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At the Intersection of Health,Health Care and Policydoi:10.1377/hlthaff.2012.0544,31,no.11(2012):2368-2378Health AffairsAccountable Care OrganizationsA Framework For Evaluating The Formation,Implementation,And Performance OfBridget K.LarsonElliott S.Fisher,Stephen M.Shortell,Sara A.Kreindler,Aricca D.Van Citters andCite this article as:http:/content.healthaffairs.org/content/31/11/2368.full.htmlavailable at:The online version of this article,along with updated information and services,is For Reprints,Links&Permissions:http:/healthaffairs.org/1340_reprints.php http:/content.healthaffairs.org/subscriptions/etoc.dtlE-mail Alerts:http:/content.healthaffairs.org/subscriptions/online.shtmlTo Subscribe:written permission from the Publisher.All rights reserved.mechanical,including photocopying or by information storage or retrieval systems,without prior may be reproduced,displayed,or transmitted in any form or by any means,electronic orAffairs HealthFoundation.As provided by United States copyright law(Title 17,U.S.Code),no part of by Project HOPE-The People-to-People Health2012Bethesda,MD 20814-6133.Copyright is published monthly by Project HOPE at 7500 Old Georgetown Road,Suite 600,Health Affairs Not for commercial use or unauthorized distributionat WELLINGTON MEDICAL LIBRARY on October 3,2014Health Affairs by content.healthaffairs.orgDownloaded from at WELLINGTON MEDICAL LIBRARY on October 3,2014Health Affairs by content.healthaffairs.orgDownloaded from By Elliott S.Fisher,Stephen M.Shortell,Sara A.Kreindler,Aricca D.Van Citters,and Bridget K.LarsonA Framework For Evaluating TheFormation,Implementation,AndPerformance Of Accountable CareOrganizationsABSTRACTThe implementation of accountable care organizations(ACOs),a new health care payment and delivery model designed to improve careand lower costs,is proceeding rapidly.We build on our experiencetracking early ACOs to identify the major factorssuch as contractcharacteristics;structure,capabilities,and activities;and local contextthat would be likely to influence ACO formation,implementation,andperformance.We then propose how an ACO evaluation program could bestructured to guide policy makers and payers in improving the design ofACO contracts,while providing insights for providers on approaches tocare transformation that are most likely to be successful in differentcontexts.We also propose key activities to support evaluation of ACOs inthe near term,including tracking their formation,developing a set ofperformance measures across all ACOs and payers,aggregating thoseperformance data,conducting qualitative and quantitative research,andcoordinating different evaluation activities.The implementation of accountablecare organizations(ACOs),a newpayment and delivery model de-signed to improve health care andlower costs,is proceeding rapidlyin both the public and private sectors.As ofAugust 2012 we had identified 227 provider or-ganizations that have established ACO contractswith Medicare,Medicaid,private payers,orsome combination thereof.The ACO concept originated in response to agrowing recognition that fee-for-service pay-ment was a major contributor to the rapidly ris-ing costs and poorly coordinated care that char-acterize the US health care system.1Under thisnew payment model,provider groups willing tobeaccountablefortheoverallcostsandqualityofcare for their patients are eligible for a share ofthe savings achieved by improving care.Proponents believe that ACOs will encourageproviders across the full range of practice set-tingsfrom individual office-based practices tointegrated delivery systemsto improve qualityand slow spending growth.Under this model,payers establish quality benchmarks and risk-adjusted spending targets for the patients caredfor by the physicians in the ACO.If the organi-zation meets the quality benchmarks,it is theneligible for a share of the savings achieved belowthe set spending target.In some models,theorganization is also at risk for a portion of anyspending that exceeds the target.Early evidenceon ACO performance is promising.24Challengestothesuccessofthemodelremain,however.Little is known about what capabilitiesand activities are most important to the long-term success of these new organizations.Also,the optimal design of accountable care contractsbetween providers and payers is uncertain.In addition,many stakeholders are concernedabout the complex interactions among publicand private reform initiatives based on ACOs.For example,some economists wonder whetherimplementation of ACOs in the Medicare popu-doi:10.1377/hlthaff.2012.0544HEALTH AFFAIRS 31,NO.11(2012):236823782012 Project HOPEThe People-to-People HealthFoundation,Inc.Elliott S.Fisher(Elliott.S.Fisherdartmouth.edu)is director ofthe Center for PopulationHealth at the DartmouthInstitute for Health Policy andClinical Practice,in Hanover,New Hampshire.Stephen M.Shortell is deanof the University of California,Berkeley,School of PublicHealth.Sara A.Kreindler is aresearcher with the WinnipegRegional Health Authority,inManitoba,Canada.Aricca D.Van Citters is aresearcher with theDartmouth Institute.Bridget K.Larson is theformer director of healthpolicy implementation at theDartmouth Institute.2368Health AffairsNovember 201231:11Accountable Care Organizationsat WELLINGTON MEDICAL LIBRARY on October 3,2014Health Affairs by content.healthaffairs.orgDownloaded from lation will lead to provider consolidation andthus higher prices for private payers.Some pol-icy makers and providers are concerned that thefinancialincentivesmightnotbelargeenoughtomotivate the substantial changes required to im-prove care and worry that the barriers to changewill be too great to achieve hoped-for qualityimprovement and cost savings.5Ongoing and systematic evaluation of the im-plementation of these new payment models isessential to providing useful guidance to theseorganizations about how best to invest to trans-form care.6Additionally,systematic evaluationoftheimpactofACOsonbothqualityandcostsunder the different types of contracts that arealready being implementedwould allow policymakersandprivatepayerstorefinethedesignofthese contracts.In this article we give a brief overview of thecurrentstatusofACOimplementationandevalu-ation initiatives;provide a framework for think-ing about how ACOs may or may not achievetheirimpact,intheformofa“logicmodel”;drawon insights from the logic model to identify bar-riers to successful evaluation;and suggest spe-cific approaches to overcoming these barriers.Early ACO Implementation AndEvaluation ActivitiesSeveral early case studies have described thepaths that organizations have taken to establishACOs.79The Robert Wood Johnson Foundationrecently announced that it will fund additionalcase studies of nascent ACOs,with a particularinterest in those involving disadvantaged popu-lations.10The Commonwealth Fund has supported avariety of activities,including a policy analysisof the challenges for vulnerable populationsunder the accountable care model,11a survey ofhospitals ACO activities,12an ongoing evalu-ation of the Alternative Quality Contract inMassachusetts,3,4and work by Dartmouth andthe University of California,Berkeley,13to iden-tify the challenges to implementing a compre-hensive approach to evaluation and find ways toaddress them.There is some evidence that the ACO paymentmodel will be successful in lowering costs andimproving quality.For example,under the BlueCross Blue Shield of Massachusetts AlternativeQuality Contract,a payment model that allowsprovider groups in Massachusetts to retain thesavings they achieve while receiving additionalbonuses for documented quality improvements,providers have been able to make substantialqualityimprovementsandachievesomesavings.3,4Similarly,an analysis of the Medicare Physi-cian Group Practice Demonstration,a test of theACO model carried out from 2005 to 2010,re-vealedmodestsavingsforMedicarebeneficiariesoverall,but substantial savings for the highlyvulnerable and high-cost“dual eligible”popula-tion who are beneficiaries of both Medicare andMedicaid.2Public-Sector Programs In trying to learnfrom ACO implementation,it is important tounderstand current federal programs,becausethese are the largest in scope and will have amajor influence on the future design of private-payer models.The Centers for Medicare andMedicaid Services(CMS)has three distinctACO programs under way:the Medicare SharedSavingsProgram,thePioneerACOprogram,andthe Advance Payment ACO program.The Medicare Shared Savings Program is anational ACO program,not a demonstration orpilot project,established under the AffordableCare Act.The programthe largest of the three,with 115 provider organizations currently en-rolledoffers two incentive options:one inwhichACOsobtainbonuspaymentsiftheircostsare below their spending target,with no penal-ties if costs exceed the target(no risk);and asecond option that offers greater bonuses butrequires ACOs to pay a portion of costs thatexceed spending targets(risk bearing).The Pioneer ACO program is a demonstrationproject involving thirty-two organizations thatare required to bear at least some degree of riskfor costs that exceed their spending targets;theprogram has six slightly different financial in-centive designs.Finally,the Advance Payment ACO program isa demonstration project that provides some up-front federal funding to help 20 smaller andpoorlycapitalizedorganizationsasubsetofthe115 Medicare Shared Savings Program siteslaunch an ACO.The Center for Medicare andMedicaidInnovationisrequiredto evaluateonlythetwodemonstrationprogramsbecause,underthe Affordable Care Act,the secretary of healthand human services may extend these currentlyexperimentalpaymentmodelsnationallyifarig-orous evaluation,which meets the standards ofthe CMS Office of the Actuary,shows that theyhave been effective.Private-Sector Efforts In addition to thesepublic-sector efforts,private-sector ACO imple-mentation is proceeding apace.Most of the ma-jor payers have ACO or ACO-like contracting ini-tiativesunderway.Ofthe227organizationsthatwehaveidentifiedwithan ACOcontract,51haveonly private-payer contracts(17 of which havecontractswithmorethanoneprivatepayer),and29 have both a private-and a public-payer ACONovember 201231:11Health Affairs2369at WELLINGTON MEDICAL LIBRARY on October 3,2014Health Affairs by content.healthaffairs.orgDownloaded from contract.Other than the Commonwealth Fundand Robert Wood Johnson Foundation initia-tives described above,however,we know of noformal efforts to evaluate the impact of theseprivate-payer ACO programs.A Framework For Evaluation:AnACO Logic ModelDuring the past two years we have collaboratedwith researchers and stakeholders to explorehow best to advance learning in this rapidlychanging policy and practice environment.Our work was rooted in the principles of real-istic evaluation.This approach explores averageeffects(for example,what the CMS actuarywould need to know to conclude that,on aver-age,the Pioneer model led to reduced costs andimproved care).It also evaluates what strategiesandimplementationactivitiespursuedbypayersand ACOs are most likely to lead to better per-formance,and how this varies across ACOs op-erating under different conditions and localcontexts.A key step in this process of evaluating ACOswas the development of a“logic model.”Such amodel provides a graphical representation ofhow we believe that this approach to paymentand delivery reform might achieve its intendedeffects,what those anticipated effects might be,and what local and national factors might influ-ence success.We developed and progressively revised thelogicmodelbasedonfindingsfromtheBrookings-Dartmouth ACO pilot sites,7,13feed-back from national experts and ACO partici-pants,and insights from observing other effortsto evaluate delivery system reforms.3,4,14The cur-rent version of the logic model is provided in theonlineAppendix.15Exhibit1presentsanabridged,schematic overview of the logic modelwith some specific examples of implementationactivities,measurable outcomes,and associatedpotential impacts.Our first step in developing the model was tobe explicit about theimpact those who proposedthe ACO model hoped to achieve:bettercare andlower costs,not only for the patients served bytheorganization,butalsofortheircommunities,to ensure that ACOs do not achieve their benefi-cial impact on some patients at the expense ofothers.16The model then distinguishes four major cat-egories of influences:the national,state,andlocal context within which ACOs are launched;the readiness of the ACOs and their payer part-nersto adoptthemodel,as wellas thestructuresof the contracts themselves;the specific imple-mentation activities that ACOs and their payerpartnerspursue;andtheintermediateoutcomesof those activities.As an example of the first type of influence,national policy on health information technol-ogy and local health information exchangescould make it more likely that a given organiza-tion has a solid health information technologyfoundation at baseline.Anexampleofthethirdsetofinfluenceswouldinclude the strategic priorities that the ACO es-tablishes,such as setting quantitative targets forthe adoption of diabetes registries across theirprimary care practices,and the specific clinicalactivities that they pursue as a result,such asaggressively treating people who have both dia-betesandpoorlycontrolledbloodpressure.Boththe strategic priorities and specific clinical activ-ities undertaken would influence the degree towhich organizations achieve changes in the pa-tient care processes required to measurably im-prove quality and lower costs.Insights And ChallengesSeveral key insights emerged from the develop-ment of the logic model and our review of thecurrent status of ACO implementation andevaluation.Key InsightsDISTINGUISHFORMATIONFROMOPERAT-ING PERFORMANCE:First,it has become clearthat distinguishing formation and implementa-tion activities from performance will be impor-tant.Successfully implementing an ACOthatis,signing a contractand implementing a suc-cessfulACOaredifferentthings.Themodelclari-fies that these are distinct but overlappingprocesses.Capability development and implementationFor manyorganizations,performance couldbegin to improvesimply throughanticipation of apossible future ACOcontract.Accountable Care Organizations2370Health AffairsNovember 201231:11at WELLINGTON MEDICAL LIBRARY on October 3,2014Health Affairs by content.healthaffairs.orgDownloaded from activities in many of the organizations partici-patinginearlyaccountablecareinitiativesbeganwell before effective working relationships orcontractswereestablishedwithpayers.Formanyorganizations,performance could begin to im-prove simply through anticipation of and prepa-ration for a possible future ACO contractinde-pendent of whether they are yet willing to signsuch a contract.TRACK PROGRESS OVER TIME:Another keyinsight has to do with the rapid pace of change.Memories fade rapidly,so it is critical to trackover time
