9 ACO Implementation Challenges

The accountable care organization model has spread through hospitals, health systems and physician groups around the country, but implementing the model successfully is still no easy feat.

Alvarez & Marsal, an independent global professional services firm, identified nine major challenges to ACO implementation in a report, "A&M Healthcare Insights: The Good Intentions and Challenging Implementation of ACOs."

1. Investment in IT alone does not automatically lead to success. Though installing an electronic medical record is a necessary step toward ACO formation, it needs to connect the hospital to its outpatient and physician office locations. Additionally, the organization needs to commit to monitoring clinical and claims data, as well as risk management.

2. Primary care physicians are hard to come by. Successful ACOs rely on a large primary care physician base, but there are not many available due to the physician shortage. A&M noted primary care physicians are also overworked and underpaid.

3. Conflict can arise between hospitals, primary care physicians and specialists. When ACOs are successful, they will lead to fewer hospital inpatient admissions, fewer procedures and less fee-for-service reimbursement, according to the report — and this will lead to financial winners and losers.

4. Care coordination is time consuming, especially for patients with multiple chronic conditions. Physicians have reported lower job satisfaction because of the difficultly of coordinating care with other physicians, according to the report.

5. Variation in care is still common. Until care becomes more standardized based on evidence-based guidelines, continuous improvement in care delivery is difficult.

6. The end-of-life care conundrum. Often, patients receive "more aggressive" end-of-life care than they would like, even though end-of-life care is a major potential source of ACO cost savings, according to A&M.

7. Limited patient engagement. Physicians cannot force patients to take action in their own health, but patient behaviors — such as medication adherence, making and attending appointments, monitoring symptoms, etc. — can account for a large chunk of costs, according to the report..

8. Patients can go out-of-network. ACOs are not allowed to limit where patients receive care. If patients see an out-of-network specialist, care coordination and cost containment can become difficult.

9. Many legal considerations. Organizations must consider antitrust, Stark and Anti-Kickback laws, as well as the ACO Final Rule before forming an ACO.

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