Accountable Care Organizations and Post-Acute Care: A Focus on Preferred SNF Networks.

Due to high magnitude and variation in spending on post-acute care, accountable care organizations (ACOs) are focusing on transforming management of hospital discharge through relationships with preferred skilled nursing facilities (SNFs). Using a mixed-methods design, we examined survey data from 366 respondents to the National Survey of ACOs along with 16 semi-structured interviews with ACOs who performed well on cost and quality measures. Survey data revealed that over half of ACOs had no formal relationship with SNFs; however, the majority of ACO interviewees had formed preferred SNF networks. Common elements of networks included a comprehensive focus on care transitions beginning at hospital admission, embedded ACO staff across settings, solutions to support information sharing, and jointly established care protocols. Misaligned incentives, unclear regulations, and a lack of integrated health records remained challenges, yet preferred networks are beginning to transform the ACO post-acute care landscape.

Landscape of Health Systems in the United States.

Despite the prevalence of vertical integration, data and research focused on identifying and describing health systems are sparse. Until recently, we lacked an enumeration of health systems and an understanding of how systems vary by key structural attributes. To fill this gap, the Agency for Healthcare Research and Quality developed the Compendium of U.S. Health Systems, a data resource to support research on comparative health system performance. In this article, we describe the methods used to create the Compendium and present a picture of vertical integration in the United States. We identified 626 health systems in 2016, which accounted for 70% of nonfederal general acute care hospitals. These systems varied by key structural attributes, including size, ownership, and geographic presence. The Compendium can be used to study the characteristics of the U.S. health care system and address policy issues related to provider organizations.

Assessing Differences between Early and Later Adopters of Accountable Care Organizations Using Taxonomic Analysis.

OBJECTIVE: To compare early and later adopters of the accountable care organization (ACO) model, using the taxonomy of larger, integrated system; smaller, physician-led; and hybrid ACOs. DATA SOURCES: The National Survey of ACOs, Waves 1 and 2. STUDY DESIGN: Cluster analysis using the two-step clustering approach, validated using discriminant analysis. Wave 2 data analyzed separately to assess differences from Wave 1 and then data pooled across waves. FINDINGS: Compared to early ACOs, later adopter ACOs included a greater breadth of provider group types and a greater proportion self-reported as integrated delivery systems. When data from the two time periods were combined, a three-cluster solution similar to the original cluster solution emerged. Of the 251 ACOs, 31.1 percent were larger, integrated system ACOs; 45.0 percent were smaller physician-led ACOs; and 23.9 percent were hybrid ACOs-compared to 40.1 percent, 34.0 percent, and 25.9 percent from Wave 1 clusters, respectively. CONCLUSIONS: While there are some differences between ACOs formed prior to August 2012 and those formed in the following year, the three-cluster taxonomy appears to best describe the types of ACOs in existence as of July 2013. The updated taxonomy can be used by researchers, policy makers, and health care organizations to support evaluation and continued development of ACOs.

Few ACOs pursue innovative models that integrate care for mental illness and substance abuse with primary care.

Accountable care organizations (ACOs) may be well positioned to increase the focus on managing behavioral health conditions (mental health and substance abuse) through the integration of behavioral health treatment and primary care. We used a mixed-methods research design to examine the extent to which ACOs are clinically, organizationally, and financially integrating behavioral health care and primary care. We used data from 257 respondents to the National Survey of Accountable Care Organizations, a nationally representative survey of ACOs. The data were supplemented with semistructured, in-depth interviews with clinical leaders at sixteen ACOs purposively sampled to represent the spectrum of behavioral health integration. We found that most ACOs hold responsibility for some behavioral health care costs, and 42 percent include behavioral health specialists among their providers. However, integration of behavioral health care and primary care remains low, with most ACOs pursuing traditional fragmented approaches to physical and behavioral health care and only a minority implementing innovative models. Contract design and contextual factors appear to influence the extent to which ACOs integrate behavioral health care. Nevertheless, the ACO model has the potential to create opportunities for improving behavioral health care and integrating it with primary care.

Innovation in the safety net: integrating community health centers through accountable care.

BACKGROUND: Safety net primary care providers, including as community health centers, have long been isolated from mainstream health care providers. Current delivery system reforms such as Accountable Care Organizations (ACOs) may either reinforce the isolation of these providers or may spur new integration of safety net providers. OBJECTIVE: This study examines the extent of community health center involvement in ACOs, as well as how and why ACOs are partnering with these safety net primary care providers. DESIGN: Mixed methods study pairing the cross-sectional National Survey of ACOs (conducted 2012 to 2013), followed by in-depth, qualitative interviews with a subset of ACOs that include community health centers (conducted 2013). PARTICIPANTS: One hundred and seventy-three ACOs completed the National Survey of ACOs. Executives from 18 ACOs that include health centers participated in in-depth interviews, along with leadership at eight community health centers participating in ACOs. MAIN MEASURES: Key survey measures include ACO organizational characteristics, care management and quality improvement capabilities. Qualitative interviews used a semi-structured interview guide. Interviews were recorded and transcribed, then coded for thematic content using NVivo software. KEY RESULTS: Overall, 28% of ACOs include a community health center (CHC). ACOs with CHCs are similar to those without CHCs in organizational structure, care management and quality improvement capabilities. Qualitative results showed two major themes. First, ACOs with CHCs typically represent new relationships or formal partnerships between CHCs and other local health care providers. Second, CHCs are considered valued partners brought into ACOs to expand primary care capacity and expertise. CONCLUSIONS: A substantial number of ACOs include CHCs. These results suggest that rather than reinforcing segmentation of safety net providers from the broader delivery system, the ACO model may lead to the integration of safety net primary care providers.