Drive Change in an ACO


From informal polls I’ve recently conducted of hospitalists, many are not even aware they are part of an accountable-care organization (ACO). And if they are aware, they might not be engaging in meaningful dialogue with ACO leaders about their role in these organizations. But, in the long term, ACOs will need to bring hospitalists to the table in order to be successful.

Are You Part of an ACO?

David Muhlestein, who blogs for Health Affairs, tracks the growth of ACOs around the country. He states that, as of Jan. 31, there were 428 ACOs in the U.S. (see Figure 1).1 In terms of numbers, Florida, Texas, and California lead the nation with 42, 33, and 46 ACOs, respectively. So it is likely that you are part of an ACO. If you are unsure, ask your chief medical officer or president of the medical staff.

Accountable-care organizations by state1

Figure 1. Accountable-care organizations by state1

How ACOs Work

All ACOs seek to manage a group, or population, of patients as efficiently as possible while maintaining or improving quality of care. For Medicare ACOs, the goal is to bring together hospitals and physicians in order to share savings derived from efficiencies in care. But before any savings can be shared, the Medicare ACO must demonstrate that it achieved high-quality care across four domains, totaling 33 individual quality measures. (see Table 1)

Table 1. Four domains of quality measures for Medicare ACOs

  1. Patient/caregiver experience
  2. Care coordination/patient safety
  3. Preventive health
  4. At-risk populations/frail elderly health

Main Flavors of ACOs

There are two types of ACOs: private ACOs and Medicare ACOs. Prior to Medicare ACOs, which were launched in January 2012, there were 150 private-sector ACOs, and this number continues to grow. Private ACOs represent a heterogeneous group in terms of reimbursement model. Some operate under shared savings programs; others use full or partial capitation, bundled payments, and/or other types of arrangements. But nearly all ACOs operate under the premise that the incentives used to make care more efficient and less costly can only be applied if measurable quality is maintained or improved. ACOs do not pay doctors or hospitals more unless high quality is demonstrated.

If we’re held accountable for the health of a population of patients, we must work more closely with the medical home/neighborhood, post-acute-care facilities, and home-care providers.

ACO Quality Measures and Hospitalists

Most of the 33 quality measures required by Medicare ACOs are based in ambulatory practice. These include measures related to blood pressure, immunizations, cancer, and fall-risk screening, and measures for diabetics, such as lipids and hemoglobin A1C. However, there are a few measures for which hospitalists should share in accountability, including:

  • All-cause hospital readmission rate—risk-standardized;
  • Ambulatory sensitive condition hospital admission rates (CHF, COPD); and
  • Medication reconciliation after discharge from an inpatient facility.

Four Key Actions for Hospitalists

Hospitalists make a significant contribution to the quality and the financial performance of ACOs. In addition to the quality metrics cited above, hospitalists impact the inpatient portion of the overall population’s cost of care. Furthermore, hospitalists are vital partners in the care coordination required for an ACO to be successful.

Here are four actions I suggest taking in order for your hospitalist group to be effective as participants in an ACO:

  1. Have a representative from your group participate in ACO committees that address hospital utilization and related matters, such as care coordination impacting pre- and post-hospital care.
  2. Learn how to work with ACO case managers on care transitions, including post-discharge follow-up and information transfer.
  3. Understand an ACO’s approach to engagement of and coordination with post-acute-care facilities. The ability of a post-acute facility, such a skilled nursing facility, to accept patients who have complex care needs, to manage changes in condition in the facility when appropriate, and to send complete information upon transfer to the hospital are important strategies for an ACO’s success.
  4. Understand how an ACO reports quality and cost performance and how savings will be shared among participants.

Mindset Change

If hospitalists are part of the chain of ACO physicians and providers held accountable for the health of a population of patients, we must work more closely with the medical home/neighborhood, post-acute-care facilities, and home-care providers. The change in mindset will occur only if we have a set of tools to get the job done, such as case managers and information technology, and the appropriate incentives to support better care coordination. I encourage my fellow hospitalists to make things happen, instead of taking a passive role in this monumental transformation.


  1. Muhlestein D. Continued growth of public and private accountable care organizations. Health Affairs website. Available at: http://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations. Accessed March 16, 2013.

The View from The CENTER

As ACOs proliferate across the country, SHM is developing resources and programs to shape the role hospitalists play in care coordination across the ACO continuum. In SHM’s Glycemic Control and Innovative Care Coordination program, a comprehensive survey was conducted of multidisciplinary glycemic management teams, identifying best practices and gaps in care regarding education of inpatients and providers, as well as processes to proactively identify patients at special risk of complications across the spectrum of care. Utilizing the survey results to inform interventions, 10 hospitals will participate in a demonstration program that will focus on improving care transitions between the hospital and post-discharge facilities for patients with diabetes.

Many of SHM’s programs are being developed with population health and post-acute-care transitions in mind. In the near future, SHM will be releasing an implementation guide for atrial fibrillation management. A full chapter is devoted to the patient who has been newly diagnosed and prescribed anticoagulants. This chapter discusses the critical need for careful coordination between the inpatient and post-acute setting and for patients to fully understand their discharge plan in order to ensure optimal outcomes.

SHM’s Project BOOST has long been promoting effective and quality discharges and will receive an update to its toolkit to specifically address transitions to post-acute care.

We also note an increase in SHM members devoting more of their time to caring for patients in skilled nursing facilities, so called “SNFists.” As this trend continues and hospitalists move along the ACO continuum, SHM is committed to staying abreast of the challenges facing our membership and providing the most up-to-date resources and programs to support your work.

For more on quality improvement and care coordination, visit www.hospitalmedicine.org/qi.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

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