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Accountable Care Organizations: Accountable for What, to Whom, and How?


The Affordable Care Act encourages the formation of accountable care organizations (ACOs), with the hope that they will help providers work together more effectively to improve health care quality and slow spending growth. In a Commonwealth Fund–supported article, two leading proponents of ACOs contend that solid performance measurement and evaluation will be crucial to the development and implementation of these entities.

Assessing the Performance of Accountable Care Organizations

Performance measures in health care are often narrowly focused on individual clinicians, rather than the systems of care in which they operate. An integral part of implementing ACOs, argue Fisher and Shortell, will be measuring processes and outcomes across the care continuum to support improvement and accountability and reduce the administrative burden associated with performance measurement.

Different levels of ACOs could use different measurement approaches. For example, level 1 ACOs—those without electronic health records (EHRs) or well-established patient registries—could at first rely on measures gleaned from claims data, like cancer screening, but then progress to health outcomes (e.g.,blood-pressure control), patient-reported care experiences, and total costs of care. Level 2 ACOs—those with site-specific EHRs and registries—could add advanced measures like patient-reported outcomes. And level 3 ACOs—with EHRs across all sites of care—could measure informed patient choice and outcomes for an array of conditions.

The authors also call for a common framework for evaluating the range of delivery and payment reform initiatives in the Affordable Care Act to help determine which ACO characteristics are critical to their success. “We need to know not only whether bundled payments work, but also whether they are more or less effective when combined with ACO or medical home programs.”

Publication Details



E. S. Fisher and S. M. Shortell, "Accountable Care Organizations: Accountable for What, to Whom, and How?" Journal of the American Medical Association, Oct. 20, 2010 304(15):1715–16.