In this section of this proposal an outline of the research aims, the research questions and the research objectives shall be detailed. In conjunction with this, the feasibility of this proposed research study shall also be discussed as will the importance of research, which intends to investigate if Accountable Care Organisations (ACO) is a viable solution to the looming healthcare crisis in the United States (U.S.).
In the U.S., experts have agreed that the existing healthcare system, which is based on a fee for service basis, does not support the coordinated care, which is needed by patients. This is reflected in the reforms, which will be enacted through the Patient Protection and Affordable Care Act (PPACA). This Act will change the way through which health care is provided. It aims to increase the proportion of the U.S. population that are insured, reduce the cost and improve the quality of healthcare delivery by focusing on preventive and primary care, linking healthcare provider remuneration to outcomes and put in place various incentives aimed at reducing the rates and cost of acute hospital admissions (Greaney, 2011).
However, this presents a problem to policy makers: as how could this be changed whilst still attaining a high quality and cost efficient service Though some have advocated the use of ACOs to seek to overcome these issues (Berwick, 2011; Fisher et al. 2009; Longworth, 2011), others have highlighted a number of problems that could arise from this (Luft, 2011; Pollack and Armstrong, 2011). Therefore, there is a level of uncertainty as to whether this solution may work. This is because ACOs are formed of groups of voluntary health care professionals that are willing to assume responsibility for those who use Medicare. Under this model of health care, these patients are able to have access to free healthcare. This is believed to be beneficial as there will be a better care provision available to these individuals or the wider population and the costs of providing this service will be lowered through the improvements, which can be realised through this. To investigate whether this model could be implemented in practice, the aims of this research is to seek to:
Analyse the organisational structures of existing ACOs. Determine the desired outcomes the ACOs such as, the quality measures, patient satisfaction scores, reduction in hospital readmission rates, etc. Investigate methods they use to incentivise healthcare providers to modify their behaviour, and Examine the payment structure to healthcare providers (i.e. bundled payment systems, etc.) Determine if they are demonstrating a reduction in the cost of healthcare delivery while maintaining quality and improving outcomes based on common benchmarks.To seek to understand if this solution to this problem may be attained this investigation is being undertaken, to seek to explore the following research questions:
How are ACOs structured What are the desired outcomes of the ACOs Which methods are being utilised to incentivise healthcare providers to modify their behaviour by ACOs What payment structures are being used by healthcare providers in ACOs To what extent, are the ACOs able to demonstrate that a reduction in the cost of healthcare delivery while maintaining quality and improving outcomes based on common benchmarks has been achievedIn conjunction, with each of these research questions, the following research objectives have been devised.
To identify through using existing and relevant data, how the ACOs are structured. To seek to understand through using existing and relevant data, what the desired outcomes of the ACOs are. To seek to understand through using existing and relevant data, methods which are being utilised to incentivise healthcare providers to modify their behaviour by ACOs. To seek to understand through using existing and relevant data what payment structures are being used by healthcare providers in ACOs. To establish to what extent the ACOs are able to demonstrate that a reduction in the cost of healthcare delivery while maintaining quality and improving outcomes based on common benchmarks has been achieved.Each of these objectives shall ensure that the research questions are answered and that the aims are met. This research shall be undertaken through using all existing and relevant data, which is pertinent to the aims, research questions and objectives, which have been outlined above. Therefore, this study is feasible as all of the information, which will be used will come from a variety of documented sources such as, journal articles, financial reports, government documents and where appropriate online reports. This will enable the study to be undertaken to seek to understand if the establishment of ACO’s is a viable solution to the looming healthcare crisis in the U.S.
A brief review of the literature shall now be presented to demonstrate which sources of information may be used for this study.
2. Literature reviewThis review has been undertaken to seek to ascertain to what extent the ACO movement has been examined in the existing literature and to seek to understand if or how ACOs have been successful in the past, to identify factors that have contributed to this success or failure, and to analyse each of these factors in detail. ?It is hoped, that through undertaking this review, the potential pitfalls or factors that have enabled ACOs to succeed will be identified through examining the available and relevant data.
The principles of ACOs stem from the early twentieth century in America though it is difficult to pin point exactly how and why these were formed, these are the foundations upon which modern organisations are based (MacCellan et. al. 2010). In 2006, Dartmouth Atlas of Health Care leader Elliot Fisher and the MedPAC commissioners started to discuss how patients care needs could be met (Fisher, 2008).MedPAC was exploring new ideas to control their costs and they drew on the expertise of the Dartmouth Atlas’ to examine how utilisation patterns varied across local clusters of hospitals and physicians (Shortell, Casalino and Fisher, 2010). From here, Fisher undertook a number of analyses regarding variations in health care (Fisher et.al. 2007; Fisher, 2008).From here the modern idea of an ACO was adopted and a number of papers were published (see as an example: Collier, 2011; Mayes, 2011; McKethan and McClellan, 2009). Each of these advocates the use ACOs and the new opportunities, which arise from their creation in the U.S.
Whilst it is acknowledged that the idea of ACOs taking on healthcare risks is not new in the U.S (Iglehart, 2008).There are a number of factors, which are new. These are derived from their flexible organisational structures, which means that a range of organisations can become part of an ACO (Phillips and Bazemore, 2010). This enables the risk and the financial incentives or burdens to be spread across a number of organisations (Mechanic and Atman, 2009). Fisher et al (2012) published a review of ACOs. This research was undertaken to understand the important factors, which would influence the formation, implementation and performance of ACOs. Specifically, they stated that payment contract specifications, the structure, activities, and capabilities of the ACO, (for e.g. how large, multispecialty or just primary care, etc.) and local factors (socioeconomic/demographic characteristics of the patient population) could all have ramifications on the performance of an ACO. Furthermore, the authors proposed strategies for evaluating the performance of ACOs, providing support, and advise conducting qualitative and quantitative research. For this author the importance of local factors is quite significant (Higgins et.al. 2011).However others have considered that the size of ACOs may be difficult to get right, as ‘big enough may be too big or small enough may be too small’ (Hillman and Goldsmith, 2010: 2231). This is because the larger ACOs will have more stable risk pools of patients, they will be able to afford the infrastructure, reporting and leadership which is necessary to manage to their targets (Goldsmith, 2009). However, the larger the risk the bigger the loss of collegiality is (Goldsmith, 2011). In comparison to this, smaller ACOs will be better able to cultivate and maintain that collegiality, but will risk the variability problem of a small risk pool or they will struggle to invest in their infrastructure and to improve their performance (Gold, 2010).
As has been shown by Fisher et al (2012), though these issues may be addressed, Goldsmith (2011) argues that health care service delivery will just become more fragmented. Therefore the income disparities and doctors lack of trust of hospitals will persist (Cebul, et al. 2008). Outpatient services will not be improved nor will local acre services as this is economically at odds with the ACOs agenda (Goldsmith, 2009). Increasingly large and powerful single-specialty medical groups will be able to formed instead of the ACOs (Hillman and Goldsmith, 2010). This will also defeat the financial incentives (Goldsmith, 2010) and the peer influence of a virtual ACO (Haywood and Kosel, 2011). Therefore, though Fisher et al (2012) advocates this new model of modern ACO’s they may cause more problems than solutions.
The peer pressure, which is derived through the shared financial incentives, which drives the need for performance improvement within the ACO may not exist if large and powerful single-specialty medical groups are formed. This will also limit the amount that financial incentives will work. However, Ash and Ellis (2012) examined the payment methods, which are used in ACOs. Currently, payments to ACOs are planned to be bundled and performance-based (Berenson and Rich, 2010). However, according to Ash and Ellis (2012) current measures account for the significant differences in various patient populations and therefore, the authors conducted a research study to attempt to adjust for these risks. Using an insurance company’s claims-based data software, Ash and Ellis (2012) modeled bundled payments to reflect the expected primary care activity levels (PCAL). Their results indicated that the PCAL model explained 67% of the variation in outcome, and performed equitably across a range of patient ages, insurance plan types and provider specialties. Therefore, another factor that may be seen as important to the success or failure of ACOs are the payment methods, which are used by them. They concluded that their results supported the risk-adjusted bundled payment calculations and that these should be used in ACO primary care models. This may reduce the risks of risk the money paid to ACOs being based on the relative medical risk and the cost of the patients that they serve.However, in the absence of successful risk adjustment mechanisms, the incentives will be spurious and invite cherry-picking behaviours on the part of hospitals and physicians (Goldsmith, 2011). The result from this could be that there is no focus on clinical improvement or cost control, and a dysfunctional market could evolve (Gottlieb, 2011).
The findings of Claffey et al (2012) who undertook a study of 750 Aetna Medicaid patients that received comprehensive primary care through an ACO called Nova Health has shown that how a provider organisation and an insurance company can “align their goals and incentives, implement a clinical plan to achieve these goals, and assess the impact on clinical quality and efficiency” (Claffey et al. 2012: 2080).They examined a number of factors such as the ACOs organisational structure, their desired outcomes, payment structures, how to the healthcare providers were incentivized and to what extent benchmarks had been reached. The authors concluded that the success of this ACO stemmed from their robust IT support systems; good care management, strategic joint planning and collaboration with the insurance payers (Larson et al 2012; Lewis et al. 2013). However, one can also see that an ACO is an insurer and enforcer. This is because ACOs are taking on functions, which were historically performed by insurance companies (Gold, 2010). To this end though there are a number of studies that advocate the use of ACOs (Fisher and Shortell, 2010; Relman, 2009) and there are those that do not (Leibenluft, 2011; McWilliams and Song, 2012).Both cite a variety of reasons for and against these organisations, as has been highlighted above.
In this brief review of the literature, a number of factors, which may determine the successful, or failure of the implementation of ACOs because of the implementation of the Patient Protection and Affordable Care Act has been identified. Each of these may be used to build a framework through which the potential pitfalls or factors that have enabled ACOs to succeed can be built. This will allow this research to ascertain to what extent the ACO movement has been examined in the existing literature and to seek to understand if or how ACOs have been successful in the past, to identify factors that have contributed to this success or failure, and to analyse each of these factors in detail.
In the next section of this proposal, the methods, which shall be used to undertake this study, shall be presented.
3. Research methodology and methods (first draft required in Week 4 of RM module)The methods that have been adopted to undertake this research have been derived from adopting a qualitative methodology, as the author is seeking to ascertain to what extent the ACO movement has been examined in the existing literature and to seek to understand if or how ACOs have been successful in the past, to identify factors that have contributed to this success or failure, and to analyse each of these factors in detail (Gulliford & Morgan, 2013). Therefore, the best means through which to commence this research is to undertake a review of the documentation, which is relevant to this. All of the sources, which will be used in this study, shall be derived from secondary information (Silverman, 2013). The advantages of adopting this approach may be considered to be:
The information, which this study is based on already, exists. The information that shall be used is independently verifiable. There is less research bias, as the researcher undertakes a review of the literature independently. There is not requirement to undertake an extensive study, which is based on primary sources of information.Comparatively, this approach also has a number of disadvantages, which may be surmised as follows:
The information that this study is based on may have been written for other reasons. Therefore, the context of studies shall need to be carefully considered by the researcher, which could be time consuming. Not all data may be relevant to the researchers study this may limit the findings, which can be gleaned from undertaking a review of secondary sources of information. Obtaining all of the documentation required for the study may not be possible. The researcher does not have control over how primary data has been collected, collated, reviewed and presented. Therefore, they need to carefully assess each of the sources of information, which are chosen for inclusion in the documentation review. The quality of the secondary data may be poor or may be derived from unverifiable sources. Therefore, the researcher needs to carefully consider how studies have been undertaken before they are included in the documentation review.Each of these factors needs to be carefully considered by the researcher as they undertake their documentation review (Straus, Tetroe & Graham, 2013). In conjunction with this, a search strategy shall be developed to ensure that all relevant and available sources of information are identified. Once this has been undertaken, all of the documentation shall be reviewed to determine if it is suitable for inclusion within this research. Where appropriate, studies or data, which has been deemed as suitable for inclusion, shall be discussed and examined through an extensive review of the literature. The findings from this shall then form the basis for the analytical framework, which shall be developed to seek to ascertain to what extent the ACO movement has been examined in the existing literature. To determine if or how ACOs have been successful in the past, to identify factors that have contributed to this success or failure, and to analyse each of these factors in detail.
In the next section, the timescales for this study shall be detailed.
4. Timing mileposts MilestoneDescriptionDue dateRemarks 1Stage 1: Area of interest identified 2Stage 2: Specific topic selected 3Stage 3: Topic refined to develop dissertation proposal 4Stage 4: Proposal written and submitted 5Stage 5: Collection of data and information 6Stage 6: Analysis and interpretation of collected data/information 7Stage 7: Writing up 8Stage 8: Final draft prepared— submission of dissertation 9Final Deadline—9 months from module start date. References:Ash, A, & Ellis, R (2012) ‘Risk-adjusted Payment and Performance Assessment for Primary Care’, Medical Care, 50, 8, pp. 643-653.
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