Evaluation Plan For An Accountable Care Organization

Measures and methods used for the evaluation plan

Evaluation Plan For An Accountable Care Organization

The following paragraphs of this paper will aim to shed light on the principles underlying the evaluation of the effective functioning and impact of an ACO’s clinical performance and patient centeredness. As postulated by the Centers for Medicare and Medicaid Services (CMS), an Accountable Care Organization (ACO) is a healthcare organization comprising of healthcare practitioners and professionals who strive for an agreement on holding accountability for the overall quality and cost of healthcare services provided for beneficiaries of Medicaid enrolled in the traditionally assigned fee-for-service programs. In other words, an ACO is a type of healthcare organization which seeks to use reimbursement incurred by it for the purpose of improving the quality of the cost effective care provided to Medicaid beneficiaries (McWilliams et al., 2016). Within the United States, ACOs have been evidenced to comprise of credible health practitioners who collaboratively function with each other and acquire payment for the care provided using alternative payment processes, which usually includes capitation (Nyweide et al., 2015).

As per the Patient Protection and Affordable Care Act (ACA), healthcare of the highest quality and at cost effective rates is every citizen’s basic right and hence, healthcare organizations must seek to provide care which is affordable, accountable, evidence based and scientifically credible (Shortell et al., 2015).  According to the CMS (2019), the goal of an ACO is to improve the overall quality of care so as to ensure deliverance of timely, safe, accountable and affordable healthcare services and products to Medicaid beneficiaries and thus contribute to the achievement of the positive health outcomes across the community. With this respect, as per the ACA’s principles as well those established by the US Department of Health and Human Services (DHHS), ACO’s must deliver affordable and quality care in alignment with some of the following major regulatory principles (Obama, 2016).

• Demonstration of accountability for the cost and quality of care provided to fee-for-service beneficiaries of Medicare.
• Inclusion of a sufficient population of primary care health professionals and practitioners who will be responsible for the deliverance of the aforementioned affordable, accountable and quality care.
• Ensure inclusion of a minimum of 5000 Medicare beneficiaries.
• Establishment of a continuous process of evaluation of changing healthcare needs of the population.
• Establishment of a continuous process of evaluation of the healthcare organization’s service’s adherence to principles of patient centered approaches via the implementation of individualized care plans, caregiver assessments as well as patient assessments .
• Establishment of structured leadership and management model within the administrative departments of the overall healthcare organization.
• Establishment of intra-departmental as well as interdepartmental continuity and collaboration within care via the implementation of services like telehealth, remote patient monitoring, care quality and cost reporting of care and prevalence of patient-engagement an evidence based care.

The rationale underlying the brief discussion of the above regulatory principles is the fact that the concerned ACO must firstly imbibe such values within its foundational principles which can then be used to align its healthcare services and products with principles of affordability, accountability and quality (Kaufman et al., 2019). Despite the onset of advancements in healthcare associated technology coupled with growing awareness of the need to adhere to healthcare accountability and quality in services, according to Chassin and Loeb (2013), healthcare organizations continue to encounter rising medical expenditures along with maintenance of long term quality and excellence. This is because considering multitude of physiological, emotional, social and economical hardships encountered by patients, healthcare organizations find it difficult to achieve all of the objectives simultaneously. Further according to Chassin and Loeb (2013), in order to achieve cost effective clinical service deliverance coupled with quality, organizations must target objectives beyond merely inclusion of healthcare technology and alleviation of disease symptoms, and thus include: implementation of effective leadership, establishment of overall culture of patient safety and avoidance of harm and execution of continuous audits via process improvement methods.  The World Health Organization (WHO, 2019), further denotes that need for health promotion evaluation across healthcare organizations because of the following reasons:

• An increased national and global interest towards the achievement of positive health outcomes and improvement in the quality of life of individuals and communities.
• An increased prevalence of patient centeredness of the ability to induce control over one’s life and health status.
• The limitations in traditional clinical educational frameworks devoid of process of auditing and quality improvement.
• The growing acceptance that individual health issues are largely a resultant of lifestyle practices.
• The growing acceptance that expensive and costly healthcare technology is not always associated with improved health status across individuals and communities.

Proposed timeline for implementation and evaluation plan for the scenario

Thus, the rationale underlying the above discussion of importance of healthcare evaluation is the fact that not only must healthcare organizations or ACOs include a performance evaluation plan but must also engage in timely assessment of the impact, assessment and potential for improvement of novel data inclusion of the same. The above guidelines will thus serve as the factors determining the type of data and outcomes to be collected and measured for the purpose of assessing the impact of the evaluation plan (McWilliams et al., 2015).

Thus, to ensure adherence to the above principles and goals which legally regulates the functioning of ACOs, the concerned healthcare organization to be reviewed in this paper must formulate and evaluation plan as means of evaluating its performance as an ACO. The following paper will hence comprise of a proposed model of evaluation, which can be used for the purpose of assessing the impact of the ACO as well as the data and metric required for the purpose of assessment of the same in comparison to other competitive ACOs.

The ACO evaluation plan will be developed with the primary aim to assess the impact of the ACO’s performance with respect to competitors and the alignment of the organization’s strategic principles with respect to ACO requirements of delivering continuous high quality collaborative and cost effective care. The evaluation plan will also be formulated with the aim to identify factors and data metrics which will serve as measurements of the ACO’s achievement of quality outcomes with respect to cost. Based on these principles, the evaluation plan will be categorized into four major components: Quality Measurement with respect to Shared Savings and Collaborative Care, Quality Measurement with respect to Medicare Savings, Quality Measurement with respect to Care Continuity and Community Health and Quality Measurement with respect to Systems Thinking. Each of these key components will be expounded upon in the following sections:

As discussed previously, one of the key regulatory principles of ACO functioning as per the DHHS, is to ensure the prevalence of structured leadership and managerial frameworks within the clinical departments of the ACO. Indeed, prior to the implementation of any organizational change or reform program, establishment of specific educational, leadership and managerial frameworks is of utmost importance in order to firstly ensure the presence of a work culture in alignment with the proposed reforms (Perrin et al., 2017). According to the mixed methods study conducted by Clark et al., (2013), healthcare organizations who have demonstrated long terms success show little alignment with traditional clinical features like presence of internal technical and clinical resources within each department and hierarchical structures and demonstrate and increased prevalence of systems thinking. Systems thinking has been implied as the practice of interrelatedness and collaboration within the sub sections of a system, meaning that each department of the healthcare organization must work in congruence with each other and not merely individual. Indeed, the DHHS’s principles of ACO regulation, necessitate ACO is to ensure principles of collaborative care, patient engagement and patient centeredness across each department (Phillips et al., 2016). Thus, with respect to the same, the concerned ACO will be evaluated based on the strategic management and systems thinking elements proposed by Clark et al., (2013), which will assess the alignment of organizational services and principles based on domains of patient flow across the care continuum, shared partnerships, scope of services and human capital.

Challenges and opportunities in regard to adhering to timeline

The main working principle underlying the functioning of ACOs is to ensure that the care which is being provided to patients is coordinated and multidisciplinary in nature, is timely, safe patient centered, free of clinical errors and duplication of services (Colla et al., 2016). The CMS (2019) thus believes that investments in provision of care, services and products which are of high quality can assist an ACO in the achievement of long term savings in terms of Medicare expenses. To ensure adherence to the same, the CMS has established a quality evaluation model assessing ACO functioning over four domains, mainly: Caregiver/patient experience, patient safety/care coordination, prevalence of clinical care for at risk populations as well as prevalence of preventive health clinical services, resources and assessments. Inclusion of such a comprehensive evaluation model will not only demonstrate ACO compliance to national recommendations but will also ensure adherence to essential ACO principles of patient centeredness, patient engagement and health promotion, which will be discussed in the succeeding sections (CMS, 2018).  

The system of ACOs was also establishment for the purpose of ensuring that healthcare organizations provide high quality and cost effective services in such as manner so as to allow Medicare beneficiaries the liberality to engage in personalized care as per their needs along with ensuring reduction in unnecessary expenditures and Medicare reimbursements (Blackstone & Fuhr Jr, 2016).  With this respect, the National Opinion Research Centre (NORC, 2018) of the University of Chicago postulated that in order to achieve quality, cost effective and safe patient centered care, ACOs must invest in some degree of risk by usage of more amount of financial resources towards quality of care services and settings in order to ensure improvement in quality and utilization parameters. With this respect, the evaluation of the ACO’s impact of services will be evaluated by the components proposed in the NORC’s ‘Next Generation ACO Evaluation Model’ which include domains like: utility, quality and amount of spending across ACO care services and settings (NROC, 2018).

It is worthwhile to remember that ACOs were formulated given in consideration of the principles laid down by the ACA – a regulation which emphasized the citizens’ right to affordable and quality care. With respect to the same, the ACA also necessitated that health organizations redirect a reasonable share of their expenses towards conducting public health assessments and deliverance of community care healthcare services. Further, one of the key regulatory principles established by the DHHS with respect to ACO functioning is the maintenance of continuity of care across organizational as well as community health services via establishment of telehealth and telemonitoring services (Adepoju, Preston & Gonzales, 2015). To measure the same, the concerned ACO and the impact of its services will also be evaluated in terms of the logic evaluation model proposed by Fisher et al., (2012), which assesses the same, based on components like the environmental context, local readiness, implementation of activities, intermediate outcomes achieved and impact. Thus, with respect to these multiple evaluation frameworks, the following aims and objectives of the ACO’s evaluation project can be identified.

Additional strategies to ensure implementation and evaluation plans are completed on time

To assess the impact of ACO performance along with organizational strategic alignment with ACO principles with the implementation of a comprehensive evaluation plan comprising of ACO regulatory components of shared collaborative case, Medicare savings, organizational and community healthcare continuity and prevalence of a systems thinking based management, leadership and occupational culture.

Thus is alignment with the above identified aim, the evaluation of the impact and strategic alignment functioning will be designed based on the following objectives:

1. To assess the impact of ACO performance based on deliverance of quality patient care with respect to shared savings and collaborative care.
2. To assess the impact of the ACO performance based on the deliverance of quality patient care with respect to savings incurred in Medicare reimbursement expenses.
3. To assess the impact of the ACO performance based on deliverance of quality patient care with respect to continuity of care and achievement of positive health outcomes.
4. To assess the prevalence and scale of alignment  between organizational strategic principles and ACO regulatory principles with respect to implementation of a work, managerial, leadership and work culture reflective of systems thinking.

Thus, in alignment with the above, the proposed evaluation program will be developed to assess the impact the ACO’s performance and functioning, by answering the following questions:

1. Are the patient care services and resources delivered by the ACO, achieving improvement in quality patient care with the help of sharing of financial resources, savings and services across all departments via inter-departmental cooperation and collaboration?
2. Are the patient care services and resources delivered by the ACO, achieving improvement in quality and safety along with incurring reductions of costs associated with Medicare and reimbursement expenses?
3. Is the ACO delivering safe and quality patient care services via principles of continuity of care within the organization as well as for achieving positive health outcomes within the community?
4. Is the ACO achieving an alignment between the healthcare organization’s strategic principles and regulatory principles of an ACO via the prevalence and implementation of a work, managerial and leadership culture of systems thinking?

The data and measures to be collected for the evaluation of the impact of the ACO and its alignment to organizational strategic principles will be based on the outcomes identified within the above proposed models of evaluation mentioned above, that is, Quality Measurement with respect to Shared Savings and Collaborative Care, Quality Measurement with respect to Medicare Savings, Quality Measurement with respect to Care Continuity and Community Health and Quality Measurement with respect to Systems Thinking. These have been outlined below:

The first set of data which will be collected for the purpose of evaluation of the ACO’s impact of services and alignment to organizational strategic principles, will include data across domains of patient flow across the continuum of care, prevalence of shared partnerships, scope of services and human capital, as proposed by Clark et al., (2013). To collect data in these aspects, the measures will include implementation of a 9 point scale of low to high on measures of: whether each department is providing a patient centered, case management based care, is providing primary and secondary care via direct investments of partnerships, is collaborating with local, community and federal level organizations, is using healthcare informatics within services and is recruiting primary healthcare level professionals. Analysis of the ACO’s administrative, organizational and patient data will serve as useful data collection measures (Clark et al., 2013). The reason for data collection across these metrics is due to their adherence to a systems thinking approach. Indeed, a systems thinking approach emphasizes on collaborative care across departments which demonstrates relevance to Clark et al., (2013) strategic principle model of including both community and interdepartmental collaboration (Hernández et al., 2017).To assess ACO’s compliance to shared savings and quality care deliverance data to be collected will be based on quality measures proposed by the CMS which assesses the ACO’s deliverance of patient centered preventive and at-risk critical care services like preventive health assessments and comprehensive assessments of diabetes, depression, cardiovascular disease, hypertension and healthcare education (CMS, 2018). The ACO’s patient and administrative records will serve as measures of data collection. The rationale underlying the collection of such data and measures is the fact that healthcare services which are critical, preventive and educational require a multidisciplinary approach coupled with patient engagement. The ACO’s positive scoring across these parameters indicates successfully adherence to patient centered and collaborative care (Ru et al., 2017). Community care and care continuity is largely defined by an ACO’s adherence to national health policies and deliverance of remote and virtual patient services which ensure positive health outcomes post discharge (Bridger, Smith & Saunders, 2017). To address the same, the ACO will be evaluated based on the logic model which will collect data on the ACO’s alignment with federal and state policies, prevalence of telemonitoring and telehealth services and usage of information technology or health informatics in its services (Fisher et al., 2012). Lastly, using administrative, patient and discharge data measures, the ACO will be evaluated based on rates of acute care admissions and patient days, emergency and outpatient visits, unplanned admissions and readmissions and follow up visits. The ACO will also be evaluated based on data such as expenditures incurred in terms of improvement in nursing, acute care, equipment, hospice and post acute care services (NROS, 2018). This is because as per the CMS, increased expenditure by the ACO for care improvement and quality is likely to yield long term Medicare savings. High expenditures and reduced admissions, readmissions, unplanned visits and quicker discharges, reflect the ACO’s deliverance of high quality care which is cost effective (Kessell et al., 2015).

Contribution of evaluation plan to feedback loop for effective management of an ACO

One of the most beneficial ways to ensure acquisition of relevant feedback as a means of ACO evaluation and continuous improvement is to conduct timely customer feedback using the ‘Patient Experience of Care’ survey proposed by the CMS (2018). Adoption of this survey method of evaluation ensures collection of objective and quantifiable feedback data which also complies with the ACO’s regulatory needs to adhere to patient centeredness (Bartels, Gill & Naslund, 2015).  Additional ways with which feedback regarding ACO functioning and evaluation can be acquired from staff and departmental heads are via ‘Robust Process Improvement (RPI)’ methods proposed by Chassin and Loeb (2013), which emphasizes on the six sigma model. This will include acquiring organizational feedback via the six sigma DMAIC tool: defining project goals and consumer needs, measurement of existing organizational data, analysis of cause and effect relationships with relevance to data, improvement in current processes and control of future threats. The six sigma model is of relevance since it ensures process improvements and prevention of defects and thus can be related to ACO’s needs of quality improvement and minimization clinical errors (Pimperl et al., 2018).

One of the most traditional yet most effective ways in which it can be ensured that the ACO’s services are in alignment with organizational strategic principles is via the establishment of, first and foremost, foundational principles containing relevant systems thinking and ACO regulatory components. Thus, this will include alteration of the healthcare organization’s original principles and working principles to include regulatory principles of the ACO’s established by the DHHS, discussed previously. Alteration and reformulation of the basic foundational principles and policies of an organization are of the first steps to ensure alignment between organizational principles and functioning (Mora & Walker, 2016).

The next procedure to ensure that the ACO’s performance is in alignment with strategic principles is by the inclusion and implementation of an educational and training program across all staff and clinical departments of the organization. Considering an ACO’s regulatory need to practice collaborative interdepartmental care, shared decision making and need to achieved shared savings, the training program so implemented can comprise of teaching staff and departmental heads on the importance and strategies of practicing a systems based approach to clinical thinking, clinical management and clinical leadership (Fisher, Shortell & Savitz, 2016). This would include teaching staff and departmental heads on the strategic management principles outlined by Clark et al., (2013), which comprises of teaching health professionals on the importance using a case management approach, delivering shared and not direct primary and secondary care, collaborating with federally accredited healthcare partner organizations, community and local health organizations, emphasis on tertiary and critical care departments and investment on hiring and recruitment of primary healthcare professionals. Another way of ensuring and evaluation ACO’s alignment to strategic organization’s strategic principles is by the adoption of the high reliability leadership model proposed by Chassin and Loeb (2013), where the ACO management board, CEO, physicians, information technology and quality control department will follow the ‘approaching’ stage of organizational maturity. This includes a comprehensive commitment across all these departments towards the deliverance of services which are of zero errors, zero harm, high quality and high safety. This will ensure that every department engages in the deliverance of quality and safe patient care as their first and highest priority (Chassin & Loeb, 2013),

Alignment of evaluation plan with mission of ACO

Implementation timeline

ACO components to be implemented	Time Period
Implementation of systems thinking leadership and management training protocol	January 2020 – February 2020
Implementation of health informatics	March 2020 – April 2020
Implementation of telehealth and telemonitoring	May 2020 – June 2020
Implementation of discussion with federal, community and local level healthcare organizations	July 2020 – August 2020
Development of organizational budget on expenses to be directed towards safety and quality improvement	September 2020 – October 2020
Alteration of organizational principles to include ACO regulations	November 2020 – December 2020

Evaluation Method	Timeline
Quality Measurement with respect to Shared Savings and Collaborative Care: CMS Quality Measures Evaluation	January 2021 – February 2021
Quality Measurement with respect to Medicare Savings: The NORC Evaluation	March 2021 – April 2021
Quality Measurement with respect to Care Continuity and Community Health: Logic Model Evaluation	May 2021 – June 2021
Quality Measurement with respect to Systems Thinking: Strategic Principles Model of Evaluation	July 2021 – August 2021
Evaluation of Processes, Impact and Alignment (Table b)	September 2021 – October 2021
Implementation of Changes	November 2021 – December 2021
Reports on Departmental successes and rewards	Weekly
Reports on Organizational successes and rewards	Monthly
Six Sigma	Weekly
Group Discussions	Weekly
Staff Debriefing	Monthly

One of the major challenges which can be possibly encountered by the staff and department is ‘project fatigue’. Project fatigue can be observed when staff will feel too overwhelmed or discouraged to dedicate their responsibilities to the comprehensive ACO requirements and evaluation (Davis et al., 2019). To overcome these challenges, weekly and monthly interdepartmental reports will be generated where departments and staff who have performed exceptionally well or have demonstrated compliance to evaluation parameters will be displayed, appreciated and rewarded across the organization (Chassin & Loeb, 2013),  To further convert challenges to opportunities, monthly feedback and debriefing sessions will be conducted where staff will be allowed to share their views on grievances, limitations, organizational strengths and areas of improvement which can be incorporated within the evaluation plan followed by appreciation of the same (Valuck et al., 2017). Such employee-centered rewards will prevent fatigue, ensure motivation and instill perceptions of positivity where staff feel that their opinions are being respected. To further ensure compliance to the evaluation plan, weekly RPI processes comprising of six sigma evaluation will be conducted whose results will again be conveyed to staff via group discussions and debriefing sessions (Chassin & Loeb, 2013).

Conclusion

Thus, this paper successfully demonstrates the key components which are to be considered for the purpose of the evaluation of the impact of an ACO, the level of alignment between organization strategic principles and ACO regulatory requirements as well as the data required for the purpose of measurement of outcomes and quality metrics relevant to the functioning of ACOs. With respect to the currently established regulatory guidelines and principles at the national level, the evaluation plan has been formulated as a sum of 4 key components, namely: Quality Measurement with respect to Shared Savings and Collaborative Care, Quality Measurement with respect to Medicare Savings, Quality Measurement with respect to Care Continuity and Community Health and Quality Measurement with respect to Systems Thinking.

To firstly ensure implementation of ACO principles and organizational strategic alignment with the same, the first need of the hour is to induce a work culture of systems thinking. To address the same, a key components of the ACO evaluation plan is the teaching and implementation of a systems thinking based managerial and leadership training and education promotion, which will be evaluated based on the components of strategic management such as: prevalence of patient flow across the care continuum, prevalence of shared and collaborative scope of services and sufficient allocation of human capital investments. To demonstrate adherence to the ACO regulatory principles of shared and reduced clinical costs as per the CMS, the evaluation plan of the concerned ACO will also comprise of quality measures established by the CMS, which will include the for domains of: Caregiver/Patient Experience, Patient Safety/Care Coordination, Prevalence of Clinical Care for At-Risk Populations and Availability of Preventive Health Services. Considering the ACOs were developed for the purpose of delivering quality care to Medicare beneficiaries at reduced costs, the ACO evaluation model recommended by the University of Chicago will be used as an additional evaluation model for the concerned ACO – based on the total Medicare Spending on utilization, quality and level of spending across care services and settings. Lastly, as per the principles established by the ACA, along with affordability, healthcare must target achievement of positive health outcomes across the community – for the evaluation of which, the concerned ACO will be assessed based on Logic Model components of State and National Context, ACO Structural Capabilities, Implementation Activities, Intermediate Outcomes and Impact. To conclude to ensure continuous process improvement, strategic compliance as well as competitive advantage, the concerned ACO must engage in timely auditing of organizational adherence to these evaluation components.

Principles underlying the evaluation of an ACO’s clinical performance and patient-centeredness

References

Adepoju, O. E., Preston, M. A., & Gonzales, G. (2015). Health care disparities in the post–Affordable Care Act era. American Journal of Public Health, 105(S5), S665-S667.

Bartels, S. J., Gill, L., & Naslund, J. A. (2015). The Affordable Care Act, accountable care organizations, and mental health care for older adults: Implications and opportunities.

Blackstone, E. A., & Fuhr Jr, J. P. (2016). The economics of Medicare accountable care organizations. American health & drug benefits, 9(1), 11.

Bridger, C. M., Smith, S. E., & Saunders, S. T. (2017). Saving Lives and Saving Money The Role of North Carolina Health Departments in Medicaid Managed Care. North Carolina medical journal, 78(1), 55-57.

Chassin, M. R., & Loeb, J. M. (2013). High?reliability health care: getting there from here. The Milbank Quarterly, 91(3), 459-490.

Clark, J., Singer, S., Kane, N., & Valentine, M. (2013). From striving to thriving: systems thinking, strategy, and the performance of safety net hospitals. Health care management review, 38(3), 211-223.

CMS. (2018). ACCOUNTABLE CARE ORGANIZATION (ACO) 2018 QUALITY MEASURES. Retrieved 11 November 2019, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2018-reporting-year-narrative-specifications.pdf.

CMS. (2019). Accountable Care Organizations (ACOs) – Centers for Medicare & Medicaid Services. Retrieved 11 November 2019, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/.

Colla, C. H., Lewis, V. A., Bergquist, S. L., & Shortell, S. M. (2016). Accountability across the continuum: the participation of postacute care providers in accountable care organizations. Health services research, 51(4), 1595.

Davis, M. M., Gunn, R., Pham, R., Wiser, A., Lich, K. H., Wheeler, S. B., & Coronado, G. D. (2019). Key Collaborative Factors When Medicaid Accountable Care Organizations Work With Primary Care Clinics to Improve Colorectal Cancer Screening: Relationships, Data, and Quality Improvement Infrastructure. Preventing chronic disease, 16, E107-E107.

Fisher, E. S., Shortell, S. M., & Savitz, L. A. (2016). Implementation science: a potential catalyst for delivery system reform. Jama, 315(4), 339-340.

Fisher, E. S., Shortell, S. M., Kreindler, S. A., Van Citters, A. D., & Larson, B. K. (2012). A framework for evaluating the formation, implementation, and performance of accountable care organizations. Health affairs, 31(11), 2368-2378.

Hernández, A., Ruano, A. L., Marchal, B., San Sebastián, M., & Flores, W. (2017). Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity. International journal for equity in health, 16(1), 26.

Kaufman, B. G., Spivack, B. S., Stearns, S. C., Song, P. H., & O’Brien, E. C. (2019). Impact of accountable care organizations on utilization, care, and outcomes: a systematic review. Medical Care Research and Review, 76(3), 255-290.

Kessell, E., Pegany, V., Keolanui, B., Fulton, B. D., Scheffler, R. M., & Shortell, S. M. (2015). Review of medicare, medicaid, and commercial quality of care measures: considerations for assessing accountable care organizations. Journal of Health Politics, Policy and Law, 40(4), 761-796.

McWilliams, J. M., Chernew, M. E., Landon, B. E., & Schwartz, A. L. (2015). Performance differences in year 1 of pioneer accountable care organizations. New England Journal of Medicine, 372(20), 1927-1936.

McWilliams, J. M., Hatfield, L. A., Chernew, M. E., Landon, B. E., & Schwartz, A. L. (2016). Early performance of accountable care organizations in Medicare. New England Journal of Medicine, 374(24), 2357-2366.

Mora, A. M., & Walker, D. (2016). Quality improvement strategies in accountable care organization hospitals. Quality Management in Healthcare, 25(1), 8-12.

NORC. (2018). Next Generation Accountable Care Organization (NGACO) Model Evaluation. Retrieved 11 November 2019, from https://innovation.cms.gov/Files/reports/nextgenaco-firstannrpt.pdf.

Nyweide, D. J., Lee, W., Cuerdon, T. T., Pham, H. H., Cox, M., Rajkumar, R., & Conway, P. H. (2015). Association of Pioneer Accountable Care Organizations vs traditional Medicare fee for service with spending, utilization, and patient experience. Jama, 313(21), 2152-2161.

Obama, B. (2016). United States health care reform: progress to date and next steps. Jama, 316(5), 525-532.

Perrin, J. M., Zimmerman, E., Hertz, A., Johnson, T., Merrill, T., & Smith, D. (2017). Pediatric accountable care organizations: insight from early adopters. Pediatrics, 139(2), e20161840.

Phillips, J. M., Stalter, A. M., Dolansky, M. A., & Lopez, G. M. (2016). Fostering future leadership in quality and safety in health care through systems thinking. Journal of Professional Nursing, 32(1), 15-24.

Pimperl, A. F., Rodriguez, H. P., Schmittdiel, J. A., & Shortell, S. M. (2018). A Two-Step Method to Identify Positive Deviant Physician Organizations of Accountable Care Organizations with Robust Performance Management Systems. Health services research, 53(3), 1851-1869.

Ru, B., Wu, Q., Wang, X., Yao, L., & Jia, Y. (2017, August). Integration of Accountable Care Organization and Additional Hospital Data into CMS Referral Analytics System. In 2017 IEEE International Conference on Healthcare Informatics (ICHI) (pp. 357-361). IEEE.

Shortell, S. M., Colla, C. H., Lewis, V. A., Fisher, E., Kessell, E., & Ramsay, P. (2015). Accountable care organizations: The national landscape. Journal of Health Politics, Policy and Law, 40(4), 647-668.

Valuck, T., Blaisdell, D., Dugan, D. P., Westrich, K., Dubois, R. W., Miller, R. S., & McClellan, M. (2017). Improving oncology quality measurement in accountable care: filling gaps with cross-cutting measures. Journal of managed care & specialty pharmacy, 23(2), 174-181.

WHO. (2019). Evaluation in health in health promotion. Retrieved 11 November 2019, from https://www.euro.who.int/__data/assets/pdf_file/0007/108934/E73455.pdf.