Accountable care organizations (ACOs) are a new development in the U.S. that aims to bring value-based provision into health. Fashioned to sensitize themselves, ACOs developed by the dual conundrum that besets healthcare, namely unequal quality and runaway costs, gearing themselves towards the realization of the “four quadruple aims” seen in healthcare: enhancing the quality of care and experiences for patients, better population health, and reduce the per capita costs of healthcare while enhancing provider experience (Wilson et al., 2020). This paper presents a critical appraisal of the evidence synthesis by Wilson et al. (2020) relating to the early performance of ACOs to achieve these goals and the mechanisms leading to their impacts.
Wilson et al. (2020) employed a rapid review methodology, a pragmatic approach to synthesizing evidence within compressed timelines. They conducted comprehensive searches of two databases and applied inclusion criteria to select the most relevant reviews and studies. The review included 59 primary studies and one systematic review, providing a broad evidence base.
The Authors report candidly and reasonably the limitations of their method. However, an accelerated timeline ensured that the search was limited to the partial parameters, and thus, it may be likely that some relevant literature needed to be included. This also creates another limitation that does little to weigh the strength of evidence from the included studies. However, these are offset by clear disclosure and great review value in providing a timely synthesis for policy consideration.
A quadruple aim has been proposed in order to improve the patient experience based on enhancing the following aspects:
Influence of ACOs on this aspect: The influence of ACOs on this aspect was found to be mixed with evidence. It is reflected that ACOs could achieve similar preference scores in terms of patient experience when compared with non-ACOs, coupled with slight gains in terms of timely access and clinician communication. The authors further expressed that most ACOs have undertaken patient engagement strategies, and more ways of emphasis, which include shared decision-making and co-participation in the co-development of a care plan, need to be practiced for effectiveness.
The measures to be studied for the experiences of patients should be considered for consistency and validity, and other studies should be considered for their validity. The identified qualitative inquiries through this review to be highlighted were only some of the satisfaction surveys. Other areas that could be touched on are qualitative studies to discover patient stories and engagement in the governance of ACOs, where the involvement and participation of patients in the improvement of care need to be enhanced.
Most importantly, the review showed there was little evidence regarding the effects ACOs have on population health outcomes. Just two studies evaluated this critical Quadruple Aim outcome and gave mixed results on the decline in mortality. This thin evidence calls out measurement, which is high on the priority list and looks like a challenge for the ACOs, the investigators, and others.
The validation of demonstrated success in improvement in population health must then be demonstrated in a full-scale demonstration to validate the effectiveness of the ACO model. It may further research in comparing whether the results in health characteristics remain alike, focusing on selective consideration and reasonable designs, among others, and follow an extended set of health indicators taken over a much longer period—the results of the population living at or near the poverty line and among high-need populations.
The main impetus of the shared goals and incentive motivations for the ACOs is to reduce per capita cost. Wilson et al. (2020) report modest cost-saving relative to non-ACOs from several other studies within the ACOs, averaging around 2% per beneficiary, which mostly comes from reduced expenditure on outpatient services and utilization of services of low value, among other items. For other studies, the evidence was mixed: some found statistically significant cost differences; others did not.
A potential limitation of this research is that it requires more granular evidence as to which exact, specific functions of ACO organizational and management characteristics underpin their financial success. Moreover, it will provide the ability to understand the impact of different models of financial risk on ACO performance, different compositions of providers, and strategies of care management for further help in the future formulation of policy or optimization of models for saving through cost-efficiency.
The most evident difference, when it comes to the literature, is a gap that relates to the ACO impact on the provider experience. As Wilson et al. observed, only five studies have entered into this quadruple-aim goal, indicating mixed results, with some pointing to better collaboration among providers and others indicating increased administrative burdens.
Disturbingly, empirical evidence has yet to be marshaled to assess the experience of ACO clinical providers, similar to evidence that does exist concerning burnout and dissatisfaction in the health workforce. Poor provider well-being is likely to be the Achilles heel of ACOs in achieving other Quadruple Aim goals. Future research will need to deliberately direct its focus in the course of developing and verifying measures of provider experience within ACOs. Although all studies directed toward capturing the perspectives of providers regarding enablers or barriers to their professional fulfillment within ACOs may offer further directions about underlying dimensions, future research may best direct targeted improvement strategy.
The first core strength is summarized and comes from the review by Wilson et al. (2020): the qualitative studies are included explaining how ACOs can realize impacts. Some of the reasons for the results in this manner that were quoted among many include the employment of additional staff to deal with the provision of care coordination, electronic sharing of health records, and the cultural state of value-based care integration. The authors similarly raised more barriers toward the realization of success, including weak financial incentives and integration difficulties emanating from mental health service delivery.
Of further note, it is pivotal to the potential for replication and generalizability to the effective, efficient, and sustainable programs of ACO, which is a deep understanding of the contextual factors and actual programmatic components that allow or inhibit the performance of ACOs. The review emphasizes that qualitative evidence provides a sophisticated understanding of the way implementation processes unfold. Interdisciplinary mixed-methods designs offer the best framework for future research to evaluate how well ACO structures, processes, and outcome metrics interact.
These available variable findings on ACO performance reviewed by Wilson et al. (2020) can only be interpreted, on balance, as suggesting that ACOs are of promise but deliver modestly and variably with respect to the goals of the Quadruple Aim. Policymakers should take up the next diffusion of ACOs with tempered optimism, knowing that structural changes alone will not bring the desired goals.
This suggests that policymakers will have to invest in “enabling factors,” such as health-information-technology infrastructure, workforce development, and a payment model that supports value-based care. The review also underwent efforts to coordinate quality measures with reporting requirements across the ACO programs.
The ACO leads, at the levels of practice, may consider the investment in developing strong patient engagement, shared decision-making, and co-development of the care plan strategies. Therefore, adequate investment in the staff line and inculcation of a collaborative and learning environment can be seen as not only helping ACOs in realizing their Quadruple Aim initiatives but also a strategy to realize the same. End of Returned Text
The gaps and limitations identified in Wilson et al.’s (2020) narrative review that limit a road map for priorities in future research are discussed. In addition, the development and validation of the measurement should be related to the entire range of outcomes for the Quadruple Aim, especially in the field of population health and provider experience. The design of the studies was also inflexible, and recommendations were made for further longitudinal studies to establish the effects of ACOs over time among different groups of people.
Contextual mechanisms and factors through which ACOs perform offer qualitative and mixed-methods research in order to understand. One comparative study may guide in a way that more than the ACO characteristics in terms of the composition of providers or the financial risk models will be evocative; a better model should be designed.
The researchers should further stress the importance of extending the program to disseminate and translate the results of the centers into improved policies and practices. Moreover, collaborative learning networks across ACOs could work to share successful innovations, speeding the spread of policy-relevant best practices.
Wilson et al.’s (2020) rapid review provides a timely synthesis of the evidence on ACOs’ early impacts on quadruple aim goals. While some promising trends are emerging, the mixed findings suggest that ACOs’ potential to drive transformative change still needs to be realized. Achieving the quadruple aim will require sustained efforts to refine ACO models, align incentives, and foster enabling contexts.
The review highlights significant gaps in the evidence base, particularly regarding population health outcomes and provider experiences. Policymakers and researchers should prioritize addressing these gaps to inform the design and implementation of more effective ACO models.
As ACOs evolve, so too must the systems evolving with them through constant education. ACOs are expected to drive continual systems change through repeated learning and adaptation from professionals and the public alike. Findings from this review and identified research priorities may help stakeholders in their efforts to realize the full potential of ACOs in advancing the Quadruple Aim of healthcare transformation.
Wilson, M., Guta, A., Waddell, K., Lavis, J., Reid, R., & Evans, C. (2020). The impacts of accountable care organizations on patient experience, health outcomes, and costs: a rapid review. Journal of Health Services Research & Policy, 25(2), 130-138. https://doi.org/10.1177/1355819620913141