The Patient Protection and Affordable Care Act of 2010 (ACA) includes important features that are likely to change how medicine is delivered in the United States. The Supreme Court will rule this summer on various aspects of the act’s constitutionality, especially the individual mandate provisions, but it is unlikely to strike down the entire act. In section 3022 of the act, the Secretary of Health and Human Services is authorized to recognize arrangements between Medicare and collections of physicians and other providers as accountable care organizations, or ACOs . If the costs to Medicare for people “assigned” to an ACO grow at a slower rate than costs for patient populations with similar patterns of medical use, and if the ACO meets certain quality targets, the implicit savings will be shared by Medicare and the ACO. These savings can be allocated by the ACO to reward its participating clinicians, build infrastructure to facilitate care, or pay for services not ordinarily covered by Medicare.
Several features of the Medicare version of ACOs and similar arrangements developed for the privately insured market (PACOs) are important. The first is that patients in ACOs and PACOs keep their traditional coverage, e.g., Medicare, rather than enrolling in an HMO-style health plan that significantly limits their choice of providers. (I use the term “provider” to include both physicians and other clinicians, such as nurse practitioners, who may be the patient’s usual source of care, and entities such as clinics and hospitals.) Indeed, some patients may be in an ACO or PACO without even knowing it. This brings us to the second feature—patients are attributed (ACA uses the term “assigned”) to an ACO based on their patterns of primary care use. The next section will explore this in more detail. The third feature of ACOs and PACOs is that they are held accountable for all services received by the patients attributed to them, even those received outside the ACO.
One might ask, “why would clinicians want to form an ACO or PACO and be held accountable for the quality and costs of care that they do not provide for patients who are not formally enrolled and have no financial incentives for receiving care within the organization?” Indeed, initial response to the concept was mixed, but it seems to be gaining traction, especially after CMS revised its initial regulations .
Perhaps the short answer is that many believe the current payment and incentive system leads to so much wasteful care and so many missed opportunities for quality improvement; the incentives and flexibility of the ACO/PACO model may encourage them to “do the right thing” more frequently and save money in the process. The lack of control inherent in the ACO/PACO structure (compared to an HMO) makes cost saving more difficult, but has the advantage of engaging providers and patients not willing to be in HMOs. More importantly, it requires and supports a different relationship between clinicians and patients.
Attribution versus Assignment
The “assignment” terminology in the ACA does not reflect an attempt to assign patients to providers, but instead reflects the origins of the accountable care organization concept in what were essentially epidemiological studies . The term “attribution” better fits what is actually being done. Although the details for attribution to Medicare ACOs and various PACOs differ, the notion is that a person can be attributed to a specific primary care provider (PCP) based on a list of the providers from whom he or she receives care. Readily available insurance claims data allows one to “crunch the numbers” to do this attribution without ever asking the patient. Attribution is intended to be a feasible, rather than an ideal, methodology.
Even in a Medicare population with a large number of visits per person per year, it is difficult to attribute patients to individual PCPs . Problems arise, for example, when a patient has an equal number of visits to two PCPs, or when so many PCPs are seen that no one accounts for a majority of the visits. Attribution typically focuses only on visits to PCPs, so problems arise when, because of a dominant chronic condition, a patient largely has his or her care managed largely by a specialist. The attribution challenge is exacerbated with younger adult populations because many have no visits to a PCP in any one year. Does this mean they do not have someone to whom they could go, or who should be monitoring their care? Such concerns are mitigated substantially if one merely needs to attribute people to a set of PCPs affiliated with one ACO/PACO; the problem of “ties” usually disappears if the attribution is to “any PCP within the ACO/PACO.”
The key aspect of attribution, however, is that it reflects a relationship between patients and their provider organizations that is fundamentally different from patient-HMO relationships. An HMO takes responsibility for an enrolled population, meaning that the premiums it receives each month allow it to know exactly for whom it is responsible. The HMO contract with its enrollees, moreover, generally says it has no financial responsibility for medical care obtained outside its system, except in emergency situations or via explicit referrals. In contrast, ACOs and PACOs do not have monthly enrollment lists, and their attributed patients have comparable coverage for care from non-ACO/PACO providers. The challenge for them is to be so attractive to their patients that patients don’t want to seek care elsewhere.
HMOs typically bear full financial risk for their enrollees; in an ACO/PACO part of that risk will be borne by Medicare or private insurers. This is a necessity given the highly skewed nature of health care costs, in which a small number of patients account for a large share of overall expenditures. Risk sharing does not, however, allow ACO/PACOs to ignore the costs of the care received by their patients. The insurer can capture information on all the patient’s care, regardless of the providers’ affiliation, and the ACO/PACO shares in savings only if overall patient costs are lower than those for comparable patient populations. If it meets such targets, however, the ACO/PACO will receive lump-sum payments from the insurer (Medicare) not tied to the services of any particular provider. This flexible pot of money allows the ACO/PACO to focus on developing standard processes for the efficient management of the problems its patients face.
Efficiency in this context does not mean shaving a 12-minute primary care visit to 10 minutes and ending the session with two prescriptions and a referral to a specialist. On the contrary, it may mean spending 20 minutes to thoroughly understand the patient’s problem and working through treatment options, perhaps with a phone call 3 days later to see how the patient is doing. Even if the insurer does not pay for the extended visit or the time to call the patient, the ACO/PACO could compensate for that time with the savings achieved.
Balancing the incentives to reduce expenditures are quality metrics. Initially, these may focus on the standard preventive screening and process measures, but they will rapidly move toward clinical and patient-reported outcomes. The latter are not the oft-maligned “generic patient satisfaction” measures but specific patient assessments of their functional status, understanding of their condition, and experience of care—that is, measures patients care about.
Physicians and other professionals deliver medical care, but organizations create the infrastructure to ensure high quality. Quality care may begin with the face-to-face encounter, but it requires the ability to transfer information efficiently among all the clinicians involved, to delegate mundane tasks so the most skilled clinicians can attend to clinical cues, to know when a patient hasn’t come in when he or she should. Large medical groups already provide much of this. ACO/PACOs seeking to include providers such as independent or small group practices will need to create such infrastructures.
ACO/PACOs and the Patient-Physician Relationship
It is too soon to know how ACO/PACOs will function, but the logic behind them is quite different from that of a standard insurance plan or an HMO. Insurers are typically passive payors of claims after events have occurred. They focus primarily on tweaking benefit packages to create patient-focused incentives to reduce expenditures. HMOs (and managed care plans) sometimes act as if they “own” the patient—at least for a time—and exercise the right to say they will not cover certain services even if the physician thinks they may be needed. They typically also have more data about what is and is not done for their enrollees.
Most physicians in independent practice know just what they do for their patients, but have little or no information on their patients’ care from other providers. Because fees do not adequately compensate for time spent with patients, financial pressures discourage the development of close and trusting connections between patients and physicians. Well designed and effectively implemented ACOs should help those who deliver primary care become trusted elicitors of informed patient preferences and knowledgeable coordinators of care. It will take a few years, however, to know if they successfully seize this opportunity.
- Centers for Medicare and Medicaid Services. Medicare program; Medicare Shared Savings Program; Accountable Care Organizations. Final rule. Fed Regist. 2011;76(212):67802-67990.
- See, for example, Galewitz P, Gold J. HHS release final regulations for ACOs. Kaiser Health News. http://www.kaiserhealthnews.org/stories/2011/october/20/accountable-care-organization-rules-regulations.aspx. Accessed April 17, 2012.
- Luft HS. From small area variations to accountable care organizations: how health services research can inform policy. Annu Rev Public Health. 2012;33:377-392. http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-031811-124701. Accessed April 17, 2012.
- Pham HH, Schrag D, O’Malley AS, Wu B, Bach PB. Care patterns in Medicare and their impliations for pay for performance. N Engl J Med. 2007;356(11):1130-1139.
Harold S.Luft, PhD, is director and senior investigator in health policy research at the Palo Alto Medical Foundation Research Institute and Caldwell B. Esselstyn Professor Emeritus of Health Economics and Health Policy at University of California, San Francisco. His primary research focus is the use of incentives and information to improve the value of health care. His book Total Cure: The Antidote to the Health Care Crisis (Harvard University Press, 2008) offers an approach to fundamental delivery system reform.
Related in VM
Health Reform and the Future of Medical Practice, November 2011
The Physician Group Practice DemonstrationA Valuable Model for ACOs? November 2011
© 2012 American Medical Association. All Rights Reserved.
A responsibility assignment matrix (RAM), also known as RACI matrix or linear responsibility chart (LRC), describes the participation by various roles in completing tasks or deliverables for a project or business process. It is especially useful in clarifying roles and responsibilities in cross-functional/departmental projects and processes.
RACI is an acronym derived from the four key responsibilities most typically used: Responsible, Accountable, Consulted, and Informed.
Key responsibility roles (RACI model )
R=Responsible, A=Accountable, C=Consulted, I=Informed
- Responsible (also Recommender)
- Those who do the work to achieve the task. There is at least one role with a participation type of responsible, although others can be delegated to assist in the work required (see also RASCI below for separately identifying those who participate in a supporting role).
- Accountable (also Approver or final approving authority)
- The one ultimately answerable for the correct and thorough completion of the deliverable or task, and the one who delegates the work to those responsible. In other words, an accountable must sign off (approve) work that responsible provides. There must be only one accountable specified for each task or deliverable.
- Consulted (sometimes Consultant or counsel)
- Those whose opinions are sought, typically subject matter experts; and with whom there is two-way communication.
- Informed (also Informee)
- Those who are kept up-to-date on progress, often only on completion of the task or deliverable; and with whom there is just one-way communication.
Very often the role that is accountable for a task or deliverable may also be responsible for completing it (indicated on the matrix by the task or deliverable having a role accountable for it, but no role responsible for its completion, i.e. it is implied). Outside of this exception, it is generally recommended that each role in the project or process for each task receive, at most, just one of the participation types. Where more than one participation type is shown, this generally implies that participation has not yet been fully resolved, which can impede the value of this technique in clarifying the participation of each role on each task.
There is a distinction between a role and individually identified people: a role is a descriptor of an associated set of tasks; may be performed by many people; and one person can perform many roles. For example, an organization may have ten people who can perform the role of project manager, although traditionally each project only has one project manager at any one time; and a person who is able to perform the role of project manager may also be able to perform the role of business analyst and tester.
Assigning people to facilities
The matrix is typically created with a vertical axis (left-hand column) of tasks (from a work breakdown structure) or deliverables (from a product breakdown structure), and a horizontal axis (top row) of roles (from an organizational chart).
|Code||Name||Project sponsor||Business analyst||Project manager||Technical architect||Applications development|
|Stage A||Manage sales|
|Stage B||Assess job|
|Stage C||Initiate project|
|- C04||Security governance (draft)||C||C||A||I||I|
|- C10||Functional requirements||A||R||I||C||I|
|- C11||Business acceptance criteria||A||R||I||C||I|
|Stage D||Design solution|
Another example from the maintenance and reliability community
There are a number of alternatives to the RACI participation types:
- This is an early version of a Responsibility Assignment Matrix, with the roles defined as:
- Review Required
- Input Required
- Sign-off Required
- This is a version very useful to organizations where the output of activities under the accountability of a single person/function can be reviewed and vetoed by multiple stakeholders, due to the collaborative nature of the culture.
- The person/function carrying out the activity.
- The person/function ultimately answerable for the correct and thorough completion of the deliverable or task, and often the one who delegates the work to the performer.
- The person/function reviewing the result of the activity (other than the accountable). He or she has a right of veto; his or her advice is binding.
- The person/function consulted to give advice based upon recognized expertise. The advice is non-binding.
- The person/function who must be informed of the result of the activity.
- This is an expanded version of the standard RACI, less frequently known as RASCI, breaking the responsible participation into:
- Those responsible for the task, who ensure that it is done as per the approver
- Resources allocated to responsible. Unlike consulted, who may provide input to the task, support helps complete the task.
- This is an alternative version of the standard RACI, foregoing the consulted participation and replacing it with:
- Resources which play a supporting role in implementation.
- This is an expanded version of the standard RACI, with an additional participation type:
- Quality Review
- Those who check whether the product meets the quality requirements.
- This is an expanded version of the standard RACI, with two additional participation types:
- Those who check whether the product meets the acceptance criteria set forth in the product description.
- Those who approve the verify decision and authorize the product hand-off. It seems to make sense that the signatory should be the party being accountable for its success.
- This is an expanded version, of the standard RACI, also known as RACIO with one additional participation type.
- Out of the loop (or omitted)
- Designating individuals or groups who are specifically not part of the task. Specifying that a resource does not participate can be as beneficial to a task's completion as specifying those who do participate.
- Another version that has been used to centralize decision making, and clarify who can re-open discussions.
- A single driver of overall project like the person steering a car.
- One or more approvers who make most project decisions, and are responsible if it fails.
- Are the worker-bees who are responsible for deliverables; and with whom there is two-way communication.
- Those who are impacted by the project and are provided status and informed of decisions; and with whom there is one-way communication.
- Another tool used to clarify decision roles and thereby improve decision making overall is RAPID®, which was created by and is a registered trademark of Bain & Company.
- The Recommend role typically involves 80 percent of the work in a decision. The recommender gathers relevant input and proposes a course of action—sometimes alternative courses, complete with pros and cons so that the decision maker's choices are as clear, simple and timely as possible.
- The Agree role represents a formal approval of a recommendation. The 'A' and the 'R' should work together to come to a mutually satisfactory proposal to bring forward to the Decider. But not all decisions will need an Agree role, as this is typically reserved for those situations where some form of regulatory or compliance sign-off is required.
- The Perform role defines who is accountable for executing or implementing the decision once it is made. Best-practice companies typically define P's and gather input from them early in the process
- The Input role provides relevant information and facts so that the Recommender and Decider can assess all the relevant facts to make the right decision. However, the 'I' role is strictly advisory. Recommenders should consider all input, but they don't have to reflect every point of view in the final recommendation.
- The Decide role is for the single person who ultimately is accountable for making the final decision, committing the group to action and ensuring the decision gets implemented.
- Another tool used in organisation design or roles analysis.
- Identify who is in charge of making sure the work is done.
- Identify who has final decision power on the work.
- Identify who actually does the work.
- Identify who is involved to provide support to the work.
- Identify who is informed that the work has been done (or will be started)
- A variant of RASCI developed by three Whitehall theorists (Kane, Jackson, Gilbert). This scheme is adapted for use in matrix management environments, and differs only from RASCI in having an additional role of Driver and a narrower definition of Support:
- An individual or party that assists those who are Responsible for delivering a task by both producing supporting collateral and setting timescales for delivery in line with the overarching aim of the individual or party who is Accountable for the overall accomplishment of the objective. The distinction between Driver and Support lies in that the former reinforces and clarifies the parameters of the task on behalf of those who are Accountable, while the latter refers to those who help those who are Responsible in reaching a given goal.
There are also a number of variations to the meaning of RACI participation types:
RACI (alternative scheme)
- There is an alternative coding, less widely published but used by some practitioners and process mapping software, which modifies the application of the R and A codes of the original scheme. The overall methodology remains the same but this alternative avoids potential confusion of the terms accountable and responsible, which may be understood by management professionals but not always so clearly differentiated by others:
- Those responsible for the performance of the task. There should be exactly one person with this assignment for each task.
- Those who assist completion of the task
- Those whose opinions are sought; and with whom there is two-way communication.
- Those who are kept up-to-date on progress; and with whom there is one-way communication.
- This alternative is focused only on documenting who has the authority to make which decisions. This can work across all sized work groups.
- Authorized to approve an answer to the decision.
- Responsible to recommend an answer to the decision.
- Those whose opinions are sought; and with whom there is two-way communication.
- Those who are informed after the decision is made; and with whom there is one-way communication.
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