ACA…ACO…Please Explain!?


Brought to you by Dr. Sukhi Bains.

A review of: McClellan M et al. (2014). Accountable Care Around The World: A Framework To Guide Reform Strategies. Health Affairs; 33(9): 1507-1515


We had another great Journal Club at the last Health Policy Mini-Fellowship meeting in November. The theme for the night was Accountable Care Organizations (ACOs). Now if you have been reading anything about how we should spend the grants offered through the Affordable Care Act (ACA), ACOs have been undoubtedly front and center. This article attempts to demystify the idea of ACOs by providing concrete examples of how other countries have implemented them, and what they are actually meant to provide.


The article frames the discussion with the so called “Triple Aim” of health care reform – increase quality, slow the growth in costs, and improve health care outcomes. How ACO’s fit in fulfilling these goals is by changing the model of health care reimbursement form one driven by providers and supply to one driven by regulation, demand and patient outcomes.


The authors explain “In accountable care, payments are designed to support groups of care providers in achieving a defined and measurable set of target outcomes for individual patients and specified patient populations. Reimbursement is partly based on the providers collective performance as measured against the target outcomes.” (pg. 1508).


The utility of the article comes in providing concrete examples of ACOs and their outcomes in other countries, and reinforcing that this idea is not a novel one. Globally, ACOs have been successfully implemented in numerous healthcare systems, and have demonstrated their ability to control health care costs without compromising health care quality or outcomes. They are not infallible in the least, but they are an option when looking at controlling health care costs. The examples presented in the article are from Spain and Singapore, both cases demonstrated the versatility of ACOs and their malleability to context.


The authors provide a theoretical framework to assess developing ACOs by stratifying the maturity of five major functional components –  their population, outcomes, metrics and learning, payments and incentives and coordinated delivery. The goal is to provide a point of departure in discussing and evaluating these organizations through this new phase of the Affordable Care Act.


Now how does this apply to us? As physicians, we are heading into an era of health care reform that is informed by pragmatism. We are going to be practicing in environments where we will be held accountable to the quality measures in reimbursement models, as defined by the  needs of specific patient populations. We are a part of a new shift in thinking about how we are going to be spending health care dollars in this country, and how we are going to define the quality of its outcomes. ACOs are in place all over the world and there is much to be gained by looking beyond the borders of this country in maximizing their potential benefit for our patients. Being informed of these changes will make us educated health care consumers and providers in the shifted framework of our future practice environments.

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