Abstract
The US healthcare system has a history of continuous organizational change. The result is by no means a perfect healthcare system. However, a by-product of this history is a large number of experiments, making the USA probably the largest laboratory for healthcare delivery reform in the world. Both quality and costs are pressing issues for US healthcare reform. Efforts to address these issues by means of integrated care delivery and innovative payment models are mostly driven by the Centers for Medicare and Medicaid Services (CMS) and specifically the Center for Medicare and Medicaid Innovation (CMMI). Many of CMS’s reform efforts can be linked to goals now known as the Quadruple Aim: improving the experience of care and the health of populations, providers attaining joy in work, while reducing per-capita costs. These aims conflict with traditional, fragmented delivery structures and fee-for-service (FFS) payments, which are still the underlying structures or circumstances for reimbursing providers and delivering care for patients. One of the most discussed alternative payment models is the accountable care organization (ACO). This chapter illustrates the concept of ACOs and discusses some preliminary findings on the impact of this mode of integrated care delivery.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
AHA. (2015). Trendwatch chartbook 2015: Trends affecting hospitals and health systems. Washington. Available from https://www.aha.org/research/reports/tw/chartbook/2015/15chartbook.pdf. Accessed March 1, 2016.
AHA. (2019a). Fast facts on US hospitals. Available from https://www.aha.org/system/files/2019-01/2019-aha-hospital-fast-facts.pdf. Accessed March 4, 2020.
AHA. (2019b). Medicare ACOs generate nearly $740 million in 2018 net savings. Available from https://www.aha.org/news/headline/2019-10-01-medicare-acos-generate-nearly-740-million-2018-net-savings. Accessed March 14, 2020.
Aspen Publishers. (2015). Medicare, managed care, & other sources of revenue. Hospital Accounts Receivable Analysis, 29(1), 20–21.
Bazzoli, G. J., Dynan, L., Burns, L. R., & Yap, C. (2004). Two decades of organizational change in health care: What have we learned? Medical Care Research and Review, 61(3), 247–331.
Benstetter, F., Negele, D., Lauerer, M., & Schmid, A. (2020). Prospektive regionale Gesundheitsbudgets: Internationale Erfahrungen und Implikationen für Deutschland. Heidelberg: medhochzwei Verlag.
Berenson, R. A., & Burton, R. A. (2012). Next steps for ACOs: Health policy brief, January 31, 2012. Health Affairs.
Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573–576.
Broome, T. (2019). Pathways to success—MSSP continues to evolve. Available from https://www.aledade.com/pathways-success-mssp-continues-evolve. Accessed March 8, 2020.
Burns, L. R., & Pauly, M. V. (2018). Transformation of the health care industry: curb your enthusiasm? The Milbank Quarterly, 96(1), 57–109.
Casalino, L. P. (2014). Accountable care organizations—The risk of failure and the risks of success. The New England Journal of Medicine, 371(18), 1750–1751.
Castellucci, M. (2020). ACOs vulnerable to penalties, no savings in light of coronavirus. Available from https://www.modernhealthcare.com/finance/acos-vulnerable-penalties-no-savings-light-coronavirus. Accessed March 27, 2020.
Champagne, N., Mills, C., & Karcher, J. (2019). Pathways to success MSSP final rule: Key revisions to the proposed rule: Milliman issue brief.
CMS. (2015). Accountable care organizations (ACO). Available from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/Aco. Accessed February 29, 2016.
CMS (2016). Innovation center, next generation ACO model. Available from https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/. Accessed February 29, 2016.
CMS (2018a). Final rule creates pathways to success for the medicare shared savings program. Available from https://www.cms.gov/newsroom/fact-sheets/final-rule-creates-pathways-success-medicare-shared-savings-program. Accessed October 13, 2019.
CMS (2018b). Press release CMS finalizes “Pathways to Success,” an Overhaul of Medicare’s National ACO Program. Available from https://www.cms.gov/newsroom/press-releases/cms-finalizes-pathways-success-overhaul-medicares-national-aco-program. Accessed March 8, 2020.
CMS. (2019a). Medicare shared savings program: Quality measurement methodology and resources. Available from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/quality-measurement-methodology-and-resources.pdf. Accessed March 8, 2020.
CMS. (2019b). National health expenditure data. National health expenditures by type of service and source of funds, CY 1960–2018 (ZIP). Available from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical. Accessed March 22, 2020.
CMS (2020a). NHE fact sheet. Available from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet. Accessed 17 March 2020.
CMS. (2020b). Second evaluation report: Next generation accountable care organization model evaluation. Available from https://innovation.cms.gov/Files/reports/nextgenaco-secondevalrpt.pdf. Accessed March 23, 2020.
County Health Rankings. (2014). County health rankings model: Explore the county health rankings model. Available from https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model. Accessed March 8, 2020.
Cunningham, P., Garfield, R., & Rudowitz, R. (2015). How are hospitals faring under the affordable care act? Early experiences from ascension health. Available from https://www.kff.org/health-reform/issue-brief/how-are-hospitals-faring-under-the-affordable-care-act-early-experiences-from-ascension-health/view/print/. Accessed March 12, 2020.
Cutler, D. M., & Scott Morton, F. (2013). Hospitals, market share, and consolidation. JAMA, 310(18), 1964–1970.
DHHS. (2018). Accountable care organizations—Pathways to success and extreme and uncontrollable circumstances policies for performance year 2017—Final rule (Vol. 83, No. 249, pp. 67816–68082).
Douven, R., McGuire, T. G., & McWilliams, J. M. (2015). Avoiding unintended incentives in ACO payment models. Health Affairs, 34(1), 143–149.
Gaynor, M., & Town, R. (2012a). The impact of hospital consolidation—Update: the synthesis project, policy brief, No. 9.
Gaynor, M., & Town, R. J. (2012). Competition in health care markets. In M. V. Pauly, P. P. Barros, & T. G. McGuire (Eds.), Handbook of health economics: Volume 2, Handbooks in economics (1st ed., pp. 499–637). Amsterdam, Boston: Elsevier/North Holland.
Gee, E., & Gurwitz, E. (2018). Provider consolidation drives up health care costs. Available from https://www.americanprogress.org/issues/healthcare/reports/2018/12/05/461780/provider-consolidation-drives-health-care-costs/. Accessed October 23, 2019.
Gonzalez-Smith, J., Bleser, W. K., Muhlestein, D., Richards, R., McClellan, M. B., & Saunders, R. S. (2019). Medicare ACO results for 2018: more downside risk adoption, more savings, and all ACO types now averaging savings. Available from https://doi.org/10.1377/hblog20191024.65681/full. Accessed March 14, 2020.
Greene, S. (2003). The rise and decline of managed care. North Carolina Medical Journal, 64(1), 21–29.
Gusland, C., Herbold, J. S., Kramer, M. J., & Mills, C. (2019). Pathways to Success. MSSP final rule: Financial benchmark. Available from https://www.milliman.com/insight/pathways-to-success-mssp-final-rule-financial-benchmark. Accessed March 8, 2020.
HCPLAN. (2018). 2018 APM measurement infographic. Available from https://hcp-lan.org/2018-apm-measurement/2018-infographic/. Accessed March 14, 2020.
HealthyPeople.gov. (2020). Social determinants of health. Available from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed March 8, 2020.
HHS. (2015). Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value: HHS press release, January 26, 2015. Available from https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Accessed February 29, 2016.
Himmler, S., & Jugl, M. (2016). Hospital costs in the U.S. and Germany. In A. Schmid, & B. Fried (Eds.), Crossing borders—Health reform in the U.S., Schriften zur Gesundheitsökonomie (pp. 41–55). Bayreuth, P.C.O.-Verlag.
Horwitz, L. I., Chang, C., Arcilla, H. N., & Knickman, J. R. (2020). Quantifying health systems’ investment in social determinants of health, by sector, 2017–19. Health Affairs (Project Hope), 39(2), 192–198.
Introcaso, D., & Berger, G. (2015). MSSP year two: medicare ACOs show muted success. HealthAffairsBlog. Available from https://healthaffairs.org/blog/2015/09/24/mssp-year-two-medicare-acos-show-muted-success/. Accessed March 1, 2016.
Jackson, G. L., Powers, B. J., Chatterjee, R., Prvu Bettger, J., Kemper, A. R., Hasselblad, V., et al. (2013). The patient-centered medical home. Annals of Internal Medicine, 158(3), 169.
King, R. (2020). ACOs seek flexibility from CMS to mitigate losses due to coronavirus. Available from https://www.fiercehealthcare.com/payer/acos-seek-flexibility-from-cms-to-mitigate-losses-due-to-coronavirus. Accessed March 27, 2020.
Manchikanti, L., Helm Ii, S., Benyamin, R. M., & Hirsch, J. A. (2017). A critical analysis of Obamacare: Affordable care or insurance for many and coverage for few? Pain Physician, 20(3), 111–138.
Marmor, T., & Oberlander, J. (2012). From HMOs to ACOs: the quest for the holy grail in U.S. health policy. Journal of General Internal Medicine, 27(9), 1215–1218.
McClellan, M., Kocot, L. S., & White, R. (2015). Medicare ACOs continue to show care improvements—And more savings are possible. HealthAffairsBlog. Available from https://healthaffairs.org/blog/2015/11/04/medicare-acos-continue-to-show-care-improvements-and-more-savings-are-possible/. Accessed March 1, 2016.
Muhlestein, D., Gardner, P., Merrill, T., Petersen, M., & Tu, T. (2014). A Taxonomy of accountable care organizations: Different approaches to achieve the triple Aim. Available from https://leavittpartners.com/wp-content/uploads/2014/06/A-Taxonomy-of-Accountable-Care-Organizations.pdf. Accessed June 1, 2015.
Nacoti, M., Ciocca, A., Giupponi, A., Brambillasca, P., Lussana, F., et al. (2020). At the epicenter of the covid-19 pandemic and humanitarian crises in italy: Changing perspectives on preparation and mitigation. Available from https://catalyst.nejm.org/doi/pdf/10.1056/CAT.20.0080. Accessed March 27, 2020.
Neprash, H. T., Chernew, M. E., & McWilliams, J. M. (2017). Little evidence exists to support the expectation that providers would consolidate to enter new payment models. Health Affairs, 36(2), 346–354.
Patel, Y. M., & Guterman, S. (2017). The evolution of private plans in medicare. Available from https://www.commonwealthfund.org/publications/issue-briefs/2017/dec/evolution-private-plans-medicare. Accessed March 8, 2020.
Pope, C. M. (2014). How Obamacare fuels health care market consolidation: The heritage foundation, backgrounder, No. 2928, Available from https://thf_media.s3.amazonaws.com/2014/pdf/BG2928.pdf. Accessed March 1, 2016.
Schmid, A., & Himmler, S. (2015). Netzwerkmedizin - Impulse für Deutschland aus den USA: Stiftung Münch, Projektbericht, München.
Verma, S. (2019). Interest in ‘Pathways To Success’ grows: 2018 ACO results show trends supporting program redesign continue. Available from https://www.healthaffairs.org/do/10.1377/hblog20190930.702342/full/. Accessed March 17, 2020.
Vogenberg, F. R. (2019). US healthcare trends and contradictions in 2019. American Health & Drug Benefits, 12(1), 40–47.
WHO. (2020). Social determinants of health: What are social determinants of health? Available from https://www.who.int/social_determinants/en/. Accessed March 8, 2020.
Wilensky, G. R. (2011). Lessons from the physician group practice demonstration—A sobering reflection. New England Journal of Medicine, 365(18), 1659–1661.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2021 Springer Nature Switzerland AG
About this chapter
Cite this chapter
Schmid, A., Des Jardins, T., Lehmann, A. (2021). Innovative Payment and Care Delivery Models: Accountable Care Organizations in the USA. In: Amelung, V., Stein, V., Suter, E., Goodwin, N., Nolte, E., Balicer, R. (eds) Handbook Integrated Care. Springer, Cham. https://doi.org/10.1007/978-3-030-69262-9_51
Download citation
DOI: https://doi.org/10.1007/978-3-030-69262-9_51
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-69261-2
Online ISBN: 978-3-030-69262-9
eBook Packages: Business and ManagementBusiness and Management (R0)