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What are the barriers and challenges such organizations might face?

As recognized by many other industries, “system-ness” in an organization provides consistency of quality and outcomes.  This is the operational imperative of any efficient enterprise, but is still sorely lacking in the U.S. healthcare system.  Clinical and financial integration and/or alignment will be necessary to achieve the aims of an ACO, but a successful integration cannot occur without a way to systematically provide good medical outcomes.  Despite the evidence that the more highly integrated and organized health care systems in this country have proven to be more adept at managing cost and quality, integrated systems of care are not the norm. 

Why not?  There are many barriers and challenges that have deterred the expansion of integration.  Some that face aspiring ACOs include:

  1. Multispecialty group formation: multispecialty group practice is a necessity to manage care across the continuum, but aligning specialties under a multispecialty group umbrella can be challenging when there are great income disparities between specialties and multiple ways that physicians can be paid.
  2. Size of the patient population:  what size patient population is necessary to produce meaningful outcomes data?  The Medicare Shared Savings provision of the ACA proposes a minimum Medicare population of 5,000, but this number may be too small.  The consensus is that the larger the population, the easier it is to measure outcomes and manage the costs of care.
  3. Cultural:  does the organization have the patient-focused, physician-led accountable culture that is the common underpinning of the most successful American health care systems?  A strong culture of self-reflection and assessment, continuous improvement, and flexibility may be the key differentiating factor between success and failure.  Trying to integrate the different business cultures of partnering organizations into one can be a significant barrier.
  4. Resources: does the organization have the resources (staff, time, money) necessary to carry it through its journey to accountability, which means completely realigning how money flows and services are delivered?
  5. Staffing:  primary care providers are critical to the ACO, yet the specialty-focused structure of the current delivery system has created a dearth of primary care physicians.  Finding enough primary care doctors will be a challenge for the nation, as well as individual organizations.
  6. Lack of consistent measures:  Quality measures requested from providers and hospitals by the various payers are often different, presenting resource challenges within the health care organization.
  7. Market-based:  health care markets vary widely, so the organization must carefully consider its current market position and the impact that an ACO transition might have on its business in the short-term and the long-term. 
  8. Legal:  there are several legal and regulatory issues that must be addressed to allow for ACO collaboration and integration, the Sherman Act anti-trust laws, anti-kickback laws, and the physician self-referral Stark Laws among them.

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