: In addition to facilitators and barriers common to many care coordination programs, pediatric epilepsy care coordinators should be particularly aware of epilepsy stigma and clinical uncertainty. A care coordination checklist and epilepsy focused educational materials written to accommodate people with low health literacy may provide additional benefit. Further research is required to understand the effect of care coordination on costs, use of health services, seizure control, and quality of life for children with epilepsy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Importance: Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care., Objective: To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred., Design, Setting, and Participants: With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014., Exposures: Patient attribution to an ACO in the MSSP., Main Outcomes and Measures: Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics., Results: For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, -$106 per beneficiary [95% CI, -$176 to -$35], or -9.0% of the precontract unadjusted mean of $1172; P = .003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (-0.6 percentage points [95% CI, -1.1 to 0.0], or -2.7% of the unadjusted precontract mean of 22.6%; P = .03), and length of SNF stays (-0.60 days per stay [95% CI, -0.99 to -0.22], or -2.2% of the precontract unadjusted mean of 27.07 days; P = .002). Reductions in use of SNFs and length of stay were largely due to within-hospital or within-SNF changes in care specifically for ACO patients. Participation in the MSSP was associated with smaller significant reductions in SNF spending in 2014 for the 2013 ACO cohort (-$27 per beneficiary [95% CI, -$49 to -$6], or -3.3% of the precontract unadjusted mean of $813; P = .01) but not in the 2013 or 2014 cohort's first year of participation (-$13 per beneficiary [95% CI, -$33 to $6]; P = .19; and $4 per beneficiary [95% CI, -$15 to $24]; P = .66). Estimates were similar for ACOs with and without financial ties to hospitals. Participation in the MSSP was not associated with significant changes in 30-day readmissions, use of highly rated SNFs, or mortality., Conclusions and Relevance: Participation in the MSSP has been associated with significant reductions in postacute spending without ostensible deterioration in quality of care. Spending reductions were more consistent with clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs.

Background: Medicare's Accountable Care Organization (ACO) programs introduced shared savings to traditional Medicare, which allow providers who reduce health care costs for their patients to retain a percentage of the savings they generate., Objective: To examine ACO and market factors associated with superior financial performance in Medicare ACO programs., Methods: We obtained financial performance data from the Centers for Medicare and Medicaid Services (CMS); we derived market-level characteristics from Medicare claims; and we collected ACO characteristics from the National Survey of ACOs for 215 ACOs. We examined the association between ACO financial performance and ACO provider composition, leadership structure, beneficiary characteristics, risk bearing experience, quality and process improvement capabilities, physician performance management, market competition, CMS-assigned financial benchmark, and ACO contract start date. We examined two outcomes from Medicare ACOs' first performance year: savings per Medicare beneficiary and earning shared savings payments (a dichotomous variable)., Results: When modeling the ACO ability to save and earn shared savings payments, we estimated positive regression coefficients for a greater proportion of primary care providers in the ACO, more practicing physicians on the governing board, physician leadership, active engagement in reducing hospital re-admissions, a greater proportion of disabled Medicare beneficiaries assigned to the ACO, financial incentives offered to physicians, a larger financial benchmark, and greater ACO market penetration. No characteristic of organizational structure was significantly associated with both outcomes of savings per beneficiary and likelihood of achieving shared savings. ACO prior experience with risk-bearing contracts was positively correlated with savings and significantly increased the likelihood of receiving shared savings payments., Conclusions: In the first year, performance is quite heterogeneous, yet organizational structure does not consistently predict performance. Organizations with large financial benchmarks at baseline have greater opportunities to achieve savings. Findings on prior risk bearing suggest that ACOs learn over time under risk-bearing contracts., Implications: Given the lack of predictive power for organizational characteristics, CMS should continue to encourage diversity in organizational structures for ACO participants, and provide alternative funding and risk bearing mechanisms to continue to allow a diverse group of organizations to participate., Level of Evidence: III., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Addressing nonmedical needs-such as the need for housing-is critical to advancing population health, improving the quality of care, and lowering the costs of care. Accountable care organizations (ACOs) are well positioned to address these needs. We used qualitative interviews with ACO leaders and site visits to examine how these organizations addressed the nonmedical needs of their patients, and the extent to which they did so. We developed a typology of medical and social services integration among ACOs that disentangles service and organizational integration. We found that the nonmedical needs most commonly addressed by ACOs were the need for transportation and housing and food insecurity. ACOs identified nonmedical needs through processes that were part of the primary care visit or care transformation programs. Approaches to meeting patients' nonmedical needs were either individualized solutions (developed patient by patient) or targeted approaches (programs developed to address specific needs). As policy makers continue to provide incentives for health care organizations to meet a broader spectrum of patients' needs, these findings offer insights into how health care organizations such as ACOs integrate themselves with nonmedical organizations., (Project HOPE—The People-to-People Health Foundation, Inc.)

Accountable care organizations (ACOs) have diverse contracting arrangements and have displayed wide variation in their performance. Using data from national surveys of 399 ACOs, we examined differences between the 228 commercial ACOs (those with commercial payer contracts) and the 171 noncommercial ACOs (those with only public contracts, such as with Medicare or Medicaid). Commercial ACOs were significantly larger and more integrated with hospitals, and had lower benchmark expenditures and higher quality scores, compared to noncommercial ACOs. Among all of the ACOs, there was low uptake of quality and efficiency activities. However, commercial ACOs reported more use of disease monitoring tools, patient satisfaction data, and quality improvement methods than did noncommercial ACOs. Few ACOs reported having high-level performance monitoring capabilities. About two-thirds of the ACOs had established processes for distributing any savings accrued, and these ACOs allocated approximately the same amount of savings to the ACOs themselves, participating member organizations, and physicians. Our findings demonstrate that ACO delivery systems remain at a nascent stage. Structural differences between commercial and noncommercial ACOs are important factors to consider as public policy efforts continue to evolve., (Project HOPE—The People-to-People Health Foundation, Inc.)

Purpose: The implementation and outcomes are described for a clinical pharmacist-generated initiative to improve the performance of a Medicare Pioneer accountable care organization (ACO) quality measure evaluating the percentage of patients at least 18 years of age with heart failure and a left ventricular ejection fraction (LVEF) of less than 40% who are prescribed with an evidence-based β-blocker (carvedilol, metoprolol succinate, or bisoprolol)., Summary: Atrius Health clinical pharmacists developed several educational documents to facilitate appropriate prescribing of evidence-based therapies in patients with heart failure. After educating clinicians, clinical pharmacists reviewed patient charts to determine eligibility for initiating or switching to evidence-based β-blocker therapy. Medicare Pioneer ACO patients 18-85 years of age with heart failure and a current or prior LVEF of less than 40% were reviewed. Patients had a current prescription for metoprolol tartrate, atenolol, or no β-blocker. Patients were considered ineligible if they had a documented contraindication or intolerance to β-blocker therapy or were clinically unstable. Recommendations to initiate or switch to an appropriate β-blocker were sent electronically by a clinical pharmacist to an eligible patient's treating physician before a scheduled office visit. In approximately three months, 48 patients underwent chart review by a clinical pharmacist. Performance improved by 8% after the implementation, with 82% of eligible patients achieving the quality measure in 2014-an increase from 74% in 2013., Conclusion: The performance on a Medicare Pioneer ACO quality measure evaluating β-blocker use in systolic heart failure improved in a one-year period after a clinical pharmacist-generated initiative was implemented at Atrius Health practice sites., (Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Background: Even within fully integrated health care systems, primary care providers (PCPs) often lack support for medication management. Because challenges with conducting medication reconciliation, improving adherence, and achieving optimal patient outcomes continue to be prevalent nationally, it is critical that PCPs are provided the resources and support they need to provide high-quality, patient-centered care in an accountable care environment., Program Description: Sharp Rees-Stealy Medical Group uses a fully electronic medication refill system that allows for a centralized team to manage all incoming requests. Over time, 16 disease-specific protocols were created that allowed the pharmacy team to absorb approximately 80% of incoming refill requests for all enrolled PCPs. The refill clinic assessed all clinic information that a PCP would normally review in order to approve a refill. Tasks performed by the clinical pharmacists included medication reconciliation, dosage adjustment, and coordination of distribution from external mail order and retail pharmacies., Observations: In 2014, the number of tasks related to refill management reviewed by the refill/medication therapy management service totaled 302,592, resulting in 140,350 refill authorizations and multiple interventions related to medication use. Physicians have estimated that the service provides between 20 and 30 minutes of time savings per day. Assuming an annual PCP salary of around $200,000, 20 to 30 minutes per day would amount to $33 to $50 saved per day per physician. The savings is even higher when time savings from other clinical staff is included., Implications: The development of this electronic medication refill service has provided the following important lessons: (a) organizations rely on a leader or champion to push through process reforms--this program started with reluctant physicians first to determine best practices; (b) the lack of clinical pharmacist profiles within electronic health records (EHR) is a serious concern, since the creation of these profiles may not be easy or timely; and (c) PCPs working within an EHR environment will quickly embrace the idea of a service that can save them up to 30 minutes per day. With PCPs continuing to take on additional population health management tasks in accountable care organizations, pharmacists can provide workload offsets by meaningfully contributing to medication-related care.

Participants in the Texas Medical Association's Accountable Care Leadership Program learn about communication skills, teamwork, and population health management. The program helps physicians adapt in a rapidly changing environment that demands more accountability and proof of value for the health care dollar. The program targets early- to mid-career practicing physicians who recognize they need new tools to survive and thrive in the new environment.

Importance: Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services., Objective: To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services., Design, Setting, and Participants: In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to health care provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other health care providers (control group) before (2009-2011) vs after (2012) Pioneer ACO contracts began. Data analysis was conducted from December 1, 2014, to June 27, 2015. Comparisons were adjusted for beneficiaries' sociodemographic and clinical characteristics as well as for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs lower baseline use of low-value services., Main Outcomes and Measures: Use of, and spending on, 31 services in instances that provide minimal clinical benefit, measured as annual service counts per 100 beneficiaries and price-standardized annual service spending per 100 beneficiaries., Results: During the precontract period, trends in the use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction (95% CI) of 0.8 low-value services per 100 beneficiaries for the ACO group (-1.2 to -0.4; P < .001), corresponding to a 1.9% differential reduction in service quantity (-2.9% to -0.9%) and a 4.5% differential reduction in spending on low-value services (-7.5% to -1.4%; P = .004). Differential reductions were similar for services less sensitive vs more sensitive to patient preferences and for higher- vs lower-priced services. The ACOs with higher than their markets' mean baseline levels of low-value service use experienced greater service reductions (-1.2 services per 100 beneficiaries; -1.7 to -0.7; P < .001) than did ACOs with use below the mean (-0.2 services per 100 beneficiaries, -0.6 to -0.2; P = .41; P = .003 for test of difference between subgroups)., Conclusions and Relevance: During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low-value care. Accountable care organization-like risk contracts may be able to discourage use of low-value services even without specifying services to target.

Accountable care organizations represent a shift in health care delivery while providing a significant potential for improved quality and coordination of care across multiple settings. Otolaryngologists have an opportunity to become leaders in this expanding arena. However, the field of otolaryngology-head and neck surgery currently lacks many of the tools necessary to implement value-based care, including performance measurement, electronic health infrastructure, and data management. These resources will become increasingly important for surgical specialists to be active participants in population health. This article reviews the fundamental issues that otolaryngologists should consider when pursuing new roles in accountable care organizations., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Providing patient-centered care from preventive medicine to end-of-life care in order to improve care quality and reduce medical cost is important for accountable care. Physicians in the accountable care organizations (ACOs) are suitable for participating in supportive end-of-life care especially when facing issues in truth telling and treatment strategy. This study aimed to investigate patients' attitudes toward truth telling and treatment preferences in end-of-life care and compare patients' attitudes with their ACOs physicians' perceptions.This nationwide study applied snowball sampling to survey physicians in physician-led ACOs and their contracted patients by questionnaire from August 2010 to July 2011 in Taiwan. The main outcome measures were beliefs about palliative care, attitudes toward truth telling, and treatment preferences.The data of 314 patients (effective response rate = 88.7%) and 177 physicians (88.5%) were analyzed. Regarding truth telling about disease prognosis, 94.3% of patients preferred to be fully informed, whereas only 80% of their physicians had that perception (P < 0.001). Significant differences were also found in attitudes toward truth telling even when encountering terminal disease status (98.1% vs 85.3%). Regarding treatment preferences in terminal illness, nearly 90% of patients preferred supportive care, but only 15.8% of physicians reported that their patients had this preference (P < 0.001).Significant discrepancies exist between patients' preferences and physicians' perceptions toward truth telling and treatment strategies in end-of-life care. It is important to enhance physician-patient communication about end-of-life care preferences in order to achieve the goal of ACOs. Continuing education on communication about end-of-life care during physicians' professional development would be helpful in the reform strategies of establishing accountable care around the world.

Background: The accountable care organization (ACO) model being adopted across the United States aims to improve patient care and reduce costs. Little is known about whether commercial ACO contracts include accountability for prescription drug spending or how ACOs are engaging outpatient pharmacies and managing prescription drug use., Objective: To explore how ACOs are addressing drug spending and pharmacy services-a potentially important determinant of quality and total spending., Methods: We used data from 2 waves of the National Survey of Accountable Care Organizations (N = 270), a survey completed by ACOs that were established prior to July 2013. ACO executives were asked about ACO engagement of pharmacy services, pharmacy-related health information technology capabilities, and ACO accountability for prescription drug spending. , Results: Among ACOs with commercial contracts, 77% reported being held responsible for prescription spending by their largest contract. Considering all ACOs (Medicare, Medicaid, and/or commercial contracts), 45% reported at least 1 contract included prescription drug spending responsibility. Nearly half of ACOs reported a formal relationship with a pharmacy; 26% included a pharmacy within the ACO; and 19% had contracted pharmacy services. On average, compared with those that do not, ACOs that engage pharmacies have a broader range of services and provider types, commercial and public contracts, and greater experience with payment reform. , Conclusions: Management of pharmacy services and prescription spending will likely influence commercial ACO contract success. Given the broad potential impact of prescription use on overall spending and quality, payers might encourage integration of pharmacy services in ACOs through prescribing quality and prescription spending performance measures.

Traditional hospital wards are not specifically designed as effective clinical microsystems. The feasibility and sustainability of doing so are unclear, as are the possible outcomes. To reorganize a traditional hospital ward with the traits of an effective clinical microsystem, we designed it to have 4 specific features: (1) unit-based teams, (2) structured interdisciplinary bedside rounds, (3) unit-level performance reporting, and (4) unit-level nurse and physician coleadership. We called this type of unit an accountable care unit (ACU). In this narrative article, we describe our experience implementing each feature of the ACU. Our aim was to introduce a progressive approach to hospital care and training., (© 2014 Society of Hospital Medicine.)

Background: Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that accountable care organization implementation would selectively limit the use of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care, such as nondiscretionary cardiovascular imaging and procedures., Methods and Results: The intervention group was composed of fee-for-service Medicare patients (n=819 779) from 10 groups participating in a Medicare pilot accountable care organization, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934 621) from nonparticipating groups in the same regions. We compared use of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and nondiscretionary carotid and coronary imaging and procedures. Our main outcome measure was the difference in the proportion of patients treated with imaging and procedures among patients of PGPD practices compared with patients in control practices, before and after PGPD implementation (difference-in-difference). For discretionary imaging, the difference-in-difference between PGPD practices and controls was not statistically significant for discretionary carotid imaging (0.17%; 95% confidence interval, -0.51% to 0.85%; P=0.595) or discretionary coronary imaging (-0.19%; 95% confidence interval, -0.73% to 0.35%; P=0.468). Similarly, the difference-in-difference was also minimal for discretionary carotid revascularization (0.003%; 95% confidence interval, -0.008% to 0.002%; P=0.705) and coronary revascularization (-0.02%; 95% confidence interval, -0.11% to 0.07%; P=0.06). The difference-in-difference associated with PGPD implementation was also essentially 0 for nondiscretionary cardiovascular imaging or procedures., Conclusion: Implementation of a pilot accountable care organization did not limit the use of discretionary or nondiscretionary cardiovascular care in 10 large health systems., (© 2014 American Heart Association, Inc.)

Rationale and Objectives: Ongoing concerns over the rising cost of health care are driving large-scale changes in the way that health care is practiced and reimbursed in the United States., Materials and Methods: To effectively implement and thrive within this new health care delivery environment, academic medical institutions will need to modify financial and business models and adapt institutional cultures. In this article, we review the expected features of the new health care environment from the perspective of academic radiology departments., Conclusions: Our review will include background on accountable care organizations, identify challenges associated with the new managed care model, and outline key strategies-including expanding the use of existing information technology infrastructure, promoting continued medical innovation, balancing academic research with clinical care, and exploring new roles for radiologists in efficient patient management-that will ensure continued success for academic radiology., (Published by Elsevier Inc.)

Objective: The objective was to describe the design, implementation and preliminary results of a collaborative care pilot program using hybrid colocation and centralized care management for patients with depression and chronic medical illness in an urban accountable care organization., Methods: Patients with chronic illness (diabetes mellitus, coronary artery disease and/or congestive heart failure) and comorbid depressive symptoms (Patient Health Questionnaire [PHQ]9 score ≥10) were enrolled. The interventions included collaborative care for depression and chronic conditions; behavioral support, including short-term psychotherapy by licensed clinical social worker on-site or telephonically; off-site nurse care management and psychiatrist consultation through an electronic medical record., Results: Forty-four percent of patients (n=61) achieved a depression response. In a diabetes subgroup with depression and glycosylated hemoglobin level HbA1c >8 (n=21), 33% had a depression response with a minimum 0.5% HbA1c reduction. Among a subgroup (n=25) with Framingham risk score >15% and depression, mean PHQ9 depression scores and mean Framingham scores were reduced by 35% and 34%, respectively., Conclusions: Early experience of the pilot for multiple chronic illnesses and depression appears feasible and shows initial promise., (Copyright © 2013 Elsevier Inc. All rights reserved.)