The Big Idea in Understanding “Accountable Care Organizations”

Here’s the big idea: accountable care organizations (ACOs) are about creating accountability.

ACOs of various types are being proposed in national health reform legislation. For all you ever wanted to know about ACOs, read How to Create Accountable Care Organizations from the Center for Healthcare Quality and Payment Reform.   I spent an hour and a half poring over the details of this excellent report written by Harold Miller.

My mistaken impression has been to focus on the organizational form of ACOs, rather than their objectives.  Organizational form is relevant in understanding ACOs, but primarily as a means toward creating accountability, not the end in itself.  Thus, expect to see many varying types of ACOs emerging based on local needs and characteristics.

I initially approached reading the report with a number of top-of-mind tactical and programmatic questions about ACOs:

• What kinds of organizations can serve as ACOs?
• What do primary care practices need to do differently to become ACOs?
• What’s the difference between a medical home and an ACO?
• Can small primary care practices become an ACO?
• Should all physicians in a geographic area be included in a single ACO?
• What is the role of specialists in an ACO?
• Should hospitals be part of an ACO?
• Are integrated delivery systems the ideal model?
• How many payers need to support an ACO?
• Accountability for all or some costs?

The answers to these questions are important, but primarily because they go to how an ACO can achieve accountability…

… and the short answer to every one of these questions is “It depends”. 

Depends on what?

To the maximum extent possible, an organization’s ability to serve as an Accountable Care Organization should be determined by its success in improving outcomes – controlling costs, improving quality, and providing a good experience for patients – not on its organizational structure or even the specific care processes it uses. 

Let me try to explain the big idea of accountability from a couple of other angles.

For regular readers of this blog, the notion is very similar to the ongoing cat/dog dialogue for funding of EHRs under HITECH Federal stimulus funds

Do we want a health care system that pays for activity — doctors visits, lab tests, hospitals days, the simple adoption of technology (the cat POV).  Or does it make more sense to focus on results — improved outcomes, improved patient health, lowered costs, using technology to improve care (the dog POV), i.e., accountability?

Finally, for another amusing (but all too painfully real) perspective on the lack of accountability in health care today, read If Air Travel Worked Like Health Care, by Jonathan Rauch.  Hat tip to John Moore. Here’s the introduction:

“Hello! Thank you for calling Air Health Care, the airline that works like the health care system. My name is Cynthia. How can I give you travel care today?”

“Hi. My name is Jonathan Rauch. I need to fly from Washington, D.C., to Eugene, Oregon, on October 23.”

“Yes, I’d be happy to assist you with that. It does look like we can get you on a flight on January 23 at 1 p.m. or February 8 at 3 p.m. Which would you prefer?”