Academic journal article Journal of Healthcare Management

Implementing Accountable Care Organizations: Lessons from a Qualitative Analysis of Four Private Sector Organizations

Academic journal article Journal of Healthcare Management

Implementing Accountable Care Organizations: Lessons from a Qualitative Analysis of Four Private Sector Organizations

Article excerpt


Accountable care organizations (ACOs) represent a new delivery model in healthcare, consisting of a network of providers who form an arrangement with a payer to take responsibility for both the costs and quality of care for a defined patient population (Fisher & Shortell, 2010; Lee, Casalino, Fisher, & Wilensky, 2010; McClellan, McKethan, Lewis, Roski, & Fisher, 2010). This network is financially rewarded (or penalized) on the basis of whether it meets cost and quality benchmarks, which, in turn, depend on the level of risk sharing between the provider network and the payer. Recent estimates suggest that there are more than 700 ACos covering nearly 24 million lives, and early results show that this payment scheme is achieving reduced costs and improved quality on a broad scale (Centers for Medicare & Medicaid Services [CMS], 2014; Muhlestein, 2015; Peterson & Muhlestein, 2014).

In these early stages of ACO development, research has focused on characterizing both the structure of ACOs and the providers choosing to enter these contractual arrangements (Lewis, Colla, Carluzzo, Kler, & Fisher, 2013; Mora & Walker, 2016; Shortell et al., 2015; Shortell, Wu, Lewis, Colla, & Fisher, 2014; Yeager, Zhang, & Diana, 2015). Although this research has clarified the national landscape of ACO development, it largely depicts provider participation as a binary construct (i.e., a provider is or is not participating in an ACO). This categorization has advantages for research purposes but is reductive of the process involved in establishing the ACO. In fact, successful implementation of the ACO model requires significant change across all levels of an organization to achieve cost reductions and quality improvement (Hilligoss, Song, & McAlearney, 2017). Yet, although the activities associated with the process of ACO implementation (e.g., implementation of health information technology [IT]) have been identified as important areas for evaluation, they remain largely unexplored (Fisher, Shortell, Kreindler, Van Citters, & Larson, 2012).

Organizational challenges and facilitators-technology, capital, labor, and cultural resources-pertaining specifically to the process of ACO implementation need to be outlined. Larson et al. (2012) examined the transformation occurring at four private sector ACO sites; they noted that the change was a journey, not simply the act of signing a contract. By examining facilitators of ACO formation, that study contributed to the framing of ACO implementation as a process; however, it did not provide an in-depth analysis of challenges experienced during the implementation process. Our study builds on existing work by assessing both the challenges and facilitators of ACO implementation within a theoretical framework of innovation implementation-the complex innovation implementation framework (CHF; Helfrich, Weiner, McKinney, & Minasian, 2007; Klein & Sorra, 1996). We present support for this model by focusing on the processes involved in ACO implementation in four diverse private sector ACOs. Viewed within this theoretical framework, ACO implementation is more complex than a payment schedule requiring adoption; rather, it is an innovation involving a comprehensive knowledge of organizational change processes.

The results of this investigation can guide healthcare system leaders considering the ACO model, as well as those in the early stages of ACO participation. In addition, a more in-depth understanding of the implementation issues facing providers can help payers as they seek to develop ACOs and other value-based incentive programs.


Given the rapidity of health policy changes accompanied by an increasingly strong emphasis on quality improvement and cost reduction, the healthcare field has frequently drawn from the robust literature on organizational change (Goonan, Muzikowski, & Stoltz, 2009; Kash, Spaulding, Johnson, & Gamm, 2014; Shea, Jacobs, Esserman, Bruce, & Weiner, 2014; Spaulding, Kash, Johnson, & Gamm, 2017). …

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