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Whether it’s filling out the same paperwork for an outpatient procedure at a hospital that you did for your family doctor, or having to track down a relative’s medical records as they transition to a rehabilitation or nursing facility, navigating the U.S. health care systems means redundancies and inefficiencies.

One way health systems have tried to improve patient outcomes has been the creation of Accountable Care Organizations (ACOs), partnerships among care providers that offer a unified combination of services. But what happens when these ACOs aren’t able to provide all the services necessary for a patient’s entire continuum of care?

New research by Aravind Chandrasekaran, professor of operations at Fisher, and his colleagues explores factors that can help ACOs deliver more efficient and effective health care, by how much, and the costs associated with these improvements.

The continuum of care

The paper, “Collaboration Structures in Integrated Healthcare Delivery Systems: An Exploratory Study of Accountable Care Organizations,” describes ACOs as umbrella organizations with ownership of facilities across a patient’s continuum of care. These can include pre-acute (primary care physicians, specialists, etc.), acute (hospitals) and post-acute (rehabilitation or nursing care) services. Using the entire population data — not sample — sourced from 528 Medicare Shared Savings Program (MSSP) ACOs from 2013-2016, the researchers looked specifically at how these organizations were structured and the impact these structures had on collaborative health care delivery.

“We found that if an ACO wants to be successful, it needs representation across all parts of a patient’s continuum of care,” Chandrasekaran said. “But that’s a large challenge. It’s easy when you look at a group of physicians or hospitals; they all speak the same language, have the same forms and records system. But when you start adding skilled nursing facilities or other services, this collaboration becomes more difficult.

“Think about a patient who is discharged from a hospital and is told to schedule follow-up services. If their provider doesn’t provide those services, or it’s difficult to access them, they’re not going to do the therapy or the follow-up services. This leads to readmissions (i.e. patients admitted to a hospital again for the same condition.)”

Chandrasekaran co-authored the paper with Yingchao Lan, of the University of Nebraska. Lan, a former doctoral student at Ohio State, served as the lead author. Other collaborators included Daniel Walker, of The Ohio State University College of Medicine and Deepa Goradia, of the Robinson College of Business at Georgia State University.

Utilizing two metrics ­­— partnership scope (the presence of providers across the continuum of care’s three stages and its interdependence) and partnership scale (the presence of providers at any point in the three stages and the degree of resource interdependencies among providers who perform similar tasks) — the researchers quantified the impact of collaboration within an ACO.

On average, ACOs with partners from all three care-continuum stages demonstrated a 5.3% increase in patient experiential quality (measured using HCHAPS scores) and a 2.9% reduction in 30-day readmission rates. Further, ACOs with providers within and across a care continuum can see an average improvement in patient experience of 3.2% and a 6.6% reduction in readmission rates. An average-sized MSSP ACO that discharges 5,360 patients annually could reduce readmissions by 354 per year.

“This is even more important because other research has shown that more than 60% of ACOs have providers from only one care-continuum stage,” Chandrasekaran said.

The cost

Bringing about the structural and organizational changes needed to improve collaboration is one challenge facing ACOs. The other is cost. The researchers found that per-capita expenses covering the full continuum of care increased on average by 12%, approximately $1,422 per patient, in the first year.

They project that the increase in spending, however, would be reduced over time as learning and familiarity across the three stages of the continuum becomes more widespread.

“There is a cost-quality tradeoff, but if ACOs are persistent and implement changes properly, those changes will pay off and that tradeoff will disappear,” Chandrasekaran said. “This research further shows that health care is a system; it’s not individual parts. If you want good health care, it’s more than just having great doctors. It means excellence and collaboration across all three aspects of that continuum of care.”