Annotated Bibliography on American Accountable Care Organizations*

Prepared for the Tongji Medical College, Wuhan, China-October 2016

by J. Warren Salmon, PhD

University of Illinois at Chicago, School of Public Health
and Ravinder Multani, MPH

INTRODUCTION
The Accountable Care Organization form was introduced by the Patient Portability and Affordable Care Ace (PPACA) of 2010, but
essentially now has become a private sector initiative, with Centers for Medicare and Medicaid (CMS) in a regulatory role. The
academic literature has still to grasp the ACO movement, so descriptions come mainly from public relations releases, health care
newsletters, and popular media. All of this development demands a "wait and see" perspective, since ACOs are really a nascent
development beginning phase one. A few issues to consider in examining a particular ACO include serving different populations;
relationship between physicians and management; involvement with patients; ownership and control over the ACO; how much
professionals participate in management decisions; whither goes the metrics, incentives that work; does preventive medicine save;
and acceptance and results of bundled payments across disciplines. For sure, the ACO development is reconfiguring the United
States health care system; quality improvements are now in the forefront of policy interventions, but it is still not an easy but long
path. Major players are shaping the merger and acquisition trend for insurers, hospital systems, physician groups, pharmacy benefit
managers, and retail chain drug stores; these are emerging into powerful large-scale national and regional corporations grasping
their way to financial success and handsome profits.

Gold, J. Accountable Care Organizations, Explained. Kaiser Health News. 2015, 14 September. http://khn.org/news/aco-
accountable-care-organization-faq/
ACOs are to seek cost reductions by engaging doctors, hospitals, and other health care providers to form networks to coordinate
patient care. Bonuses can be awarded for delivering care more efficiently. Six million Medicare beneficiaries are in ACOs and a total
of 744 ACOs serve another 23.5 million Americans as of September 2015. Consolidations among providers and now the largest
insurers has spurred forward the Medicare Shared Savings Program, which was intended to restrain costs as baby boomers entered
retirement ages. After paying bonuses, the program resulted in a net loss of $2.6 million dollars to the trust fund.
Punke, Heather. "3 Things the Most Innovative Health Systems Do." Becker's Hospital Review. ASC COMMUNICATIONS 2015, 19
Sept. 2014. http://www.beckershospitalreview.com/hospital-management-administration/3-things-the-most-innovative-health-
systems-do.html
In a constantly changing industry of healthcare, innovation is the key. New ideas, originality and creative thinking helps set healthcare
apart from other organizations. Centralizing innovation in the mission statement creates a different mindset and re-imagines the
layout of the system altogether. The practice of medicine is rethinking their curriculum in order to become more innovative, they are
now not only accepting students based on academic accomplishments but also on their emotional intelligence. The change came
about after the Patient Protection and Affordable Care Act. As they both emphasizing working in teams and becoming more
connected and patient centered. Changing the selection criteria will change how the physicians are trained. True innovative health
systems teach and spread the word throughout the industry in order to become successful by spreading the concept and execution
of the innovation to the public.
Ellison, Ayla. "7 Recently Announced ACOs." 7 Recently Announced ACOs. ASC COMMUNICATIONS 2015, 04 June 2014.
http://www.beckershospitalreview.com/accountable-care-organizations/june-4-2014.html
Within the last month these 7 ACOs have been accounted for value based care; United Health care in association with Arizona Care
Network, Kindred Healthcare Partners with Silver Stare in Louisville, KY, Aetna Northeast Medical group affiliated with New Haven,
Connecticut, Aetna Santa Clara County affiliated with San Mateo, CA, Northshore, Alexian Brothers received stated approval from
Illinois to form Medicaid ACOs, Bellin Health from Green Bay, Wisconsin joined Blue Priority, and Tenet Healthcare Dallas based and
Florida Blue also established ACOs.

*My thanks to Naimah Mailk and Agatha Gallo for assistance in preparing this paper.

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Gamble, Molly, Heather Punke, Ayla Ellison, Akanksha Jayanthi, and Dani Gordon. "100 Accountable Care Organizations to Know."
Becker's Hospital Review. ASC COMMUNICATIONS 2015, 13 Aug. 2014. http://www.beckershospitalreview.com/lists/100-
accountable-care-organizations-to-know.html
In this 2014 Becker’s Hospital Review has a 100 variety of Medicare and commercial ACOs are highlighted, led by either hospitals or
health systems. The selection of the ACOs depended upon the number of physicians partaking and lived covered, the duration of the
ACO, if it has multi-payer arrangements, and if it recently made new agreements with its payers. The ACOs are listed in alphabetical
order and by their formal name. If the ACO has more than one contract then they are listed by its affiliated health system or provider
group name.
Frakt, Austin. "Accountable Care Organizations: Like H.M.O.s, but Different." The New York Times. The New York Times, 19 Jan.
2015. http://www.nytimes.com/2015/01/20/upshot/accountable-care-organizations-like-hmos-but-different.html
ACOs are not HMOs. As put by Harvard health economist David Cutler, ‘ACOs are providers that decide on good care and work with
patients to provide that care.’ Medicare ACOs don’t require beneficiaries to receive all of the care within the organization in order to
be compensated, but HMOs do. ACOs also do not rely on capitation, are developing better information resources such as EMRs, and
they put providers at risk for a portion of the cost of care. The design of ACOs was evolved from capitation-based HMOs, but
capitation and ACOs encourage the providers to integrate. ACOs can lead to increased market power through mergers of hospitals
and integration with physician groups.
Barnett, Shannon, Tamara Rosin, and Heather Punke. "ACO Manifesto: 75 Things to Know about Accountable Care Organizations."
Becker's Hospital Review. ASC COMMUNICATIONS 2015, 9 Oct. 2014. http://www.beckershospitalreview.com/accountable-care-
organizations/aco-manifesto-75-things-to-know-about-accountable-care-organizations.html
ACOs are a new model of care created by the Patient Protection and Affordable Care Act in 2010. Becker’s Hospital Review provides
an updated version of the 2013 edition that includes ACO basics, ACOs by the numbers, words and phrases associated with ACOs,
specifics about Medicare and Medicaid ACOs, commercial ACOs and the relationship between health IT and ACOs.
Colla, Carrie. "Swimming Against the Current-What Might Work to Reduce Low-Value Care?" The Commonwealth Fund. New
England Journal of Medicine, 29 Oct. 2014. http://www.commonwealthfund.org/publications/in-brief/2014/oct/swimming-
against-the-current
One-third of U.S. healthcare spending is wasteful, healthcare organizations are attempting to reducing overuse to improve quality
and slow spending growth. American Board of Internal Medicine Foundation's Choosing Wisely program, the U.S. Preventive Services
Task Force, and the National Quality Forum have been pushing for low-value services to improve the overall value of care for years.
Low-value care can be defined in terms of net benefit, “a function of the expected benefit and cost for an individual or group and is
assessed relative to alternatives, including no treatment.” Demand-side interventions (aimed for patients), supply-side interventions
(aimed for providers) can be used to get physicians and patients to support low-value care policy. The best alternative is population-
based supply side incentives.

History of Past Organization Forms as "Solutions"

At times in the history of American medical care, various organizational forms have been proffered as solutions to the cost, access,
and quality issues. The Committee on the Costs of Medical Care in the late 1920s proposed the prepaid group practices (PPPGs),
which were to employ doctors by hospitals in a new division of labor with allied health professionals. The Great Depression and stiff
opposition from the American Medical Association prevented this form from becoming a nationwide phenomenon. Nevertheless,
certain employer groups (Kaiser Industries) and unions (the UAW, ILGW, and more) and co-ops (the Group Health Cooperative of
Puget Sound) embraced PPGPs lasted up until the Nixon’s HMO movement took up the banner again for large-scale, prepaid,
enrolled population groups. Other group practices formed at Ross-Loos, Mayo Clinic, Cleveland Clinic, among others that are
mainstays in their respective areas today. The HMO strategy of the late 1960s revitalized the prepaid group practice movement
seeking 1000 giant profit-oriented systems of care across the nation. Watergate and the 1973-75 recession stymied federal
stimulation, but private insurers, hospitals, and other startup firms began HMOs that grew for the employer group and gained a
sizeable Medicare population. Without federal subsidization, the IPA form 9individual practice associations) spread widely to engulf
private patients into prepaid and capitation arrangements dominated by corporate HMOs. The Balanced Budget Amendments of
1992 signed by Clinton led to mass withdrawals from the Medicare market, and significant failures to perform led HMOs that faced
disadvantaged, sicker patients facing huge popular opinion crises. In the end, the principles of managed care were eroded by its
practice, both due to bottom-line dictates and the inherent challenges of improving care models amidst patient satisfaction.

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Frakt, Austin. "Accountable Care Organizations: Like H.M.O.s, but Different." The New York Times. The New York Times, 19 Jan.
2015. http://www.nytimes.com/2015/01/20/upshot/accountable-care-organizations-like-hmos-but-different.html
ACOs are not HMOs. As put by Harvard health economist David Cutler, ‘ACOs are providers that decide on good care and work with
patients to provide that care.’ Medicare ACOs don’t require beneficiaries to receive all of the care within the organization in order to
be compensated, but HMOs do. ACOs also do not rely on capitation, are developing better information resources such as EMRs, and
they put providers at risk for a portion of the cost of care. The design of ACOs was evolved from capitation-based HMOs, but
capitation and ACOs encourage the providers to integrate. ACOs can lead to increased market power through mergers of hospitals
and integration with physician groups.
Gardner, Paul. "How Many Patients Are in ACOs?" Becker's Hospital Review. Becker's Healthcare, 18 June 2014.
http://www.beckershospitalreview.com/accountable-care-organizations/how-many-patients-are-in-acos.html
Since June 2012 ACOs have grown from 221 to 626 as of May 2014. Since it’s difficult to determine the increase if one looks at the
number, so looking at the number of patients impacted by ACOs will be significant. Enrolled patients are the most useful way of
measuring the impact of ACOs since they only offer certain services to patients. Another method of measuring impact is through
looking at the number of patients being served by the providers partaking in an ACO. And lastly access to an ACO is another method
to view impact of ACOs.
Overland, Dina. "5 Complex Care Management Methods to Boost ACO Success." FierceHealthPayer. FierceMarkets, 19 Aug. 2014.
http://www.fiercehealthpayer.com/story/5-complex-care-management-methods-boost-aco-success/2014-08-19
ACO’s require high-need and high-cost patients leading to expensive and challenging programs. However, a team of researchers have
identified ACOs that can successfully implement complex care management (CCM) programs that insurers and providers can use to
decrease the cost and enhance the care. From the Commonwealth Fund five of the eighteen methods are listed: 1) tailor to the local
environment, 2) identify best patients, 3) share information, 4) offer specialized training and 5) incorporate technology.
Bithoney, William. "6 Necessary Guidelines to Create and Manage a Successful ACO." Becker's Hospital Review. ASC
COMMUNICATIONS 2015, 21 July 2014. http://www.beckershospitalreview.com/accountable-care-organizations/6-necessary-
guidelines-to-create-and-manage-a-successful-aco.html
ACOs are bringing a revolutionary shift in the healthcare industry from focusing off of volumes and onto outcomes. The focus has
shifted from treating a sick individual to taking precautionary measures at the right time and the right place to keeping individuals
healthy. To successfully create and manage ACOs the following six guidelines should be followed: 1) understand the ACO model, 2)
recognize the necessity of information of technology, 3) implement clinical strategies, 4) Assure admission to lower cost in-network
hospitals, 5) follow CMS’ quality metrics, and 6) improve care across the continuum. In order for a ACO to become successful these
guidelines should be followed meticulously, with a high focus on clinical care improvement. No ACO will be successful if the clinical
outcomes, patient engagement and satisfaction are not met.
Overland, Dina. "What If Insurers Operated More like ACOs?" FierceHealthPayer. FierceMarkets, 22 Mar. 2014.
http://www.fiercehealthpayer.com/story/what-if-insurers-operated-more-acos/2014-03-22
Many of the ACO models looked in this report have controlled costs and boosted quality care. They believe this is due to
communication and coordination among providers. These insurances are also using EMRs, integrating care and focusing on
prevention. The insurance industry is shifting since ACA requires a new business to consumer approach and has an emphasis on care
and coordination. If insurances shifted they would see a greater consumer satisfaction rate and could result in a larger membership
rate.

ObamaCare and ACOs

The ACO conceptualization was ushered in by the ACA of 2010 to create organizational systems of identified providers (physicians
and hospitals) to achieve quality measured and financial performance for cost savings. Sixty-five attempts by the Republican
Congress to end ObamaCare and two Supreme Court decisions have been unable to do much other than slow and interfere in its
implementation. ACOs were created under sec. 2706 of Patient Protection and Affordable Care Act of 2010 and under section 3022
to take part in Medicare Shared Savings Program (MSSP). The ACA established ACOs, MSSP, and other new patient care models.
ACOs include primary care physicians, hospitals, specialists, nurse practitioners, physicians’ assistants, and others. MSSP rewards
ACOs that take responsibility for quality and cost received by their patient panel. ACOs that are successful at meeting the target
quality of care and reduce costs of their patients to a spending benchmark are rewarded with a share of the savings. Under the ACA,
ACOs are expected to cover pre-existing condition exclusions, end arbitrary withdrawals of insurance coverage, guarantee right to

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appeal, keep adults under 26 years covered under parents policies, end lifetime limits on coverage, review premium increases, help
get the most for premium dollars, cover preventive care at no cost, protect choice of doctors, and remove insurance company
barriers to emergency services.
Here’s how ACOs plan to increase healthcare value.

Overland, Dina. "5 Complex Care Management Methods to Boost ACO Success." FierceHealthPayer. FierceMarkets, 19 Aug. 2014.
http://www.fiercehealthpayer.com/story/5-complex-care-management-methods-boost-aco-success/2014-08-19
ACO’s require high-need and high-cost patients leading to expensive and challenging programs. However, a team of researchers have
identified ACOs that can successfully implement complex care management (CCM) programs that insurers and providers can use to
decrease the cost and enhance the care. From the Commonwealth Fund five of the eighteen methods are listed: 1) tailor to the local
environment, 2) identify best patients, 3) share information, 4) offer specialized training and 5) incorporate technology.
Medicare Learning Network, Summary of Final Rule Provisions for Accountable Care Organizations Under the Medicare Shared
Savings Program. Department of Health and Human Services, 2014 April. ICN-907404. www.cms.gov/Medicare/Medicare-Fee-
for-Service-Payment/
Finalized regulations under the ACA speak to how to create an accountable care organization and help reduce "the rate of growth in
health care spending." Differences remain between Medicare ACOs and private managed care plans under the Medicare Advantage
Program. CMS role is to assess ACO quality and financial performance each year. ACOs may include: practitioners in group
practices; networks of individual practices; joint ventures between hospitals and professionals; hospitals and other medical care
providers and suppliers. ACOs must accept 5000 Medicare fee-for-service enrollees to participate in the Shared Savings Program,
but there is no guarantee that it will be automatically accepted by CMS. The regulations establish quality performance measures
and the methodology for tracking quality tied to financial performance, set at a "high bar" for coordinated care.

Bithoney, William. "6 Necessary Guidelines to Create and Manage a Successful ACO." Becker's Hospital Review. ASC
COMMUNICATIONS 2015, 21 July 2014. Web. <http://www.beckershospitalreview.com/accountable-care-organizations/6-
necessary-guidelines-to-create-and-manage-a-successful-aco.html>
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ACOs are bringing a revolutionary shift in the healthcare industry from focusing off of volumes and onto outcomes. The focus has
shifted from treating a sick individual to taking precautionary measures at the right time and the right place to keeping individuals
healthy. To successfully create and manage ACOs the following six guidelines should be followed: 1) understand the ACO model, 2)
recognize the necessity of information of technology, 3) implement clinical strategies, 4) Assure admission to lower cost in-network
hospitals, 5) follow CMS’ quality metrics, and 6) improve care across the continuum. In order for a ACO to become successful these
guidelines should be followed meticulously, with a high focus on clinical care improvement. No ACO will be successful if the clinical
outcomes, patient engagement and satisfaction are not met.
Ellison, Ayla. "The Changing Healthcare World: 7 Trends to Watch." Becker's Hospital Review. Becker's Healthcare, 8 Sept. 2014.
http://www.beckershospitalreview.com/hospital-management-administration/the-changing-healthcare-world-7-trends-to-
watch.html
Seven of the biggest healthcare trends in 2014 were discussed during a forum. Becker discussed these seven trends: cost vs. benefit
of healthcare reform, growth in high-deductible health plans, balancing of freedom of religion with provisions of the PPACA,
uncertainty of insurance subsidies, “ends justify the means” politics, broad agreement on one provision of health reforms, and
growth in consolidation.

Quality Assessments
CMS has led the way on establishing metrics and measurement methodologies and led to incentivizing doctors for adoption of
electronic health records (meaningful use) to foster clinical integration and coordinated care. With established referral patterns,
bundling, medical homes, among other steps taken, some successes have been noteworthy, perhaps overall still suffering from lack
of widespread dissemination of these "best practices." Measures established for the Medicaid/Medicare programs are now being
expanded by private insurance companies with the greater number of benchmarks indicating varied approaches. Bundled payments
across specialties remain technically challenging and politically unfavorable.

Jayanthi, Akanksha. "10 Improving Quality Measures, 8 Worsening Quality Measures." Becker's Infection Control & Clinical
Quality. ASC COMMUNICATIONS 2015, 22 May 2014. http://www.beckershospitalreview.com/quality/10-improving-quality-
measures-8-worsening-quality-measures.html
The 2013 National Healthcare Disparities Report released by the Agency of Healthcare Research and Quality that reported quality
measures improved from 2000 to 2011, noting most years before Obamacare. There are 10 quality measures improved nationwide
and 8 quality measures worsened nationwide.
Rau, J. and Gold, J. Medicare Yet to Save Money through Heralded Medical Payment Model. Kaiser Health News. 2015, 14
September. http://khn.org/news/medicare-yet-to-save-money-through-heralded-medical-payment-model/
CMS bonuses for ACOs have yet to save the government money, nearly half of the ACOs costing more than the estimate would
normally cost. Medicare paid $60 billion dollars to 353 ACOs in 2014 to care for nearly 6 million beneficiaries, with a resulting loss to
the Medicare trust fund of $3 million dollars. Bearing risk by 157 ACOs was obviously problematic.
O'Gorman, J. Pilot Program Brings Modest Medicaid Savings. 2015, 9 September. Vermont Press Bureau.
http://rutlandherald.com/article/20150909/NEWS03/709099881/0/FEATURES08
A pilot program saved $14.6 million for the Vermont Medicaid program after three years for the 65,000 Medicaid beneficiaries.
Vermont was the first state to handle such a program which was an attempt to move from fee-for-service to incentivize providers for
positive health other patients.
Claxton, G., Cox, C., Gonzales, S., Kamal, R., Levitt, L. Measuring the Quality of Health Care in the U.S. Kaiser Family Foundation.
2015, 10 September. http://www.healthsystemtracker.org/insight/measuring-the-quality-of-healthcare-in-the-u-s/
Health care is extremely complex and specialized, so most consumers do not know what to expect or whether they are treated
appropriately or optimally. Objective metrics about performance can point to where and how the system can be improved.
Approaches to measuring quality and issues at the system level are discussed here. Although data are incomplete and sometimes
flawed, quality of health care in the U.S. is believed to be improving, but falls short compared to other large and wealthy countries.

Subramanian, R. The Dawn of the Age of Value Pricing in Cancer? 2015, 4 August. www.pharmexec.com/ram-subramanian

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Cancer care's contribution to cost escalation is disproportional to the small fraction of overall health care costs. More expensive
diagnostic and therapeutic interventions have ballooned the costs without improving outcomes. Increasing financial burdens on
patients from copayments also demands a look beyond clinical benefits to consider costs. The American Society of Clinical Oncology
is trying to construct a value assessment framework. Six implications for pharmaceutical manufacturers are discussed to indicate the
changing conditions in our health care system.
Caramenico, Alicia. "3 ACO Lessons from Integrated Systems." FierceHealthPayer. FierceMarkets, 12 June 2014.
http://www.fiercehealthpayer.com/story/3-aco-lessons-learned-integrated-systems/2014-06-12
 To improve care and lower costs, leaders from Washington-based integrated systems at an AHIP Institute discussed lessons for ACO
success. The three elements are: 1) aligned incentives, 2) partnerships and 3) shared decision-making. Aligning incentives will lead to
payers and providers making investments that can avoid the cost of poor quality. But healthcare organizations must go beyond
aligned incentives and work to manage ACO arrangements with new models of care and non-fee-for-service activities. ACO
arrangement should work with patients from the planning and providing side with a direct interaction with the costumer.
Partnership leads to collaborating for the best practices for care. Lastly, shared decision-making can lead ACOs to improve their
outcomes, care experience and reduce costs.
Gordon, Dani. "12 Things Clinical Integration Is - and Is Not." Becker’s Hospital Review. ASC COMMUNICATIONS 2015, 29 July 2014.
http://www.beckershospitalreview.com/hospital-physician-relationships/12-things-clinical-integration-is-and-is-not.html
DHG Healthcare which provides advisory and accounting services released a report that defines clinical integration and what
industrial force drives it. Clinical integration is defined as ‘a network of providers working together, using proven protocols and
measures, to coordinate patient care, improve quality, decrease cost and demonstrate value to the market.’ DHG Healthcare then
lists what clinical integration is and is not.
Ellison, Ayla. "30 Largest ACOs by Physician Participation." Becker's Hospital Review. ASC COMMUNICATIONS 2015, 14 Nov. 2014.
http://www.beckershospitalreview.com/accountable-care-organizations/30-largest-acos-by-physician-participation.html
According to SK&A market insight report, over 190,000 physicians, nurse practitioners and physicians’ assistants partake in ACOs. This
lists the 30 largest ACOs, along with participants from the Pioneer program, the Medicare Shared Savings Programs and commercial
contracts by physician participants.
Jayanthi, Akanksha. "100 Patient Safety Benchmarks- 2014." Becker's Hospital Review. ASC COMMUNICATIONS 2015, 21 May
2014. http://www.beckershospitalreview.com/quality/100-patient-safety-benchmarks-2014.html
Becker’s Hospital Review has assembled a list of 100 patient safety benchmarks from several sources for hospital comparison. The list
includes readmissions, mortality and complications, healthcare-associated infections, process of care measures, patient
experience, patient volumes & hospital beds, access to care and patient safety culture.
Tuohy, Cyril. "Accountable Care Organizations: How to Define Quality?" AMJC. American Journal of Managed Care, 01 Oct. 2013.
http://www.ajmc.com/journals/evidence-based-diabetes-management/2013/2013-1-Vol19-sp7/Accountable-Care-Organizations-
How-to-Define-Quality
Quality factors are discussed in healthcare regularly. There are 449 ACOs in the nation, how do they define quality? There may be no
consensus about what quality care entails, however, there are clues of how ACOs plan to deliver better care. ACOs aren’t trying to
change the patient but they are trying to change how the healthcare is delivered. Quality is dependent upon several aspects like:
metrics, providers and payers.
"ACO Quality Performance: Key Success Factors." Inovalon. Inovalon, 24 Sept. 2014.
http://resources.inovalon.com/h/i/54956977-aco-quality-performance-key-success-factors
In order to obtain quality performance, ACOs must improve patients’ care experience, improve the health of patient populations and
reduce the per capita cost of healthcare. The Triple Aim Framework’s goals are met through testing and innovative data analytics.

Lutz, Rachel. "Are Employed Physicians Fully Integrated?" MD Magazine. Physician's Money Digest, 24 Mar. 2014.
http://www.hcplive.com/physicians-money-digest/practice-management/Lutz-Are-Employed-Physicians-Fully-Integrated

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It is generally agreed that the integrated physician model will succeed, but whether the physicians are fully integrated in their health
system or hospital is questionable. Integration allows for improved communication, better physician job satisfaction and more
patient-centered focus. A survey from American College of Physicians Executives (ACPE) found that integrated physician models are
in favor of physicians and healthcare leaders. There were 20 questions in the survey, and was sent out to 10,000 ACPE members and
completed by 617. The survey results indicate 53% said physicians were fully integrated and the other 47% said they were not. The
answers for the survey were almost split evenly. Most survey participants agreed there was a strong potential for the integrated
model, and things that needed to be improved upon were IT support, aligned incentives and strong physician leadership. Some
challenges for the model include difficulty blending employed and non-employed physicians, reconciling geographical differences
and lack of financial incentives.
Caffery, Mary. "Author Finds High Degree of Variation Among States to Accommodate Accountable Care." AMJC. AJMC 2006-2015
Intellisphere, 31 Oct. 2014. Web. <http://www.ajmc.com/focus-of-the-week/1014/author-finds-high-degree-of-variation-among-
states-to-accommodate-accountable-care>
Tara Ramanathan, JD, MPH explores how the legal and regulatory frameworks rolls with the tide and how the word “waiver” has
become common as states and providers experiment with new delivery methods. “Legal Mechanism Supporting Accountable Care
Principles” shows ACOs improving the coordination of care and lowering costs through integration with the MSSP program.
However, it seems better as a theory than in practice, due to the switch from fee-for-service models. Ramanthan looked at different
types of accountable care frameworks. She viewed Medicare ACOs, Medicaid and Accountable Care, and Private Accountable Care
Entities. She believes because of the inability to reach an agreement on benchmarks and using them there will be some time before
accountable care in Medicare and Medicaid population is seen.
Douven, Rudy, J. McWilliams, and Thomas McGuire. "Avoiding Unintended Incentives in ACO Payment Models."The
Commonwealth Fund. New England Journal of Medicine, 5 Jan.2015.Web.<http://www.commonwealthfund.org/publications/in-
brief/2015/jan/avoiding-unintended-incentives-in-aco-payment-models>
Medicare Shared Saving Program’s goal is to encourage healthcare providers to decrease service spending through a coordination of
the care delivered to beneficiaries across care settings. CMS will share savings with ACOs if spending is kept below a benchmark level
over the 3 years of contract. The study found the methods CMS uses to calculate ACO spending can create negative incentives. They
also found of providers increase spending the year before signing the contract by inflating their benchmark. The author suggests CMS
plans and considers improvements of ACOs’ incentives for reaching savings, with changes such as modifying the benchmark
weighting system.
Evans, Melanie. "Bundled Payment Attracts Providers—but Will They Sign?" Modern Healthcare. Crain Communications, Inc, 31
July 2014. http://www.modernhealthcare.com/article/20140731/NEWS/307319827
CMS Innovation Center stated there are 4,100 providers joining 2,400 hospitals, nursing homes and medical groups as candidates of
Medicare’s Bundled Payment for Care. Not everyone is agreeing to bundled payments. The next round of candidates will have before
the end of the year to decide if they want to become part of the system. Organizations that fail to prevent hospital readmissions will
not be proceed further and will not receive a contract. Medicare initiative’s four models will be a key in testing bundled payments on
a smaller scale. Bundling took place after the Patient Protection and Affordable Care Act to test incentives and control costs. CMS
officials believe there will be an increase in the number of candidates agreeing to the contract.
Brillstein, Lili, and Steve Spaulding. "Bundled Payment Models: Bottom-Line Strategies for Insurers." AIS Health. Atlantic
Information Services, Inc., Mar. 2014.https://aishealth.com/marketplace/bundled-payment-models
Insurers over the nation are experimenting with bundled payments to improve quality of care and member satisfaction and control
costs. This reports a case study of two insurers that have developed a bundled payments system to reimburse providers. Bundled
Payment Models: Bottom-Line Strategies for Insurers gives insight to the plans chosen by Horizon Healthcare Services, Inc. and
Arkansas Blue Cross and Blue Shield. They show how they worked with provider groups to choose the episodes, track quality
measures, share savings and choose budgets. The report displays the results they acquired and provide insight on how the insurers
established cost and quality targets, and shared cost and quality data with provider, the differences between retrospective and
prospective bundled payment models and how to transition from the easier-to-implement retrospective method to a prospective
program, the financial and quality outcomes the insurers have seen, how the insurers share savings with providers and to what
extent providers are taking downside risk, and special circumstances to consider, such as how often costs are reconciled and how
payers handle catastrophic “outlier” episodes or patients.
Overland, Dina. "Bundled Payments Gain Momentum among Insurers, Providers." FierceHealthPayer. FierceMarkets, 20 Nov.
2013. http://www.fiercehealthpayer.com/story/bundled-payments-gain-momentum-among-insurers-providers/2013-11-20
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Survey results indicate insurers, patients; providers and employers bundled payments have resulted in reducing costs and boosting
transparency across the healthcare industry. Gary Ahlquist partner with Booz & Company wrote ‘There is mounting evidence that
bundles will be a critical part of any solution for the U.S. healthcare system--a means to deliver a higher-quality patient experience,
achieve better results and reduce costs.’ Improving outcomes and reducing costs results in a win-win scenario for the demand side.
FierceHealthPayer has reported government programs becoming part of the bundled payments program; currently Blue Cross Blue
Shield of North Carolina and Center for Medicare &Medicaid Services have been seen using the bundled payments.
Overland, Dina. "Bundled Payments Need Quality Guidelines." FierceHealthPayer. FierceMarkets, 9 July 2014.
http://www.fiercehealthpayer.com/story/bundled-payments-need-quality-guidelines/2014-07-09
Many healthcare organizations are starting to bundle up payments in order to lower costs, but they need to do so with quality care
guidelines. The Pittsburgh Business Times reported UPMC Health Plan in Pittsburgh developed several ways to look at the success of
the bundle program for hip and knee replacement surgeries. The guidelines discuss how much blood was needed for the operations
and patients satisfaction. They seemed to be pleased with the results since physicians are showing a lot of engagement.
UnitedHealth has also used bundled payments successfully and have lowered costs for breast, colon and lung cancer treatments.
This new payment model benefits the doctors, payers, patients and the entire health system.
Begley, Sharon. "New Form of U.S. Healthcare Saves Money, Improves Quality, One Insurer Finds." Reuters. Thomson Reuters, 10
July 2014. http://www.reuters.com/article/2014/07/10/us-healthcare-medicalhome-idUSKBN0FF0AI20140710
Insurer CareFirst Blue Cross Blue Shield announced 1.1 million people under their care through PCMH last year were hospitalized less
than compared for patients under fee-for-service care. Medical homes under Obama’s healthcare reform have been found to reduce
the cost of healthcare and improve quality. Medical homes are groups of primary care providers who guarantee care and follow
guidelines to improve the patients’ health, while avoiding unnecessary tests. Primary care accounts for 6 percent of all medical
spending, and it can reduce hospitalizations and visits to expensive specialists, making it affordable for the insurers to reimburse the
doctors in the long haul. Medical homes have not been deemed successful as a whole, due to aspects like are they open on
weekends and evenings and are they managing care of the sickest patients.
Song, Zirui, Sherri Rose, Dana G. Safran, Bruce E. Landon, Matthew P. Day, and Michael E. Chernew. "Changes in Health Care
Spending and Quality 4 Years into Global Payment." New England Journal of Medicine 371.18 (2014): 1704-714.
http://www.nejm.org/doi/full/10.1056/NEJMsa1404026
Paying for individual visit, test and procedure overuses services and is costly. To prevent this Blue Cross Blue Shield of Massachusetts
(BCBSMA) created their Alternative Quality Contract (AQC) in 2009. BCBSMA pays the provider groups budgets for the continuum of
care. Commonwealth Fund executed a study that compared spending and quality data for patients of the providers who were under
AQC program. The study’s time period was from 2009-2012. The findings include spending on health care claims grew more slowly,
AQC enrollees shower more improvement on measures of chronic disease management, adult preventive care, pediatric care and
control of cholesterol, blood pressure and diabetes, and savings were highest for procedures, imaging, and tests performed in the
outpatient facility setting. Spending and quality data from the first four years of the contract showed improved quality relative to
fee-for-service reimbursement.
Evans, Melanie. "CMS: Medicare ACOs Improve Quality, Have Mixed Results on Slowing Spending." Modern Healthcare. Crain
Communications, Inc, 16 Sept. 2014. http://www.modernhealthcare.com/a rticle/20140916/NEWS/309169938

CMS ACOs launched in 2012 have reduced Medicare spending by $817 million. Under Patient Protection and Affordable Care Act,
CMS has launched two tests of accountable care; Pioneer ACOs and Shared Savings ACOs. Hospitals and doctors are rewarded by
the program if they uphold Medicare enrollee health spending below target and meet the quality benchmarks. If they fail they
get penalized by Medicare. They have been mixed feeling regarding the slowed spending, so CMS has introduced possible
changes to the ACO quality reporting, now requiring the ACOs to meet 37 quality measures. The CMS has also offered ACOs a
new bonus based on quality improvement.

Evans, Melanie. "CMS Fee Schedule for Shared Savings Program Emphasizes Outcomes." Modern Healthcare. Crain
Communications, Inc, 3 July 2014. http://www.modernhealthcare.com/article/20140703/NEWS/307039940

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CMS is planning on increasing the number of quality measures MSSP for ACOs. The change sin 2015 Medicare physician intends to
increase the of quality measure form 33 to 37. ACOs must meet these quality performance targets to earn bonuses in the program.
New measures includes whether patients say providers educated them about the medical costs; the rate of patients admitted to a
nursing facility within 30 days of leaving the hospital, unplanned readmissions for diabetes, heart failure or multiple chronic
condition patients. New rules also ties in incentive for ACOs with quality improvement. ACOs will get a bonus when they reach the
goals for quality and reduced healthcare spending. ACOs scoring higher on quality measures will get a higher bonus.
"CMS Proposes Medicare Reimbursement Changes, Increases for 2015 - California Healthline." California Healthline. California
HealthCare Foundation, 7 July 2014. http://www.californiahealthline.org/articles/2014/7/7/cms-proposes-medicare-
reimbursement-changes-increases-for-2015
CMS has increased quality measures in the MSSP for ACOs, the new measures have a greater focus on patient outcomes. The
measures have been increased from 33 to 37. The measures include: whether patients say providers informed them about treatment
costs, the rate of patients who are admitted to skilled nursing facilities within 30 days of being discharged from a hospital; and
unplanned readmissions for patients with diabetes, heart failure or more than one chronic condition for any reason. And CMS added
these: replacing a measure dealing with medication management, changing a requirement that ACOs adopt electronic health
records, and eliminating some measures dealing with treatments for coronary artery disease, diabetes and ischemic vascular
disease. Quality measures for DME, Dialysis are tied to new quality and performance targets and if dialysis providers fail to meet
quality performance score they would be paid less than facilities that meet the target. Services that will not be included in bundles
payments are certain psychiatric-related services, drug administration-related services, and preventive services.
Keefe, Alyssa. "California Hospital Association." CalHospital. California Hospital Association, 2 Dec. 2014.
http://www.calhospital.org/cha-news-article/cms-proposes-updates-aco-program
Revisions to the Medicare Shared Savings Program (MSSP) include ACOs facing penalties relief. CMS is giving ACOs a period of three
years to better their performance before punishment. Kaiser Health Network believes these changes will attract more organizations
to become ACOs and keep participating ACOs in the program. Currently the two options MSSP has are: Track 1 is a one-sided shared
savings only model for a 3-year agreement period, and Track 2 is the two-sided shared savings/losses model for a 3-year agreement
period. ACOs in track 1 have to switch over to track 2 after three years, so essentially they have 6 years before they face any kind of
punishment if they renew their track 1. Downside of this is ACOs will be able to keep 40% of their savings instead of 50% if they
choose to have 6 years before penalties. CMS is proposing a Track 3 that would allow participants to keep up to 75% of shared
savings.
Overland, Dina. "Exchanges Required to Provide Quality Metrics of Plans in 2016." FierceHealthPayer. FierceMarkets, 31 July
2014. http://www.fiercehealthpayer.com/story/exchanges-required-provide-quality-metrics-plans-2016/2014-07-31
ACA has allowed consumers to compare plans based on quality and value. Out of the 36 state-based exchanges, 13 have already
taken steps to promote quality in plans sold to marketplaces according to Commonwealth Fund. Out of the 13, 11 collected quality
information from insurers and 9 states publicly displayed their quality information. Commonwealth Fund has questioned the metrics
and if they will aid consumers in choosing plans based on quality and value data. Quality information has limitations and becomes
problematic in the early years of exchanges.
Evans, Melanie. "For Their First Year, ACOs See Varied Scores in Quality Measures." Modern Healthcare. Crain Communications,
Inc, 26 Sept. 2014. http://www.modernhealthcare.com/article/20140926/NEWS/309269939
ACOs received bonuses if they reported their quality measures to CMS. CMS has targets 33 measures of quality. The results varied
across the ACOs but they knew incentives will increase the numbers of quality measures accomplished. Quality experts knew they
needed additional information to see providers’ performance from previous years. They knew ACOs improve quality since there is a
heavy focus on chronic conditions. Health policy professor at Harvard, Dr. Ashish Jha thinks quality measures ‘are just not very good,’
since many of them lack assessing management of population health or the results patients see from their treatment.

"Guidance Offered for Ethical Referrals Within ACOs." MPR. Haymarket Media, 15 Jan. 2015. http://www.empr.com/medical-
news/guidance-offered-for-ethical-referrals-within-acos/article/392631/

9
ACOs can have referrals from within as long as they are ethical in their selection process. Matthew DeCamp, M.D., Ph.D., from John
Hopkins University in Baltimore, and Lisa Soleymani Lehmann, M.D., Ph.D., from Brigham and Women's Hospital in Boston, discusses
ethical concerns pertaining to referrals within ACOs. Influencing referrals by giving incentives raises questions pertaining to a
patient’s right to select their own physicians. ACOs are allowed to influence referrals as long as they are influences in an ethical
manner. Three issues that should be considered when influencing are: transparency, appropriate metrics and correct incentives.
Demko, Paul. "HHS Sets Goals for Expanding New Medicare Payment Models." Modern Healthcare. Crain Communications, Inc, 26
Jan. 2015. http://www.modernhealthcare.com/article/20150126/NEWS/301269811
The Obama administration wants 30% of the payments of Medicare benefits to go to ACOs by the end of 2016. It’s the first time a
federal agency is setting specific goals for overhauling the payment system. FFS model has been criticized for offerings of volume
regardless of outcomes. As of now only 20% of Medicare payments for traditional beneficiaries have been made through alternative
payment models. HHS has created Health Care Payment Learning and Action Network that aims to spread value-based payment
models.
Busse, R., and J. Stahl. "Result Filters." National Center for Biotechnology Information. U.S. National Library of Medicine, Sept.
2014. http://www.ncbi.nlm.nih.gov/pubmed/25201659
Examinations of caring coordination that haven’t been included in the systemic reviews are evaluated. They are viewed in Germany,
the Netherlands, and England. Same methods were used to study all programs, but savings were observed only in Germany and
England.
Anderson, Jane. "Mature ACOs See Trouble Moving Beyond Simple HIT Capabilities (with Chart: Barriers to Health IT, Data and
Analytics)." AIS Health. Atlantic Information Services, Inc., Sept. 2014. https://aishealth.com/archive/nabn0914-03
Majority of the ACOs have health information technology (HIT) infrastructure that supports quality measurement and physician
payment. ACOs are having trouble moving pass these entry level HIT towards risk management health information exchange and
patient engagement according to an eHealth Initiative survey. The survey interviewed 62 ACOs participating in shared savings
models. For ACOs to excel and reduce their hospital readmissions and emergency room visits health information technology has to
be used. Many ACOs have been utilizing them and there has been a 15-12% improvement for ACOs. A problem ACOs are facing is
growing rapidly and being unable to properly staff, interfering in workflow integration. Access to care can be increased without
increasing staff through the use of services like self-service scheduling, phone-based telemedicine or video-based telemedicine. And
only those that are the most mature feature remote monitoring. Not all ACOs are a part of HIE but several of the do pull data from
several platforms. The three common types of data analyzed by ACOS are clinical data and/or electronic health record data, post-
adjudicated claims data, and pre-adjudicated administrative, billing or financial data. Other ACOs have also looked in state or disease
registry data, patient reported data, data from remote monitoring devices and sensors and HIE data.
Overland, Dina. "Medical Homes, ACOs Offer Better Business Models." FierceHealthPayer. FierceMarkets, 21 May 2014.
http://www.fiercehealthpayer.com/story/medical-homes-acos-offer-insurers-states-better-business-model/2014-05-21
According to Health Affairs post, Arkansas designed PCMH payment system to support primary care doctors in the state to
implement team-based strategies, coordinate chronic care delivery and achieve better patient outcomes. Their PCMH model rewards
providers that hit the target, risk adjusted per-member per-year spending level. New Jersey BCBS is also attempting to make a shift to
PCMH or ACO.
Pear, Robert. "Medicare to Start Paying Doctors Who Coordinate Needs of Chronically Ill Patients." The New York Times. The New
York Times, 16 Aug. 2014. http://www.nytimes.com/2014/08/17/us/medicare-to-start-paying-doctors-who-coordinate-needs-of-
chronically-ill-patients.html
The Obama administration plans to pay doctors to coordinate care of Medicare beneficiaries since there is growing evidence that
suggest patients with chronic illnesses suffer from fragmented care. Starting January, Medicare will pay monthly fees to doctor who
care for patients with 2 or more chronic conditions. According to a statistician at Department of Health and Human Services, two
thirds of Medicare beneficiaries have at least two chronic conditions and account for 93% of the spending. Doctors are expected to
receive $42 a month for managing care for a Medicare patient; they will check the patients’ medical, social and psychological needs.
Medicare is also asking doctors to use EMRs so information could be exchanged easily when treating a patient with more than one
condition.
McCurdy, Debra. "MedPAC Voices Concerns about Growing Volume, Burden of Medicare Quality Measures | Health Industry
Washington Watch." Health Industry Washington Watch. Reed Smith, 16 Jan. 2015.

10
http://www.healthindustrywashingtonwatch.com/2015/01/articles/odds-ends/medpac-voices-concerns-about-growing-volume-
burden-of-medicare-quality-measures/
CMS releases a 329 page list of the quality measures for the Medicare program in December 2014. In January 2015, MedPAC looked
at the measures and thought the activities were rising without any looking at the costs or benefits of the increasing number of
measures. MedPAC believes CMS is ‘relying on too many clinical process measures that are, at best, weakly correlated with health
outcomes.’
Anderson, Matthew. "Nine Questions About My New Medical Home." Health Affairs Blog. Health Affairs, 17 Mar. 2014.
http://healthaffairs.org/blog/2014/03/17/nine-questions-about-my-new-medical-home/
Here are nine questions written by someone who want to go back to their old home. They know they live in a new home, but they
aren’t entire sure how they got there. They were old everything would be okay. The worst part about this new home is how it
resembles the old home in some ways. Questions going through their minds are is this a home or is it a hostel, will my old friends still
be welcome in my new home, does Mommy love me or is she just paid to say so, why are we playing computer games during family
time, are there any family secrets left, everyone tells me how important I am, so why is my allowance being cut, do I have to go to
Church now, can we get some family therapy and can’t we afford a better home.
Frellick, Marcia. "Medscape Log In." Medscape Log In. WebMD, 26 Jan. 2015. http://www.medscape.com/viewarticle/838706
Researchers from Massachusetts General Hospital have created a collaborative model that will help coordinate primary care and
hospitalists’ care for inpatient settings. The hospitalists would have a primary care provider (PCP) that would give guidance and
support and counsel and recommend care plans for the primary care patients. This model aims to lessen the work load of the
hospital and create a better and personalized care. Some hospitalists believe this model is impractical because, there’s no good
billing system for the PCP visits. There’s no substantial evidence that says there would be more savings.
Anderson, Jane. "Pediatrics Have a Place in ACOs, but Adult Medicine Still Is Primary Focus." AIS Health. Atlantic Information
Services, Inc., Sept. 2014. https://aishealth.com/archive/nabn0914-02
CHOC Children and St. Joseph Hoag Health have decided to come together for an ACO that focuses on adults and pediatric care.
ACOs believe the ROI is aimed at adults not children, so this may not be as beneficial as intended. CHOC had approached St. Joseph
with this idea and intended to get more involved in community care and in transforming health care delivery. Their goal is to get
enough patients together and manage them aiming towards prevention and intervention. They plan to develop an electronic
specialist referral program for pediatric specialists so patients that need to be seen can be checked faster. Becoming an ACO will also
help enhance the pediatrics network.
McGlynn, Elizabeth, Eric Schneider, and Eve Kerr. "Reimagining Quality Measurement — NEJM." New England Journal of
Medicine. Massachusetts Medical Society, 10 Dec. 2014. http://www.nejm.org/doi/full/10.1056/NEJMp1407883
In order to reimagine quality measurement these three principles should be considered: quality measurement should be integrated
with care delivery instead of existing as a parallel; it should acknowledge and address challenges doctors face; and it should reflect
on patients’ preferences and goals for treatment and health outcomes. If a measurement system integrated these principles the
whole person would be viewed with these three components: inventory of patients’ health and healthcare needs, mechanism for
evidence-based interventions, and an assessment of patients’ health goals and preferences.
Joszt, Laura. "Report Outlines How to Improve Measures for Accountable Care." AMJC. AJMC 2006-2015 Intellisphere, 30 Oct.
2014. http://www.ajmc.com/newsroom/report-outlines-how-to-improve-measures-for-accountable-care
According to a report by the National Pharmaceutical Council and Discern Health, gaps in accountable measure sets exist for costly
and prevalent conditions. The gaps lead to unable to improve patient care and health systems. There have been no delivery
innovations that can help address the gaps; however, payment systems are providing a little financial support. Gaps can’t be
addressed by the same measure types and strategies in use. This report provides a framework that will assist in measuring gaps
using alternative measurement approaches and addresses barriers to measurement by enhancing data sources. Measures that
should be addressed are: outcome measures, cross-cutting measures, patient-reported measures and layered and modular
measures.

Nash, David. "Room for Improvement -- Even in Quality Measures." MedRoomPage. MedPage Today, 30 July 2015.
http://www.medpagetoday.com/Columns/FocusonPolicy/46999

11
CMS has established Hospital Readmissions Reduction Program to reduce 30 day admissions. When these measures were applied in
real would settings the results were controversial. Studies have been done to see if there were any associations with socioeconomic
variables and 30-day readmissions for patients discharged from the hospital. This study found patients living in high poverty; low
education and low household income were at a greater chance for readmission. Another study found that low SES resulted in an
increased risk of 30-day readmission. These findings raise these questions: does the measure disproportionately affect hospitals that
provide care to patients of lower socioeconomic status (e.g., urban teaching hospitals, rural community hospitals), should CMS'
readmission measure and its associated financial penalties be adjusted for the effects of factors beyond a hospital's influence; e.g.,
poverty and lack of social support and it correct to assume that the thing being measured -- in this case, 30-day readmissions --
results solely from poor quality of care?
Burwell, Sylvia. "Setting Value-Based Payment Goals - HHS Efforts to Improve U.S. Health Care — NEJM." New England Journal of
Medicine. Massachusetts Medical Society, 5 Mar. 2015. http://www.nejm.org/doi/full/10.1056/NEJMp1500445
The Department of Health and Human Services (HHS) is focused on using incentives for higher-value care, changing the way care is
delivered through teamwork and integration and using the power of information to improve care for patients. They want to build a
healthcare system that delivers better care and spends their money wisely. They have set three strategies for this progress: first, set
incentives so hospitals, physicians and providers are rewarded for providing high-quality care. This also includes creating new
payment methods and alternative payment methods. Second, improve the way healthcare is delivered, along with preventing
hospital readmissions. And lastly, provide individuals with more information for proper decision making.
McAndrew, Claire. "Standards for Health Insurance Provider Networks: Examples from the States." Families USA. Families USA,
Nov. 2014. http://familiesusa.org/product/standards-health-insurance-provider-networks-examples-states
Before designing a network, health plans ensure the networks are adequate and provide a meaningful access to care. ACA
established the federal rights that guaranteed private insurance consumers access to adequate networks. The brief discusses these
protections for a networks deliverance of access to meaningful care: accurate information about providers, timely access to care,
adequate numbers of providers, adequate types of providers, inclusion of essential community providers, adequate geographic
distribution of providers, access to out-of-state providers, accessible hours, language-accessible and culturally competent care,
rights to go out of network and continuity of care.
Perna, Gabriel. "Study: ACOs Improve the Patient Experience." HealthCare Informatics. Vendome Group, 30 Oct. 2014.
http://www.healthcare-informatics.com/news-item/study-acos-improve-patient-experience
Harvard Medical School Department of Health Care Policy did a study to see the impact ACOs had on patients. They found beneficiaries
under ACOs reported improvements in timely access to care, access to their medical information and coordination of their care. There
was no noticeable difference in how ACO patients rated their physicians and their communication skills. They found the greatest
improvement in experience for patients with multiple and complex illnesses.
Hall, Susan. "Study Backs Importance of Robust Analytics Infrastructure for ACOs." FierceHealthIT. FierceMarkets, 22 July 2014.
http://www.fiercehealthit.com/story/study-backs-importance-robust-analytics-infrastructure-acos/2014-07-22
According to Academic Medicine, analytics infrastructure is one of the keys to success for ACOs. Scott Berkowitz and Jennifer Pahira
are focusing on academic medical centers. They are paying attention to three areas: structure, leadership and governance; use of
data systems and information technology, and care management and population health. Their findings concluded ACOs require
integrated data and analytic systems that can provide real-time data to care teams, promotes improvement and monitor spending
trends. These systems can offer insight to care teams, highlight areas for improvement, and educational opportunities.
Delbanco, Suzzane. "The Payment Reform Landscape: Bundled Payment." Health Affairs Blog. Health Affairs, 2 July 2014.
http://healthaffairs.org/blog/2014/07/02/the-payment-reform-landscape-bundled-payment/
Bundled payments are growing in private and public sectors. No evidence suggests that private sector results in savings or better
quality. Bundled payments and savings depend on the design of the payment system, the services offered and the performance of
the system before implementing. Bundled payments have a potential to improve care coordination and quality and reduce costs.

Krusing, Clare. "The Results Are In – Health Plans’ Payment Reforms Improve Value, Quality for Patients." AHIP Coverage. AHIP
Coverage, 09 Oct. 2014. http://www.ahipcoverage.com/2014/10/09/the-results-are-in-health-plans-payment-reforms-improve-
value-quality-for-patients/

12
In order to solve problems like quality care, or overuse of necessary treatments a transformation in payment methods for the care is
required. Health plans are working with providers to identify care issues early for high blood pressure, heart conditions and chronic
diseases so they can deliver care at the right time, and avoid unnecessary hospitalizations and costly treatments later on. It comes
down to data in order to develop a structured coordinated delivery of care.
Overland, Dina. "What If Insurers Operated More like ACOs?" FierceHealthPayer. FierceMarkets, 22 Mar. 2014.
http://www.fiercehealthpayer.com/story/what-if-insurers-operated-more-acos/2014-03-22
Many of the ACO models looked in this report have controlled costs and boosted quality care. They believe this is due to
communication and coordination among providers. These insurances are also using EMRs, integrating care and focusing on
prevention. The insurance industry is shifting since ACA requires a new business to consumer approach and has an emphasis on care
and coordination. If insurances shifted they would see a greater consumer satisfaction rate and could result in a larger membership
rate.

Players and Payers

CMS began its experiment with Pioneer ACOs that were monitored and assessed with mixed results for quality and financial
performance. The track record here was not stellar, with several dropouts. Doctor groups have been amalgamating in preparing for
value-based reimbursement, but it remains to be seen with private insurers, nationwide insurers playing a dominant role, who will
achieve the advanced analytics to conduct new rounds of assessments and how they will be used. The trend toward concentration
and centralization in the health sector holds profound implications for the medical profession, and substantial population health
improvements are a long trek from tinkering with medical care, even if the ACOs really gain solid ground in quality improvements. In
an era of greater consumer awareness and dissatisfaction, patients and the public expectation will be a growing force to contend
with.

Zweig, Dori. "3 Ways to Create Value-oriented Healthcare." FierceHealthPayer. FierceMarkets, 15 May 2014.
http://www.fiercehealthpayer.com/story/3-ways-create-value-oriented-healthcare/2014-05-15
In order to address the increasing cost of healthcare and the worth of a service, payers, providers and consumers should focus on
these key findings on a value-oriented healthcare delivery system: 1) balancing Medicare, 2) transitioning from fee-for-service
models and 3) encouraging employers to manage their health. In the future, Medicare should be balanced through a realignment
of hospital financial incentives that leads to an increased enrollment of Medicare plans and practices more ACOs. Hospital
expenditures and physician and clinical services are projected to hit billions of dollars, transitioning from a fee-for-service to a risk-
sharing approach may halt the rising costs. Private businesses and employees’ premiums make up a third of the trillions in health
expenditures, encouraging employers to manage their health by implementing value opportunities will result in employers to no
longer rely on external brokers and actuaries.
Zweig, Dori. "Payer-led ACOs Find Early Success." FierceHealthPayer. FierceMarkets, 16 May 2014.
http://www.fiercehealthpayer.com/story/payer-led-acos-find-early-success/2014-05-16
Since ACOs are in the early stages they are having trouble finding success. One of their main challenges is collecting data across the
healthcare system. To overcome this, may providers and insurers are creating data integration strategies to allow for data monitoring
and real-time care coordination. Other ACOs led by insurers are creating committees and review boards to analyze effectiveness,
safety, cost-effectiveness and patient-centeredness to decide if new care protocols should be used.
Anonymous. Medicare ACOs Continued to Improve Quality of Care, Generate Shared Savings.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-08-25.html
CMS 2014 quality and financial performance results showed more Medicare ACOs continue to generate financial savings and
fostering greater collaboration. In 2014, twenty pioneer and 333 Shared Savings Program ACOs generated over $411 million dollars
in savings.

Caramenico, Alicia. "4 Lessons from Pioneer ACOs." FierceHealthcare. FierceMarkets, 23 Sept. 2013.
http://www.fiercehealthcare.com/story/4-lessons-pioneer-acos/2013-09-24
Since accountable care organizations have doubled since June 2012, Alliance Health Reform hired experts to share their experiences
and lessons they have learned. The 4 main lessons are: 1) focus on data, 2) engage partners, 3) rethink emergency care and 4)
13
expand workforce. Data can be used to drive quality and change, predict high analytics to identify high-risk patients and allows
hospitals to identify patients and their specific needs. Engaging patients can be done through working with community organizations
and is necessary because many of the patients do not know they are in an ACO. Emergency care plays an enormous role in helping
ACOs accomplish their goal of improved health, experience of care and costs. Physicians are conditioned to admitting people and in
order to change this different emergency rooms should be created. For example, NYC’s geriatric emergency room created for
individuals 65 and older. Expanding workforce leads to individualized health care and creating a focus there are different solutions for
different communities.
Japsen, Bruce. "UnitedHealth's $43 Billion Exit From Fee-For-Service Medicine." Forbes. Forbes Magazine, 23 Jan. 2015.
http://www.forbes.com/sites/brucejapsen/2015/01/23/unitedhealths-43-billion-exit-from-fee-for-service-medicine/
United Health believes a shift from FFS to VBP will yield better health outcomes, performance and quality of care. They expect a 20%
increase in VBP reimbursements. VBP include: pay-for-performance programs, patient-centered medical homes and accountable care
organizations. CMS has stated 20 percent of their payments are no longer FFS. Aetna, Cigna and Humana are shifting to VBP.
Luthra, Shefali. "Win-Win? CVS Joining Forces With Hospitals, Doctors." Kaiser Health News. Kaiser Family Foundation, 24 Sept.
2014. http://khn.org/news/cvs-medstar-team-on-electronic-medical-records-coordination/
CVS is joining forces with hospitals and doctors so seeing patients’ records is easier and they will be able to notify the patients if they
did not pick up their prescriptions. Many pharmacies are looking into collaborating with clinics and hospitals. Hospitals win this
because it helps reduce how often the chronically ill go to the hospital. Reducing admissions and readmissions helps hospitals
manage their budgets. Pharmacists look at the patients’ drug intake and can detect when they are at risk so integrating records can
transmit useful information to the doctors.
Rosin, Tamara. "10 Characteristics of Physicians in ACOs." Becker’s Hospital Review. ASC COMMUNICATIONS 2015, 18 Sept. 2014.
http://www.beckershospitalreview.com/accountable-care-organizations/10-characteristics-of-physicians-in-acos.html
Through a recent survey it was discovered physicians involved in ACOs are younger and more likely to be hospital employed rather
than private practice. There is also an increase in physicians that are partaking in ACOs since Patient Protection and Affordable Care
Act came about according to Jackson Healthcare’s annual Physician Practice Trends Survey of 2014. Other findings from the survey
indicate physicians involved in ACOs are more likely to practice in urban areas, are younger than 54, on call rotation, work more than
10 hours per day and use nurse practitioners more than physician assistants. Physicians who aren’t partaking in ACOs are more likely
to be older than 55, say their income decreased over the past year, have a solo practice and own or maintain in a single-specialty
practice.
Evans, Melanie. "89 ACOs Will Join Medicare Shared Savings Program in January." Modern Healthcare. Crain Communications, Inc,
22 Dec. 2014. http://www.modernhealthcare.com/article/20141222/NEWS/312229929
The Medicaid Shared Savings Program was launched in 2012 under the health reform law. In January 89 ACOs will join the program
increasing the number to 405 and help increase the number of physicians from 4.9 to 7.2 million. Over 200 of the current
organizations will decide if they want to continue in the Shared Savings Program. CMS has proposed changes to Medicare’s
accountable care initiatives in order to keep the organizations. One of the changes would allow ACOs to avoid the risk of penalties
from three years to up to six years. Early ACOs have shown quality improvement benefiting Medicare enrollees, but greater savings
will come in time as the new ACOs get experience with quality improvement and cost-control initiatives.

"Accountable Care Organizations Market 2015 Outlook and Implications for Suppliers and Providers." PR Newswire. PR Newswire
Association, 2 Oct. 2014. http://www.prnewswire.com/news-releases/accountable-care-organizations-market-2015-outlook-and-
implications-for-suppliers-and-providers-277920241.html
ACOs have the most influential power over health care sector than and changes in the ACA. It has doubled since 2012 and analysts
have predicted more than 200 million Americans will be covered by an ACO by 2016. How one pays for health care and what we
actually pay for in the U.S. is highly dependent upon how ACOs influence us. If ACOs are successful then the cost will be controlled
14
and there will be high quality care deliverance. In this report one can find out how ACOs view pharmaceuticals, home health and
other supplies and their ability to provide care, what tools are important and effective at reducing readmission rates and what
partners are important and effective, what suppliers and providers do ACOs trust and what discussions, relationships and contracts
are ACOs involved in with providers and suppliers. Their learning objectives include ACOs and their relationships with suppliers and
providers, along with history, legal and operational framework of ACOs.
Wall, J. K. "Accountable Care Organizations Strike out in Indiana." IBJ. Indianapolis Business Journal, 6 Oct. 2014.
http://www.ibj.com/articles/49849-accountable-care-organizations-strike-out-in-indiana
St. Francis Health joined ACO in 2013 and scored top 5 nationally among participants in the Medicare Pioneer ACO program. They
are looking to switch to Medicare Shared Savings program to achieve savings due to a lower number of physicians. So far there isn’t
much of a difference from the switch. Franciscan has 2 ACOs in Shared Savings program and hasn’t saved money or received a bonus
for 2013 according to Centers for Medicare and Medicaid Services. This due to being accountable for lives when they are out of your
system.
Ellison, Ayla, and Jake Wise. "ACO Directory: 272 ACOs in America." Becker's Hospital Review. ASC COMMUNICATIONS 2015, 23
July 2014. http://www.beckershospitalreview.com/accountable-care-organizations/aco-directory-268-acos-in-america.html
ACOs have gained popularity since the shift from fee-for-services to pay-for-performance; naturally the numbers of ACOs are
growing. To provide reduce costs and improve the quality of healthcare Pioneer ACOs were created. Since the program was launched
in July 2013, nice Pioneers left the program after the first year performance. Seven of the nine Pioneer ACOs that left the Pioneer
program switched to Medicare Shared Savings Program. According to the Growth and Dispersion of Accountable Care Organizations
June 2014 update from Leavitt Partners lists 272 ACOs in America that covers more than 20 million lives.
Andrews, John. "ACOs Get down to Brass Tacks." Healthcare Finance News. Health Care Finance, 12 May 2014.
http://www.healthcarefinancenews.com/news/acos-get-down-brass-tacks
ACO organizers are experiencing challenges of cumulating data from disparate entities over healthcare enterprises. To overcome this
obstacle ACOs are investing in clinical data integration strategies to enable real-time performance monitoring and care coordination.
By understanding the care gaps early, the system can become more proactive about quality improvement and start succeeding
against the contracts. LTC is a sector of healthcare that may not be getting the full benefit of ACO partnership. LTC may not have a
prominent role right now but as ACOs gain strength LTC’s role will also rise.
Overland, Dina. "Aetna: Bumpy Road Ahead for ACOs." FierceHealthPayer. FierceMarkets, 19 Mar. 2014.
http://www.fiercehealthpayer.com/story/aetna-acos-have-bumpy-road-ahead/2014-03-19
Aetna’s chief of ACO believes organizations can succeed even if there are a few bumps ahead. ACOs have to manage operations when
insurers and providers transition towards value-based payments even for fee-for-service reimbursements remain dominant. In order
to be financially stable ACOs have to be careful when removing care that has no value during their switch from volume to value. ACOs
also have to avoid HMO mistakes from 1980s and 1990s. ACO can exceed HMO due to data analytics and EMR.
Anderson, Jane. "Aetna Readies Plan to Offer ACO Products via Private Exchanges." AIS Health. Atlantic Information Services, Inc.,
5 June 2014. https://aishealth.com/archive/nabn0614-04
Aetna spokesperson Sherry Sanderford has stated they are actively working with existing ACO products to make private exchanges in
the future. Privatizing ACOs is further strengthening the value proposition of the products. Providers will be attracted to ACOs since it
creates an economic sustainability and helps ensure profits as the payment model changes from volume of care to reward value. If
patients are encouraged to see providers in the ACO network, ACO-based products, a larger patient share is in their market that
allows for them to receive a larger portion of patients medical spending. ACOs in private insurance markets are believed to become
more prominent due to the melding of private exchanges and ACOs. ACO-linked plans also leverage narrower networks to reduce
premium and the lower price is going to draw in more employers who are offering coverage to their employees. Private exchange
displays the different plan designs easily and provides tools that move the policy selection process faster.
Ellison, Ayla. "All ACOs Are Not The Same, Which Type Is Yours?" Becker's Hospital Review. ASC COMMUNICATIONS 2015, 04 June
2014. http://www.beckershospitalreview.com/accountable-care-organizations/all-acos-are-not-the-same-which-type-is-
yours.html
Leavitt Partners released a report identifying six types of ACOs based on their organization structure, ownership and patient care
focus. Researchers used information from 40 surveys and 100 different interviews with ACO leaders to develop the characteristics
and create the classifications. The surveys helped develop classification types and the interviews led to information regarding the

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organizations in each category. The six types of ACOs are reported in “A Taxonomy of Accountable Care Organizations: Different
Approaches to Achieve the Triple Aim.” There are full spectrum integrated, independent physician group, physician group alliance,
expanded physician group, independent hospital, and hospital alliance. The classifications will aid in identifying the failures and
success of organizations. This also allows for vendors to know what to sell to what ACO, since the same product doesn’t necessarily
work for all ACOs.
Wehrwein, Peter. "An Accounting of ACOs." Managed Care. MediMedia USA, Nov. 2014.
http://www.managedcaremag.com/archives/2014/11/accounting-acos
An ACO is defined as a group of providers’ with accountable care contracts, and often a private and public ACO is the same entity
according to David Muhlestein of Leavitt Partners. Muhlestein started counting ACOs since no one else was. He first descrived what
accountable care was, then looked at the over trajectory and looked at what lives were covered, then what percentage of lives
covered by ACOs were by hospital referral region, the ACO sponsoring entities and lastly the types of ACOs. Muhlestein found one
common theme to ACOs, and that’s the estimates of how long it took to set them up with IT and that physician buy-in are optimistic.
White, Joel. "The Time Is Now for Data-driven Medicine, Requiring Elimination of Regulatory Relics." Modern Healthcare. Crain
Communications, Inc, 31 Jan. 2015. http://www.modernhealthcare.com/article/20150131/MAGAZINE/301319978
Since the enactment of the HITECH Act in 2009, taxpayers and the medical industry have invested more than $100 billion to meet
America’s healthcare needs. With incentives, data resources and technology can be leveraged to speed treatments and cures to
patients. At a summit in Washington hosted by Health IT Now Coalition and the Center for Data Innovation the participants
discovered what solutions were needed to leverage genomics, big data and technology. First we need to invest in modern data
infrastructure, and then create system efforts to digitize patient records, get technology to electronically match patients to clinical
trials and lastly get the congress to update and clarify regulations to accommodate new technologies.
Overland, Dina. "Blue Cross: Value-based Care Delivers Huge ROI." FierceHealthPayer. FierceMarkets, 10 July 2014.
http://www.fiercehealthpayer.com/story/blue-cross-value-based-programs-provide-solid-roi/2014-07-10
Blue Cross Blue Shield Association’s plans spend over $65 million a year in value-based payment programs that have a high return on
investment. According to a BCBSA report their plan administers more than 350 value based programs and in 2012 the plan saved
$500 million. There has been a decrease in readmission, hospital admission and ER visits. Their plan has also improved preventative
care, including a rise in screenings and immunizations and a better diabetes control. The three keys for the success of this plan
include: changing payment incentives and reimbursements to reward providers when they offer value and quality care, partnering
with clinicians to provide necessary support, data and tools so they can implement quality care and engaging patients with wellness
programs and transparency tools, plus educating them about how to be more healthful and manage chronic conditions.
Davis, Steve. "Blues Plans Steadily Expand Their Private Exchange Presence." AIS Health. Atlantic Information Services, Inc., 31 July
2014. https://aishealth.com/archive/nhex073114-05
Blue Cross Blue Shield plans are discussed along with dominating government-run public health insurance exchanges. Majority of the
Blue plans have released their private exchanges. Single-carrier exchanges operated by Blue plans are: Blue Cross Blue Shield of
Massachusetts, Blue Cross Blue Shield of Michigan, Blue Cross BlueShield of South Carolina, Cambia Health Solutions, Capital
BlueCross, Health Care Service Corp, Horizon Blue Cross Blue Shield of New Jersey and Independence Blue Cross.
Overland, Dina. "Cigna's Dick Salmon Shares Collaborative Care Insights." FierceHealthPayer. FierceMarkets, 13 Sept. 2013.
http://www.fiercehealthpayer.com/story/cignas-dick-salmon-shares-collaborative-care-insights/2013-09-13
Positive results are attained through collaboration of providers and payers. Patient care becomes coordinated, quality increases and
costs drops. During a FierceHealthPayer webinar, Cigna’s Dick Salmon, vice president of performance management and
improvement, explained how collaboration of providers and payers can improve health. These are the questions Salmon answered
after the webinar; what kinds of tools or data does Cigna offer to providers to help them set up a collaborative care program, how
do you define cost of care for providers? Do you show the allocation of costs within the market basket of services, and what the
process for a provider group to become involved in the Cigna program is.
Gordon, Dani. "CMS to Increase Quality Measures for MSSP ACOs: 4 Things to Know." Becker's Hospital Review. Becker's
Healthcare, 11 July 2014. Web. <http://www.beckershospitalreview.com/accountable-care-organizations/cms-to-increase-
quality-measures-for-mssp-acos-4-things-to-know.html>
Under 2015 Physician Fee Schedule, changes have been proposed to CMS for assessing ACOs in the MSSP from 33 to 37. The four
things to know about the changes regarding ACOs are: adding new measures (Stewardship of Patient Resources, 30-day all-cause

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skilled nursing facility measure, depression readmission, diabetes measure, coronary artery disease symptom management, and
Documentation of Current Medication in the Medical Record measure), CMS planning to retire eight measures that "have not kept
up with clinical best practice, are redundant with other measures that make up the quality reporting standard, or that could be
replaced by similar measures that are appropriate for ACO quality reporting, CMS proposing the new total of 37 measures be used
for establishing the quality performance standards that ACOs must meet to achieve shared savings and the measures added would
be calculated by CMS using administrative claims data or data from a patient survey.
Overland, Dina. "Data Analytics Drives ACO Success." FierceHealthPayer. FierceMarkets, 10 June 2014.
http://www.fiercehealthpayer.com/story/data-analytics-drives-aco-success/2014-06-10
According to Healthcare Informatics successful ACOs rely on data analytics of the program. Insurers look at technology that has the
ability to measure value ad prevent providers from falling back to fee-based care. The challenge is finding and implementing the right
technology for each ACO. While data is helpful in an accountable care structure, it’s not the only thing required for success.
Evans, M. Investors Hope to Profit from Sharing the Bundled Payment Load. Modern Healthcare. 2015, 14 September. Pp 12-13.
http://www.modernhealthcare.com/article/20150912/MAGAZINE/309129963
Several companies have emerged to capitalize on the ACAs complex new programs. Cardinal Health, a medical supply firm, paid
$290 million dollars to acquire a major stake in naviHealth, a consulting tech firm working on bundled payments. Team Health, a
staffing firm, paid $1.6 billion for IPC Healthcare, a hospitalist company. Bundled payments are expected to be $10 billion dollars
from CMS next year, so this can become a lucrative market segment as "conveners" get fees or share in profits. Private equity firms
are circling such areas also amidst several other major players staking out this market segment.
Marbury, Donna. "Delegating Tasks to Practice Staff Enhances Team-based Care." Medical Economics. UBM Medica, 7 Aug. 2014.
http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/licensure/delegating-tasks-practice-staff-
enhances-team-based-care?page=full
Physicians believe administrative involvement threatens their relationship with patients. Physicians have grown to like working with
other physicians since diagnosing patients has become difficult over the years with chronic illnesses. Once physicians start trusting
their teams with new task, they can start shifting focus on long-term strategies that thoroughly engages patients. Adding new staff
increases patient faithfulness and helps the staff work as a team.
Pronovost, Peter, and Ashish K. Jha. "Did Hospital Engagement Networks Actually Improve Care?" New England Journal of
Medicine N Engl J Med 371.8 (2014): 691-93. nejmp 1405800.pdf
CMS launched PPP to reduce harms and readmissions. They have been successful in bringing down the readmission rate, but it is
unclear if they led to a better care. Three problems with the agency’s evaluation and reporting of results it its weak design, lack of
valid metrics and lack of peer review for its evaluation. They are improving problems of cost and quality in healthcare. It all depends
on the amount of money that’s invested in helping these problems along with the providers, public and policymakers.
Gregg, Helen. "Dr. Farzad Mostashari's New Startup Will Help Independent Physicians Form ACOs." Becker's Hospital Review.
Becker's Healthcare, 18 June 2014. http://www.beckershospitalreview.com/accountable-care-organizations/dr-farzad-
mostashari-s-new-startup-will-help-independent-physicians-form-acos.html
Former National Coordinator for Health IT, Dr. Farzad Mostashari’s launched a new company designed to help independent primary
care physicians’ form and join ACOs. Aledade hopes to create an ACO that provides physician clients affordable ways to access all the
tools. Aledade will not charge up-front fee, but takes a 40% cut of the savings realized through the ACO. He believes Health IT wasn’t
an end up a way to better health and care. He states the mission of Aledade to empower doctors on the frontlines of medicine with
cutting edge technology that helps understand and improve the health of all their patients. Aledade is backed up by health IT venture
capital firm Venrock.

Caramenico, Alicia. "Episode Analytics Key to Value-based Success." FierceHealthPayer. FierceMarkets, 09 May 2014.
http://www.fiercehealthpayer.com/story/episode-analytics-key-value-based-success/2014-05-09
White paper from SAS believes episode analytics can help health insurers thrive under payment bundling value-based healthcare
models. Bundling reduces costs and boosts transparency, it’s in insurers benefit to succeed in bundling payments. Major obstacle in

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achieving this is defining episodes of care and what’s included in them. Episode analytics are suggested to overcome bundle price
challenging and create flexibility in defining clinical episodes. Bundled payments can also eliminate waste through data analysis.
Newman, Denny, Jr. "Essential Health Joins Accountable Care Pilot Project." Brainerd Dispatch. Brainerd Dispatch and Forum
Communications Company, 02 June 2014. http://www.brainerddispatch.com/content/essentia-health-joins-accountable-care-
pilot-project
Essential health is one of the 20 healthcare systems in the nation that is part of ACOs. It’s coordinating doctors, hospitals and other health professionals to
ensure patients are getting the care they need without inefficiency and waste. National Committee for Quality Assurance (NCQA) has a project
that will evaluate ACOs ability to calculate and report quality results. NCQA will be collaborating with 20 organizations to set
measures, submit results and generate benchmarks. After ACOs submit their results on a standard set of quality measures; NCQA
will then determine the accreditation of the ACO. Commonwealth Fund is funding this study.
Zweig, Dori. "Former CMS Head Talks Accountable Care ROI." FierceHealthPayer. FierceMarkets, 25 July 2014.
http://www.fiercehealthpayer.com/story/former-cms-head-talks-accountable-care-roi/2014-07-25
ACOs have been increasing their promise to provide low costs and high quality care. Both payer and providers will receive benefits
from ACOs in this situation. Some ACOs are gaining this benefit faster than others, but eventually all will get there if readmissions are
lowered. Ultimately less readmission will help in lowering costs. The new payment and delivery model shift from fee-for-service will
seem desirable if more ACOs gain success.
"Guiding the Shift from Volume to Value in Medicare Payments." AMJC. AJMC 2006-2015 Intellisphere, 2015.
http://www.ajmc.com/meetings/past-event/newsroom/guiding-the-shift-from-volume-to-value-in-medicare-payments
While Congress has accepted to move away from FFS, they are not entirely sure about how to address the issue of paying. Mark
McClellan, senior fellow and director of the Health Care Innovation and Value Initiative at the Brookings Institution, explains that
eliminating site of service payment and getting a better understanding on what is considered an effective alternative payment
model, what qualifies as a bonus will result in reduction of cost and an increase in improving quality of care. There are three
recommendations: Encouraging the movement to effective alternative payment models; improving Medicare’s physician FFS
payment system; and improving and simplifying the quality measures used in alternative payment models and the new Merit-based
Incentive Payment System. They want the Congress to reform FFS payments while legislation is replacing the current system.
"Health Plans Find Bundled Payment Works For More Than Just Procedural Care Cases." AIS Health. Atlantic Information Services,
Inc., 4 Aug. 2014. https://aishealth.com/archive/nhpw080414-02
Bundled care has caught the attention of the health insurance industry. The more complexity the bundled system can handle the
more money it can potentially save. A challenge they face is how to pay multiple providers, track and coordinate data and move from
manual coding and processing. They know bundled payment comes in phases and there are 3 stages of it. Full integration is believed
to be 5 to 10 years away. Blues plans are most likely to get the full-integration stage since they have the capital and necessary
reserves.
Caramenico, Alicia. "How Cigna Cultivates Bundled Payments." FierceHealthPayer. FierceMarkets, 18 June 2014.
http://www.fiercehealthpayer.com/story/how-cigna-cultivates-bundled-payments/2014-06-18
There can’t only be one type of value-based program so Cigna suggested bundled payments for episodes of care for deliveries.
Bundled payments model requires collaboration of payers and providers. Cigna hopes to measure bundled payments success with
claim-based metrics.
McConnel, K. "How Do Alternative Payment Models Fit In With State And National Reform Efforts?" Health Affairs Blog. Health
Affairs, 1 Dec. 2014. http://healthaffairs.org/blog/2014/12/01/how-do-alternative-payment-models-fit-in-with-state-and-
national-reform-efforts/
ACA has been described as a method of expanding coverage with little to no emphasis on controlling costs. Healthcare spending is
not being controlled so federal debt will continue to rise. Ways to control this is through creating coordinated care organizations and
payment models. The purpose of this payment reform is to move healthcare to a different model to reduce the growth of spending
and to improve health.
Galoozis, Chrisina. "How High-Deductibles Are Changing the Payer-Provider Relationship." Modern Healthcare. Crain
Communications, Inc, 2015. http://www.modernhealthcare.com/article/20141027/SPONSORED/150129984

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Jeff Jones has 26 years of healthcare consulting experience in strategy, operations improvement and information technology
implementation. He currently leads the strategic markets for Huron Healthcare. Since more patients are becoming responsible for
their healthcare finances, providers and payers have to collaborate to educate their patients and reduce barriers. Christina Galoozis
from Modern Healthcare asked Jeff the following questions to get a better understand of the relationship between the payer-
provider: how should payers and providers be involved in patient education around health costs related to treatment options,
considering recent changes with health reform, where should providers focus negotiations for contracts with payers, how can
hospitals start addressing higher rates of bad debt among patients with high-deductible plans?
Caffery, Mary. "In Wake of RAND Study, What's the Future of Bundled Payments in Managed Care?" AMJC. AJMC 2006-2015
Intellisphere, 24 Sept. 2014. http://www.ajmc.com/focus-of-the-week/0914/in-wake-of-rand-study-whats-the-future-of-
bundled-payments-in-managed-care
In August, RAMD Corporation reported a second study of bundled payments had failed. This news made healthcare reform
advocates look for answers. The American Journal of Managed Care thinks this is due to lack of keeping track of healthcare
organizations becoming a part of CMS and their want to expand bundled payments program. Jan E. Berger, MD, MJ, stated in The
American Journal of Pharmacy Benefits in June, ‘We are in a sort of ‘experimental phase’ with many of these new models, and we
will not have all the answers from the start.’ They are trying to meet the goals of bundled payment models without transparency,
inquisitiveness and willingness to work together.
Overland, Dina. "Insurers Shift Prescription Costs to Members with Drug Tiers." FierceHealthPayer. FierceMarkets, 26 Mar. 2012.
http://www.fiercehealthpayer.com/story/specialty-drug-tiers-let-insurers-shift-prescription-costs-members/2012-03-26
Insurers are moving the cost of expensive medications towards their chronically ill members and they have to pay an extra 30 to 50
percent more. The Lund Report says this is due to them using the tier system, originally they wanted ‘people to try the lowest-cost
medications first, but now the goal seems to be to get the sickest consumers to pay as much as possible.’ Insurers are having
problems moving the drugs into different tiers so they are increasing the copayment. America's Health Insurance Plans (AHIP) they
support insurers' increased use of specialty tiers and say the pharmaceutical industry is at fault for high drug costs.
Zweig, Dori. "Kaiser, Humana, Florida Blue Sit High on Customer Satisfaction Rankings." FierceHealthPayer. FierceMarkets, 1 Apr.
2014. http://www.fiercehealthpayer.com/story/kaiser-humana-florida-blue-sit-high-customer-satisfaction-rankings/2014-04-01
Kaiser Permanente, Humana and Blue Cross Blue Shield of Florida were at the top for patient satisfaction according to a survey by
Insure.com. The survey looked at 9,586 company reviews for life, auto, health, home insurance carriers and measured customer
service, claims satisfaction, customer renewals and recommendations. Kaiser had the top spot for customer satisfaction at 93.4%.
FireceHealth Payer reported this is due to Kaiser’s integrated healthcare model. Around 94% of customers renew their plan with
Kaiser and 76% said they would recommend them to their friends. Humana and Blue Cross Blue Shield were also in the ninetieth
percentile and their customers also said they would strongly recommend their insurances to their friends.
"Payer's Role in Care: Gatekeeper or Change Agent?" AMJC. AJMC 2006-2015 Intellisphere, 22 July 2014.
http://www.ajmc.com/journals/evidence-based-diabetes-management/2014/patient-centered-diabetes-care-putting-theory-
into-practice-2014/payers-role-in-care-gatekeeper-or-change-agent
Healthcare has changed over the years but many things remain the same. Amy Tenderich, founder of DiabeteMine.com discusses
what role the payer’s have. She believes the payers can play a role in supporting the patients’ needs. She among others believe it will
be beneficial if there is a more concentration on patients and asking them why it’s so hard and confusing after they leave the
hospital and are bombarded with several bills.
Verel, Dan. "Payers Focused on Solving the Primary Care Problem - MedCity News." MedCity News. Breaking Media, Inc, 15 July
2014. http://medcitynews.com/2014/07/payers-focus-primary-care-technology/
In order to drive down costs a premium has to be paid for primary care by engaging enabling and empowering primary care
physicians. Technology can aid in this if insurers included new-to-market technologies such as wearable devices. Integrating systems
is another way to cover gaps in healthcare and delivery. With a focus on technology and accountable care consumers can then
navigate through the disparate health system and primary care. Increasing financial reimbursement rate can help with physician
shortage for primary care.
Evans, Melanie. "Pioneer ACOs Show Uneven Progress in Push to Risk." Modern Healthcare. Crain Communications, Inc, 16 Jan.
2015. http://www.modernhealthcare.com/article/20150116/NEWS/301159940

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ACOs in CMS Innovation Center’s Pioneer ACO model should have shifted into risk-based business but many of them have still yet to
do so. Pioneer model has reached 50% of their goal, the accepted ACOs were deemed capable of handling care coordination and
financial risk the model demanded. Pioneer has been adding new contracts with private plans and with Medicaid in states that have
expanded their care programs. ACOs need more time to create a relationship with health plans to better integrate delivery systems.
Rosenfeld, Michelle. "Poised for Growth, Commercial ACOs Also Face Considerable Challenges - California Healthline." California
Healthline. California HealthCare Foundation, 21 May 2014. http://www.californiahealthline.org/road-to-reform/2014/poised-
for-growth-commercial-acos-also-face-considerable-challenges
ACOs are changing the payment system by creating incentives for providers to offer more efficient treatments by offering incentives
for meeting benchmarks. ACOs have increased to 600 since January; even private ACOs are on the rise. ACOs are expected to expand
in the coming years. With government support, ACOs can become the dominant healthcare model.
Alidina, Shehnaz, Eric Schneider, Sara Singer, and Meredith Rosenthal. "Structural Capabilities in Small and Medium-Sized
Patient-Centered Medical Homes." AMJC. AJMC 2006-2015 Intellisphere, 24 July 2014.
http://www.ajmc.com/journals/issue/2014/2014-vol20-n7/structural-capabilites-in-small-and-medium-sized-patient-centered-
medical-homes
Structural capabilities in 30 pilot practices were assessed using a cross-sectional study design. Changes over 2 years in 5 Rhode
Island practices were examined using pre/post design. National Committee for Quality Assurance Physician Practice Connections,
Patient-Centered Medical Home (PPCPCMH) survey was used to measure capabilities. Changes from 0 to 24 months were
analyzed. Results indicate the barriers to improvement were technology shortcomings, slow cultural change, change fatigue, lack
of broader payment reform, and extent on transformation required.
Japsen, Bruce. "UnitedHealth's $43 Billion Exit From Fee-For-Service Medicine." Forbes. Forbes Magazine, 23 Jan. 2015.
http://www.forbes.com/sites/brucejapsen/2015/01/23/unitedhealths-43-billion-exit-from-fee-for-service-medicine/
United Health believes a shift from FFS to VBP will yield better health outcomes, performance and quality of care. They expect a 20%
increase in VBP reimbursements. VBP include: pay-for-performance programs, patient-centered medical homes and accountable care
organizations. CMS has stated 20 percent of their payments are no longer FFS. Aetna, Cigna and Humana are shifting to VBP.
Herman, Bob. "Value-based Care Not Likely to End Payer/provider Financial Spats." Modern Healthcare. Crain Communications,
Inc, 22 Jan. 2015. http://www.modernhealthcare.com/article/20150122/NEWS/301229959
Even though companies are switching from FFS to VBP there still seem to be disputes regarding payer/provider contract terms. Some
think we are going to see more of these arguments in the future. There’s a movement towards value-based payment but the number
of contracts is not definite. Since VBP requires price transparency it leads to industry fighting.
Snell, Elizabeth. "Value-Based, Accountable Care Is Here to Stay for Cigna." RevCycleIntelligence. Xtelligent Media, 09 Oct. 2014.
http://revcycleintelligence.com/news/value-based-accountable-care-is-here-to-stay-for-cigna
Healthcare world is constantly changing to find ways to provide patients with high-quality, affordable care. ACOs are improving care
and outcomes while keeping costs low. If healthcare providers and payers do not allow for data to be exchanged and shared then it
becomes difficult to provide high-quality care. Cigna is working with its patients to provide quality and affordable care. Cigna is trying
to attain the three goals of better health, affordability and experience through meaningful relationship with them. Cigna is hoping to
create collaborative care for groups, hospitals and smaller groups.

ACO Achievements
Across the United States, there have been a number of accomplishments in addressing quality issues that are noteworthy. Several
ACOs have been able to be successful, but these are ones with past experiences and competence in HIT and analytics, and fairly
good control over physician decision making, carefully monitored by electronic health records.

Sanders, Dale. "Accountable Care Organization Software: 5 Critical Systems." Health Catalyst. Health Catalyst, 26 July 2013.
https://www.healthcatalyst.com/information-systems-for-accountable-care-organizations

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Like any other industry, ACOs also need software supporting it. There are five systems that lead to a successful ACO. The softwares
include: 1) electronic medical record (EMR), 2) health information exchange (HIE), 3) activity based costing (ABC), 4) patient reported
outcomes (PRO), and 5) enterprise data warehouse (EDW). EDW is the platform that allows the analysis of clinical, financial, and
patient reported data in a single database. It is also the reason the Return in ROI of healthcare IT for ACO. There are three principles
of IT that are common across industries. It’s important healthcare executives understand that business moves at the speed of the
software, big value comes from big data, and data management evolves predictably. It is believed that EDW will allow for a deeper
understanding of quality care, variations in care and costs of care after it’s adopted by IT investments.
Overland, Dina. "3 ACO Marketing Strategies." FierceHealthPayer. FierceMarkets, 31 July 2014.
http://www.fiercehealthpayer.com/story/3-strategies-market-acos/2014-07-31
Transitioning to ACO calls for different tactics of marketing, here are three of the five strategies listed in the white paper focusing on
wellness, tailored messages and analytics. Starting off with market wellness, ACOs goal is to keep their patients healthy, so it’s crucial
to market wellness instead of sickness. It’s also in their insurers and providers’ best interest to display wellness and preventative
measures that persuades their patients to take better care of themselves with a focus on explaining what preventative care really is.
Further analyzing the consumer base can lead to a better marketing, since they will be able to cater to the specific health needs of
the ACO members. Insurers and providers can guide the patients to less expensive facilities while sustaining a high quality of care.
Analyzing the consumer base also shows where excessive money is spent. Consumers are not aware of ACOs and their benefits, thus,
communicating benefits in terms the consumer understands can educate the members about participating in the care models and
the value of them.
Ellison, Ayla. "90% of Hospitals Participating in Independence Blue Cross ACO Lowered Readmission Rates." Becker's Hospital
Review. ASC COMMUNICATIONS 2015, 15 July 2014. http://www.beckershospitalreview.com/accountable-care-organizations/90-
of-hospitals-participating-independence-blue-cross-aco-lowered-readmission-rates.html
Blue Cross health insurers in association with ACOs have not only lowered their readmission rate by 90% but they have also improved
at least one hospital-acquired infection or obtained a top distinction for infection control from Pennsylvania Department of Health.
After collaborating with ACO the hospitals also scored higher in assessing the patients experience during their stay. CEO of
Independence stated collaborating with healthcare systems results in ‘higher quality, lower cost care and higher patient satisfaction.’
Muhlestein, David. "Accountable Care Growth In 2014: A Look Ahead." Health Affairs Blog. Health Affairs Blog, 29 Jan. 2014.
http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/
Leavitt Partners Center for Accountable Care Intelligence published Modern Healthcare’s accountable care organizations by
state/rank, number of ACOs and estimated lives. California ranked the highest.
McCaskill, Ryan. "Accountable Care Organizations Make News in Massachusetts." RevCycleIntelligence. Xtelligent Media, LLC, 27
Oct. 2014. http://revcycleintelligence.com/news/accountable-care-organizations-make-news-in-massachusetts
Massachusetts hospitals receive $60 million dollars to improve participation in ACOs by Health Policy Commission (HPC). These funds
are meant to increase access to behavioral health services and help ready hospitals partake in accountable care instead of fee-for-
services. The funds ($900,000) are also to be used for adoption of new systems such as electronic health records and alternative
payment methods, while increasing safety of the patient. Ultimately, MassHealth aims to improve delivery, coordination and quality
of health care, along with using payment methods other than fee-for-services. MassHealth wants to transform the health care
system in Massachusetts by reforming the methods of delivery of care and changing the compensation of healthcare services.

"Accountable Care Organizations Rapidly Changing Healthcare Marketplace." PR Newswire. PR Newswire Association, 16 Jan.
2015. http://www.prnewswire.com/news-releases/accountable-care-organizations-rapidly-changing-healthcare-marketplace-
300021989.html
ACOs and Integrated Delivery Networks (IDNs) have challenged Biopharmaceutical and Medical Device companies since they started
transforming the healthcare system. A study done by benchmarking firm, Best Practices, LLC, revealed 40% of benchmarked
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companies plan to expand into ACO networks. A related study tried to see how organizations were adjusting and utilizing their staff
to sever ACOs/IDNs. Reshaping Commercial Models to Serve ACOs, IDNs, &Emerging Provider Networks connected through
benchmarking survey with 36 leaders at 31 pharma and medical device companies in hopes of developing qualitative findings and
insights. Key topics covered in this study ere resource deployment, change management activities, sales force structure,
coordination and knowledge sharing, customer targeting and segmentation, understanding care delivery models, identifying decision
makers, strategies to improve performance, employing health outcomes and lessons learned and trends.
Peikes, Deborah, Erin Taylor, Janice Genevro, and David Meyers. "A Guide to Real-World Evaluations of Primary Care
Interventions: Some Practical Advice." PCMH Evaluation Guide. Agency for Healthcare Research and Quality, Oct. 2014.
https://pcmh.ahrq.gov/page/pcmh-evaluation-guide
The Agency for Healthcare Research and Quality (AHRQ) has published a guide for evaluating real-work evaluations of primary care interventions. AHRQ has
several resources of primary care interventions like patient-centered medical homes. They believe effective evaluation is the best way to improve primary
care health and cost outcomes and experiences. The guide can be used by a number of individuals in the health field wanting to test an intervention in a
small number of primary care.
"CMS Releases Performance Results for Pioneer ACOs - California Healthline." California Healthline. California HealthCare
Foundation, 9 Oct. 2014. http://www.californiahealthline.org/articles/2014/10/9/cms-releases-performance-results-for-pioneer-
acos
Under the Pioneer program, released in 2012, providers with contacts with CMS are required to meet quality targets and assume
new risk for Medicare beneficiaries. Modern Healthcare released a report regarding Medicare’s Individual pioneer ACOs quality and
financial performance. The financial results include performance of 232 Pioneer ACOs. The results show a decrease of 7% in health
spending among some ACOs, but an increase by 5% in others. ACOs that slowed spending in 2012 are: California-based Monarch
HealthCare, Indiana-based Franciscan Alliance, New York City-based Montefiore ACO and Northern California-based Brown & Toland
Physicians. The 2013 results show Pioneer ACOs spending slowed by 5.4% and others increased by 5.6%. The largest spending came
from Beacon Health in 2013.
Overland, Dina. "Covering All Preventive Tests Leads to Higher Utilization, Costs." FierceHealthPayer. FierceMarkets, 19 Aug.
2014. 09 Sept. 2015. <http://www.fiercehealthpayer.com/story/covering-all-preventive-tests-leads-higher-utilization-costs/2014-
08-19
Since insurers are covering more screenings and preventive tests, two financial experts are questioning if that kind of coverage if
increasing costs for the companies. ACA wants insurers to pay for preventive care for early diagnosis of diseases so in the long haul
more money is saved, but that can only happen if the procedures are priced low. One of their biggest concerns is making preventive
care coverage beneficial. For example, incentivizing general public for certain screenings like colonoscopy doesn’t essentially lead to
less cancer; however it does raise utilization rates and costs. Another obstacle they face is how insurers are interpreting provisions by
the ACA’s preventive care coverage.
Bresnick, Jennifer. "Does Accountable Care Improve Hospital Quality for Minorities?"HealthITAnalytics. Xtelligent Media, 10 Nov.
2014. http://healthitanalytics.com/news/accountable-care-improve-hospital-quality-minorities
Pay-for-performance reimbursement structures are associated with gains in quality and reduced mortality for minority patients, says
a new study. According to American Journal of Managed Care (AJMC) accountable care and value-based incentives may be effective
in closing quality gaps between white and minority patients suffering from chronic diseases. Instead of fee-for-service, pay-for-
performance models have been successful in improving quality and mortality for minority patients. Researchers from Harvard School
of Public Health and VA Boston Healthcare System and Brigham and Women’s Hospital compared treatment and mortality data from
2004 to 2008 from hospitals partaking in Premier Hospital Quality Incentive Demonstration (HQID). They found a difference in the
way white patients and black patients received care; however, the researchers called the findings reassuring as a way to reduce
costs and improve quality.

Nakhimovsky, Sharon, John Langenbrunner, James White, Abigail Vogus, Hailu Zelelew, and Carlos Avila. "Domestic Innovative
Financing for Health: Learning From Country Experience - HFG." HFG. Abt Associates, 13 Jan. 2015.
https://www.hfgproject.org/domestic-innovative-financing-health-learning-country-experience/
A HFG report Domestic Innovative Financing for Health: Learning From Country Experience highlights domestic innovative financing.
Advancing in health care extends and improves the quality of life for people on a global scale, not sometimes it increases inequities
in health access and pushes people into poverty. Domestic innovative financing will help in preventing that from happening.
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Additional resources will be generated by those coming from a domestic source. The report focused on assessing country experience
with domestic innovative financing options, both failures and successes to understand global wisdom on selecting and implementing
them in low and middle income countries.
Leventhal, Rajiv. "EHNAC Develops Accreditation Program for ACOs." HealthCare Informatics. Vendome Group, 21 July 2014.
http://www.healthcare-informatics.com/news-item/ehnac-develops-accreditation-program-acos
The Electronic Healthcare Network Accreditation Commission (EHNAC) has developed an accreditation program focusing on ACOs.
According to EHNAC officials the accreditation program focuses on business, technical, resource management, population health,
care coordination and other aspects of ACOs to create a bond of trust for all the stakeholders within the ACO. EHNAC is working with
ACO accreditation candidates to identify ways to improve quality of service, efficiency and ensure the organization is up with today’s
trends and standards. Washington, D.C.-based Capital Clinical Integrated Network (CCIN) and HEALTHEC are two organizations to
undergo accreditation process.
Joszt, Laura. "Financial Results from First 2 Years of Pioneer ACO Program Show Mixed Results." AMJC. AJMC 2006-2015
Intellisphere, 09 Oct. 2014. http://www.ajmc.com/newsroom/financial-results-from-first-2-years-of-pioneer-aco-program-show-
mixed-results
There have been gains and losses from the 32 organizations that started in the Pioneer ACO Mode. After the first year 9
organizations dropped and recently another 4 left as well and lost over $9.3 million. The ACO didn’t have to pay shared losses. Even
though many organizations left, 19 are still involved. They have shared high total savings. Here are the 13 ACOs that left the
program: Franciscan Alliance; Genesys PHO; Healthcare Partners of California; Healthcare Partners of Nevada; JSA Medical Group, a
division of HealthCare Partners; Physician Health Partners; Plus! / North Texas ACO; Presbyterian Healthcare Services; PrimeCare
Medical Network; Renaissance Health Network; Seton Accountable Care Organization, Inc.; Sharp HealthCare ACO; and University of
Michigan.
Viebeck, Elise. "HHS Unveils $840M Initiative to Reform Doctors' Offices." TheHill. Capitol Hill Publishing Corp, 23 Oct. 2014.
http://thehill.com/policy/healthcare/221636-hhs-unveils-840m-initiative-to-reform-medical-practices
The Department of Health and Human Services (HHS) will spend $840 million over the next four years in hopes of helping 150,000
doctors become modern and improve their patient care and reduce costs. The practices can use EMRs, expand the way patients
communicate with their doctors and create a better coordination of care across providers. Value-based model can help improve the
experience for patients and help the healthcare industry reduce costs. AMA believes practicing this transition will help improve
quality of care for patients, control health care costs and increase practice sustainability. The applicants will be judged on their
ability reach measurable goals, like reducing readmissions.
Cohen, Gary. "High Quality, Affordable Care: Making The Case For Smarter Networks." Health Affairs Blog. Health Affairs, 13 Nov.
2014. http://healthaffairs.org/blog/2014/11/13/high-quality-affordable-care-making-the-case-for-smarter-networks/
Different types of narrow networks should be adopted by policy makers and they should make sure they don’t adopt policies that
hinder contractual arrangements across payers, providers and hospitals. Since ACA came to be uninsured levels have dropped to
their lowest levels since 1997 according to CDC. Insurers have adopted narrow networks to prevent increases in premiums. They
have been credited for lowering premiums and reducing health expenditure. Narrow networks create a lot of controversy. Some
concerns include adequacy of these networks, choice of providers consumers have access to in the network and transparency. Due
to these concerns state legislatures and regulators have considered changing and adopting new laws and regulations. There are
different types of narrow models with different levels of integration.

Japsen, Bruce. "How Accountable Care Is Transforming U.S. Healthcare." The Motley Fool. The Motley Fool, 27 June 2014.
http://www.fool.com/investing/general/2014/06/27/how-accountable-care-is-transforming-us-healthcare.aspx
Health insurance companies are persuading hospitals and doctors to move from FSS to ACOs in hopes of improving quality, boosting
earnings and controlling costs. Patients get overcharged under FFS model which is why value-based care has been pushed by the
industry. Various types of value-based arrangements such as bundled payments, ACOs, and patient-centered medical homes are
now operational. There are over 110,000 contracted physicians and more than 100 ACO-type organizations in comparison to 50

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ACOs a year ago. Physicians would rather be paid for better outcomes, spending more time with patients and for delivering value
care according to UnitedHealth.
Rizzo, Ellie. "Inpatient Utilization Stagnates, Falls for 68% of Nonprofit Hospitals." Becker's Hospital Review. Becker's Healthcare,
23 Sept. 2014. http://www.beckershospitalreview.com/capacity-management/inpatient-utilization-stagnates-falls-for-68-of-
nonprofit-hospitals.html
According to Kaufman Hall survey, inpatient utilization was didn’t change or went down 68% in the first and second quarters of 2014.
They also found 72% of responding hospitals an increase in outpatient utilization. There was only 60% use of emergency
departments.
Gregg, Helen. "Interoperability a Stumbling Block for ACOs, Finds Survey." Becker's Hospital Review. Becker's Healthcare, 25 Sept.
2014. http://www.beckershospitalreview.com/healthcare-information-technology/interoperability-a-stumbling-block-for-acos-
finds-survey.html
Recent survey results from Premier suggest 66% of ACOs said health technology improved their care quality, 63% said it improved
preventive screening and vaccination rates, 59% said it improved chronic disease management and 55% said it improved their overall
health outcomes. Since there isn’t interoperability between the data sources, ACOs aren’t getting the full advantage. Of the
participants in the survey, 62 said they had trouble combining data from other sources and 88% said integrating was an obstacle.
Rappleye, Emily. "Largest Massachusetts Independent Physician Group Condenses." Becker's Hospital Review. Becker's
Healthcare, 09 Dec. 2014. http://www.beckershospitalreview.com/hospital-physician-relationships/largest-massachusetts-
independent-physician-group-condenses.html
According to The Boston Globe, three independent physician groups are merging to become a nonprofit managed by one team. The
mergers include Harvard Vanguard Medical Associates, Dedham Medical Associates and Quincy and Granite Medical Group. They all
have over 650,000 patients and 750 physicians all ruled under Atrius Health Network. It’s the largest independent physician group in
Massachusetts.
Caramenico, Alicia. "Low-value Care Cost Medicare $8.5B." FierceHealthPayer. FierceMarkets, 13 May 2014.
http://www.fiercehealthpayer.com/story/low-value-care-cost-medicare-85b/2014-05-13
A JAMA study found Medicare beneficiaries to receive low-value services despite attempts to increase healthcare efficiency. The
study looked at 26 measures of low-value services. The researchers found that claim-based measures of low-value services can
essentially help evaluate and develop programs to decrease wasteful care. And direct claims-based measures can help determine
when something is overused. Researchers believe bundled payments are a way to decrease low-value services.
Rau, Jordan. "One-Quarter Of ACOs Save Enough Money To Earn Bonuses." Stat Revenue. Kaiser Health News, 17 Sept. 2014.
http://www.statrev.com/one-quarter-of-acos-save-enough-money-to-earn-bonuses/
Out of 243 groups of hospitals and doctors a quarter has agreed to work as an ACO. ACOs are a voluntary based affiliation. Doctors
and hospitals collaborate to earn extra money by saving Medicare money while maintaining the health of their patients. There are
two types of ACOs: Medicare Shared Savings Program and the Pioneer ACO Model.
Ellison, Ayla. "Report: ACOs to Cover 130M Lives by 2017." Becker's Hospital Review. Becker's Healthcare, 31 July 2014.
http://www.beckershospitalreview.com/accountable-care-organizations/report-acos-to-cover-130m-lives-by-2017.html
Dallas-based Parks Associates reported there will be an increase in the number of individuals covered under ACOs from 40 million in
2015 to 130 million by 2017. This is be due to an increased emphasis on performance-based metrics, along with business and
regulatory changes in ACOs.

Antonio, Jane. "Survey: Docs Order Needless Tests Weekly." FierceHealthPayer. FierceMarkets, 3 May 2014.
http://www.fiercehealthpayer.com/antifraud/story/survey-docs-order-needless-tests-weekly/2014-05-03
Results from Choosing Wisely show three out the four physicians prescribe unnecessary tests or procedures at least once a week. An
unnecessary test is requested by 47% of doctors for at least one patient per week due to continual insistence even though they
would not have recommended it. Some doctors believe they cave in because they fear of not being “liked.”

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Rosin, Tamara. "Survey: Top 1% of Patients Account for 22% of Costs." Becker's Hospital CFO. Becker's Healthcare, 17 Oct. 2014.
http://www.beckershospitalreview.com/finance/survey-top-1-of-patients-account-for-22-of-costs.html
A report by Medical Expenditure Panel Survey reveals in 2012, US health expenditures totaled $1.35 trillion. Top 1 percent accounted
for 22.7% of the total healthcare expenditure with an annual income of $97,956. The top 1 percents healthcare spending increased
by .9 percent from 2009 to 2012 ad top 5 percent accounted for 50 percent spending in 2009 and 2012. The 2014 report shows,
general findings, age-specific findings and insurance status-specific findings.
Sullivan, Katie. "Two-thirds of Americans Have ACO Access." FierceHealthcare. FierceMarkets, 23 May 2014.
http://www.fiercehealthcare.com/story/two-thirds-americans-have-aco-access/2014-05-22
Over two thirds of Americans live in an area where 500 ACOs exist. ACOs serve between 46-52 million Americans. ACOs are triggering
a revolution in the American healthcare. Their payment methods are reimbursed differently from the FFS providers. They can result
in profit by avoiding unnecessary services and focusing on preventive care. ACOs are expected to double according to
FierceHealthcare.

Implications/Outlook
As ACOs provide different performance since more widespread control over quality and finances takes time, the question remains
whether all the innovations will be proven worthwhile through health services research, and what it may take for such to be
instituted across most provider systems to achieve changes in the population's health. In the era of "Big Data," intense monitoring
becomes much easier if analytic capabilities are used so that the spending trends related to quality can be identified. Rising drug
costs remain problematic to address still (particularly with very costly specialty introductions), and consumers are not yet equipped
with levels of health literacy to make choices over what is best for their care. Most consumers remain very concerned with the rising
out-of-pocket expenditures they face in this reforming health care system (sic). Disruptions come with the technological changes in
both science and new management systems: hospitals are closing, CEO turnover is recorded regularly, routine layoffs and service
cuts are common, bankruptcies continue, data breaches are significant, drug formularies are being restricted, and financial losses hit
communities in various ways. With the merger and acquisition fervor, relationships for the medical profession must be sorted out
nationally, as well as regionally and locally. Employers have not been happy with the double-digit rise in their outlays for health
insurance for workers, and they continue the pressure for this value-based care. It remains to be seen how much coordinated care
can contribute to significant quality improvement that really saves costs. Will the ACO development produce real cost savings, or
merely trim or curtail the rising trajectory of spending in the country. It is beginning to be noted what public health professionals
have claimed historically that medical care is only part of improving health. Social, occupational, and environmental conditions for
healthier living and characteristics of communities being served need to be fully recognized much more for certain groups in certain
kinds of systems if substantial health improvements in the society is to be achieved. The U.S. appears to be far away from
guaranteeing effective health promotion and protection to every citizen, seeing how long it has been to promise universal health
care.
Reisman, M. The Affordable Care Act, Five Years Later: Policies, Progress and Politics
http://www.ptcommunity.com/journal/article/full/2015/9/575/affordable-care-act-five-years-later-policies-progress-and-politics
Five years into the ACA, and after the SCOTUS decision in King vs. Burwell (the make or break case) the law seems to be working in
reducing the number of uninsured (estimated 17 million new). The gains in access were for all types of insurance and with some
minorities and economically disadvantaged individuals acquiring insurance. The ACA's 10,000 pages touch about every aspect of the
healthcare system. Many myths have been promulgated by the opposition party and many still endure. Folks did not lose their
insurance, nor did employers drop health benefits in droves, and the predicted influx of newly insured did not overwhelm existing
providers. Dynamic changes are also underway for the pharmaceutical marketplace. Plans do not have to cover all formularies (as is
happening, with mandated generics and limiting certain brands as exclusions). ACOs will be seeking cost-effective alternatives for
expensive therapies and data transparency should support consumer decision making. The hope is that the ACA will improve health
and reduce costs. The president has said that the ACA is here to stay and may be imbedded too much for even a Republican
president in 2016 to uproot it.
Scanlon, D. The Healthcare System Future. American Journal of Managed Care. 2015, 19 August. http://www.ajmc.com/peer-
exchange/healthcare-reform-stakeholders-summit- spring-2015/the-healthcare-system-future
Over the next five years, innovations in the private sector will be the primary engine with the federal government learning what
works from the models as they evolve.

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Overland, Dina. "ACO Emerges as Dominate Care Model despite Challenges." FierceHealthPayer. FierceMarkets, 22 May 2014.
http://www.fiercehealthpayer.com/story/aco-emerges-dominate-care-model-despite-challenges/2014-05-22
Insurers believe ACO success can be achieved due to their ability to track patient data and evaluate care. ACOs also allow different
arrangements for their organizations circumstances, assets, and needs for commercial plans that are flexible catering to the
participants needs. David Muhlestein, director of research at Leavitt Partners believes ACOs will thrive and become successful due to
government support and an increase in number of organizations becoming ACOs.
Ellison, Ayla. "The Changing Healthcare World: 7 Trends to Watch." Becker's Hospital Review. Becker's Healthcare, 8 Sept. 2014.
http://www.beckershospitalreview.com/hospital-management-administration/the-changing-healthcare-world-7-trends-to-
watch.html
Seven of the biggest healthcare trends in 2014 were discussed during a forum held by Randy Hultgren and Scott Becker. Becker
discussed seven trends: cost vs. benefit of healthcare reform, growth in high-deductible health plans, balancing of freedom of
religion with provisions of the PPACA, uncertainty of insurance subsidies, “ends justify the means” politics, broad agreement on one
provision of health reforms, and growth in consolidation.
Rapaport, Lisa. Poverty May Increase Odds of Repeat Hospitalizations. 2015, 15 September.
http://www.reuters.com/article/2015/09/15/us-health-healthcare-socioeconomic-readm-idUSKCN0RF2OI20150915
Medicare penalties for hospital readmissions are seen to be beyond doctors' control due to their treating more socially
disadvantaged. Current Medicare deduction of 3% for inpatient payments, with rates adjusted only for patients' age, sex, and recent
diagnosis. In 2014, 2600 hospitals were fined 428 million dollars for excessive admissions, about half of the nation's hospitals. A
study of patient education, income, marital status, employment, race and ethnicity, and smoking and drinking habits showed such
patient characteristics found half the difference in repeat hospitalizations between highest and lowest rates, which are due to
patients not currently conducted by Medicare. Hospitals serving more disadvantaged communities remain likely to be penalized
more unless CMS changes its formulary for the calculation.
Sullian, Katie. "NCQA Proposes Integration of Medical Homes and Ambulatory Clinics." AMJC. AJMC 2006-2015 Intellisphere, 15
July 2014. http://www.ajmc.com/focus-of-the-week/0714/NCQA-Proposes-Integration-of-Medical-Homes-and-Ambulatory-Clinic
The employer-oriented National Committee for Quality Assurance (NCQA) proposed a program that integrates patient centered
medical homes (PCMHs) with nontraditional ambulatory sites. If the program is embraced it will assess quality of care delivered by
ambulatory care, urgent care centers, retail clinics, and worksite clinics. Clinical performance will vary depending on the type of
facility. NCQA will take public commentary about the program until August 6, they believe this will help create a program that
encourages communication and support quality. Through integration of nontraditional ambulatory sites with medical homes, they
hope to reduce the fragmentation of patient care.
Budryk, Zack. "Special Report: The Future of Accountable Care Organizations." FierceHealthcare. FierceMarkets, 7 Feb. 2014.
http://www.fiercehealthcare.com/special-reports/special-report-future-accountable-care-organizations
ACOs are focusing quality-based reimbursement instead of FFS and are providing incentives for outcomes rather than volume. In
2012 Pioneer ACOs and ACOs part of MSSP generated over $400 million in savings and there has been a noticeable drop in inpatient
use. FierceHealthcare plans on revealing what ACOs plans are for the future.
Herman, Bob. "Value-based Care Not Likely to End Payer/provider Financial Spats." Modern Healthcare. Crain Communications,
Inc, 22 Jan. 2015. http://www.modernhealthcare.com/article/20150122/NEWS/301229959
Even though companies are switching from FFS to VBP there still seem to be disputes regarding payer/provider contract terms. Some
think we are going to see more of these arguments in the future. There’s a movement towards value-based payment but the number
of contracts is not definite. Since VBP requires price transparency it leads to industry fighting.

Wechsler, Jill. "The Quest Continues for Quality Metrics." PharmTech. Advanstar Communications Inc., 20 Jan. 2015.
http://www.pharmtech.com/quest-continues-quality-metrics-0
Leaders of FDA’s Center for Drug Evaluation and Research (CDER) are working with biopharma manufacturers for several years to
obtain quality measures and get reliable production of high-quality drugs and biologics. The International Society for Pharmaceutical
Engineering (ISPE), and trade associations for drugs, biologics and generic drugs have created a consensus on metrics approaches.
26
ISPE ran metrics to collect data to assess costs and options. The goal of it is to get a reporting system that is more effective and
produces more consistent observations and inspection reports.
Overland, Dina. "ACOs Leverage Data Analytics for Quality Care." FierceHealthPayer. FierceMarkets, 17 July 214.
http://www.fiercehealthpayer.com/story/acos-leverage-data-analytics-ensure-quality-care/2014-07-17
Data analytics are a necessity for insurers creating ACOs due to their ability of improving quality of care they deliver to ACO
participants. According to Health Data Management Salt Lake City-based Intermountain Healthcare is collecting data from its clinical
and financial systems and creating data marts. They believe it pays to look at data sine you finding thing you didn’t previously know.
Intermountain Healthcare has reduced elective inductions for pregnant women, leading to fewer babies admitted to ICU through the
use of their data marts, eventually improving the quality of care. Aetna’s ACOs are using this tactic and the insurer shares all their
data with its provider to deliver a higher quality of care at a lower cost. University of Pittsburgh Medical Center is also working with
data analytics and the insurer has the ability to view patient claims, prescriptions and census records to predict which member is
most likely to end up in the emergency room and urgent care facilities.
Eisenberg, W. and Butterfield, K. A. What Roles Do Patient Characteristics Play in Value-Based Performance? American Journal of
Managed Care. 2015, 20 August. http://www.ajmc.com/journals/ajpb/2015/AJPB_JulyAugust2015/What-Roles-Do-Patient-
Characteristics-Play-in-Value-Based-Performance
Engagement of patients and families and promoting effective communication are strategic for care coordination. Making people
healthier requires new performance measures (as opposed to quality improvement indicators) which are influenced by many factors
beyond medical care services. Particularly of concern are disadvantaged populations so that metrics accurately measure quality of
care under the control of providers. Risk-adjusted performance measure rates are calculated by comparing providers' actual rate to
their expected rate. Historically disadvantaged patient groups have experienced worse quality of care and the disparities literature
reveals this in detail. As payers and purchasers begin to incorporate social demographic status, risk-adjusted performance measures
into public reporting, careful evaluations will be necessitated to avoid unintended consequences.
Rosenbaum, L. Scoring No Gold - Further Adventures in Transparency. New England Journal of Medicine. 2015, 9 September.
http://www.nejm.org/doi/full/10.1056/NEJMp1510094
Medical proceduralists realize publically reported quality will motivate them to avoid the sickest patients. Studies have shown wide
disparities so the promise of score cards to aid patients' selection of doctors is not ever reached. Such efforts in assessing
transparency face challenges in design implementation as well as stiff resistance from certain M.D.'s and hospitals. Reliability in data
and stratification of risk requires constant "quality improvement" in the process. Future quality and transparency efforts will require
a broader effort to establish standards across hospitals and better means for peer review.
Himmelstein, D. and Woolhandler, S. Quality Improvement: "Become good at cheating and you will never need to become good
at anything else." Health Affairs Blog. 2015, 27 August. http://healthaffairs.org/blog/2015/08/27/quality-improvement-become-
good-at-cheating-and-you-never-need-to-become-good-at-anything-else/
"Gaming the system" became a popular phrase in the implementation of DRGs in the 1980s, and the recent CMS effort to reduce
hospital readmissions within 30 days of discharge revealed some hospitals avoiding the imposed penalties. Relabeling patients who
are under "observation status" in the ER department helps hospitals avoid costly fines, and detracts on whether they actually meet
quality standards. Thus, the evidence for the CMS "carrot and stick" approach is unconvincing. Greater effort to evaluate such
schemes may show little or no improvement in patient outcomes and dampen the enthusiasm generated by the rosy short-term
findings. Well meaning, but misguided laws and reimbursement policies will necessitate program experimentation and quality
health services research to evaluate positive achievements.

Crow, D. Health Insurers Rush to Consolidate After ACA Ruling. Physicians' Money Digest.
http://www.msn.com/en-gb/news/other/us-health-insurers-rush-to-consolidate-after-obamacare-ruling/ar-AAcHTc0
Following the Supreme Court ruling vindicating ObamaCare, takeover talks zoomed among hospitals and insurers. The "big three"
insurers (if approved) would have dollar marked $346 billion in revenues with 134 million customers. Medicare and now Medicaid,
are becoming heavily privatized by these insurers. Roughly 16.8 million beneficiaries are enrolled in Medicare Advantage plans,

27
expected to climb to 22 million shortly. "There is a tacit understanding in Washington that consolidation is not something they care
about."
Evans, M. Primary Care Docs Reaping the Most from Shared-Savings ACOs. Modern Healthcare. 2015, 31 August.
http://www.modernhealthcare.com/article/20150829/MAGAZINE/308299961
The Medicare Shared-Savings ACOs got an average of $7.5 million in bonuses, with primary care docs benefiting the most in the
distributions for coordinated care. Forty-six percent went to primary care physicians, 20% to specialists, and 27% to hospitals. ACOs
can determine how they distribute the bonus money from CMS. This is a small indication of the payment shift from volume to value-
based performance.
Mechanic, R. E. Mandatory Medicare Bundled Payment - Is It Ready for Prime Time? New England Journal of Medicine. 2015, 26
August. http://www.nejm.org/doi/full/10.1056/NEJMp1509155
Bundling payments for surgical interventions has gained favor among CMS and private insurers. The bundled payments for care
improvement (BPCI) currently is voluntary, but CMS will eventually require such incentivizing to coordinate all care for such matters
as total hip and knee replacements (400,000 Medicare beneficiaries had these last year for $7 billion dollars) for hospital stays alone,
which represents 55% of that total. This policy of bundled payments remains controversial besides its mandatory provision due to
hospital control over the financial surpluses based retrospectively and the inherent variation in average spending per episode. In
sum, bundling payments face many technical and political obstacles in realigning the delivery system.
Caffrey, M. K. ACOs Continue to Show Mixed Results in Producing Savings. American Journal of Managed Care. 2015, 26 August.
http://www.ajmc.com/focus-of-the-week/0815/acos-continue-to-show-mixes-results-in-producing-savings
Most ACOs did not qualify for shared savings in 2014. More time in the program is more likely for ACOs to reap bonuses. Of the
Pioneer ACOs, 15 achieved savings, but only 11 qualified for bonuses. Quality of care scores did not jump as large as in the last year.
Rau, J. and Gold, J. Medicare Yet to Save Money through Heralded Medical Payment Model. 2015, 14 September. Kaiser Health
News.
Half of Medicare's 353 ACOs cost more than the government estimated their patients would normally cost. The lure of bonuses did
not appear to be working. The Obama administration has touted ACOs as the most promising reform of the 2010 law, and set a goal
that by the end of 2018, half of Medicare spending would be linked to quality and frugality. In 2014, Medicare paid $60 billion
dollars to ACOs, with nearly $3 million dollars being lost by the Medicare trust fund. See above this is a repeat but a different text.
Firth, S. CMS: "Healthier People, Smarter Spending" with ACOs. http://www.crh.arizona.edu/news/1444
CMS claims that the 420 Medicare ACOs, caring for 7.8 million patients have made "strong improvement" but longevity at
coordinated care is key for changing behavior of doctors and hospitals. The 20 pioneer ACOs and 333 Shared Savings Programs ACOs
produced an estimated 411 million in savings. Among pioneer ACOs, significant measures were medication reconciliation from 70%
to 84%; screening for clinical depression up 50% to 60%; and qualification for EHR incentive payments 77% to 86%.
Peterson-Kaiser Health System Tracker, How Does the Quality of the U.S. Healthcare System Compare to Other Countries? Kaiser
Family Foundation Analysis. 2015, 15 September. Kaiser Family Foundation. http://kff.org/slideshow/how-does-the-quality-of-
the-u-s-healthcare-system-compare-to-other-countries/
Beyond falling mortality rates (influenced by much more than medical care), the U.S. has the highest rate of death amenable to
health care interventions among comparable OECD nations. Disease burden is higher in the U.S., noted in hospital admissions for
preventable diseases (like circulatory conditions, asthma and diabetes). The U.S. has higher rates of medical, medication, and lab
errors; higher postop clots and similar sepsis and suture eruptions than OECD countries. Other indicators are listed here to show
quality gains in cancer, amidst indicators comparable across the OECD.

Silverman, E. The New Equation of American Health Care. Managed Care, 2015 August. Pages 18-29.
managedcaremag.com/.../imported/1508/managedcare_201508.pdf
Health and Human Services' goal for value-based care was announced as 85% of traditional Medicare payments would be under this
reimbursement by 2016, plus 90% by 2018. Private sector parties vowed for 75% by 2020. Such aspirations, the article doubts,
despite purchasers' pressures for cost control. Providers remain not ready to take on risk, but seek more time to deploy dollars to

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maintain maximum effect. "Two-sided risk and penalties are needed if the system is to leave its fee-for-service days behind and give
up on its volume and intensity ways." The "Mr. Nice Guy era" of health care may be coming to an end. Bundling poses numerous
and complex challenges in implementation, and the movement forward is fraught with conflicts.
Woolhandler, S. and Himmelstein, D. U. Collateral Damage: Pay-for-Performance Initiatives and Safety-Net Hospitals. Annals of
Internal Medicine. 2015, 7 September. Pages 1-3. http://annals.org/article.aspx?articleID=2434618
Pay-for-Performance (P4P) initiatives are found to divert money from under-resourced safety net hospitals, the mainstays of care for
minority communities. Medicare's P4P program does not adjust for socioeconomic status, so when quality is due to a hospital's
financial distress, penalizing low scorers may well punish patients and exacerbate quality disparities across communities. Both
Medicare and private insurers are set to ratchet P4P rewards and penalties. "Tethering physicians' rewards to box checking and
redundant documentation risks both substituting insurers' priorities for patients' goals and demoralizing physicians."
Ladika, S. The New Era of Mega-Plans. Managed Care. 2015, September. Pages 18-22.
www.managedcaremag.com/archives/2015/9/new-era-mega-plans
Immediately following SCOTUS decision on King vs. Burwell, billion-dollar mergers trended to consolidate private insurance market
as follows: Centene-Health Net, Aetna-Humana, Anthem-Cigna, the latter two along with United Healthcare becoming the "Big
Three." The article lists about a dozen previous amalgams from 2011 predicting a handful of firms by 2016. Currently six firms
account for 72% of the Medicare Advantage market (31% of all seniors), but Medicaid awaits for this corporate takeover. Now
between 40 to 50 million members will be in each of the top three companies. Antitrust regulations will have a challenging scrutiny.
Concerns over price and competition in local markets may ask for divestiture of certain businesses by market segment or in
geographic locales. Will there still be room for smaller players? Blue Cross Blue Shield plans are only partially consolidated and the
acquisitions of PBMs may fit into the insurer equation very soon.
Evans, M. Investors Hope to Profit from Sharing the Bundled Payment Load. Modern Healthcare. 2015, 12 September. Pages 12-
13. http://www.modernhealthcare.com/article/20150912/MAGAZINE/309129963
Several companies have emerged to capitalize on the ACAs complex new programs. Cardinal Health, a medical supply firm, paid
$290 million dollars to acquire a major stake in naviHealth, a consulting tech firm working on bundled payments. Team Health, a
staffing firm, paid $1.6 billion for IPC Healthcare, a hospitalist company. Bundled payments are expected to be $10 billion dollars
from CMS next year, so this can become a lucrative market segment as "conveners" get fees or share in profits. Private equity firms
are circling such areas also amidst several other major players staking out this market segment.
Caffrey, M. K. More Accurate, Timely Medical Diagnoses Require Overhaul, Report from National Academy of Medicine States.
2015, 22 September. http://www.ajmc.com/focus-of-the-week/0915/more-accurate-timely-medical-diagnoses-require-overhaul-
report-from-national-academy-of-medicine-states
Getting the right diagnosis and faster will take across the board reform that targets doctors, how they are trained, spend their time
with patients, and the way the legal system handles information about mistakes and near misses. Diagnostic errors account for the
largest number of paid medical malpractice claims. Overdiagnosis remains a challenge to quality improvement also. This NAM
report complements the previous "To Err is Human: Building a Safer Health System" and "Choosing Wisely." Two key points are
crafting better work environments and alternative legal dispute mechanisms in medical liability reform.
Dranove, David. "The Future of Physicians in ACO Era Remains Secure, Though Their Roles Will Change." Modern Healthcare.
Crain Communications, Inc, 12 July 2014. Web. <http://www.modernhealthcare.com/article/20140712/MAGAZINE/307129979>
ACA has promoted using ACOs. ACOs have many forms, some are led by large group practices and others by hospitals, but they are
improving quality slowly but surely. Even with using ACOs insurance companies still have a purpose, ACOs will still listen to doctors,
digital medicine will drive the cost/quality equation and only cost-conscious physicians need apply. Physicians’ future is secure even
after working with/for ACOs. If they partake in ACA they will deliver a better care and result in a higher job satisfaction. This health
reform will result in saving lives and money.

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