Recent media reports have expressed concern about the failure of some Medicare and commercial ACOs to meet savings and quality targets. While many ACOs have complained that design issues in Medicare ACOs, such as open networks and existing CMS payment rules are impediments to making cost deficiencies, commercial plans do not have these problems since they have the ability to prevent leakage and have fewer clinical requirements. Yet commercial ACOs are also falling short of targets. Since targets should be set to push performance rather than incentivize the status quo, risk-bearing organizations must have the ability to implement clinical changes that require new practices and skills. A passive approach that assumes that each individual will successfully make the necessary changes is not going to produce the group-wide transformation that leads to the results that the new reimbursement models envision.
Generating group-wide adoption is a challenge confronting both new organizations created to become ACOs as well as existing organizations. For existing organizations, the change from a volume-based to value-based strategy, can create conflict with existing organization’s values and norms. Norms related to patient scheduling, making referrals, and addressing requests for after hours care have to change in a value-based environment. Without assistance, many physicians will not make the necessary changes. Additional risks occur when ACOs add new physicians to accommodate geographic need or to have a broader panel of specialists. While longstanding members of the organization may have been prepared for the transformation to value-based care, newer members have had less time to adjust. Ensuring that new members blend in with the group is a critical factor to meeting performance targets.
In the absence of an existing identity and culture, newly formed ACOs face the challenge of corralling the heterogeneous interests of the members of the new group. What were their motivations for joining? When physicians joined, did they understand their obligations to the group? Did they demonstrate that they could adapt to meeting group needs, rather than operating as an independent practitioner (in Doctoring Together, Friedson noted that even physicians in group practices operated independently under most circumstances). Since their practice was oriented to a different set of incentives, what assistance do they need to make the necessary changes?
These issues do not mean that new ACOs cannot be successful, in fact, many have been. The key is not to delegate the adoption of change to individuals. Some people will figure out what to do on their own. Others will luck out and perform well initially but because they do not understand what they did right, they are at risk for failure in subsequent measurement periods. Others will fail completely, pulling down the group’s performance. Smart ACOs must ensure complete adoption of new models of care.
Healthcare organizations should look to the research on the diffusion of innovations for insight. The rate of adoption, which measures the number of adopters of change over time, is usually an S-shaped curve. While there are early adopters, in most situations, there will be late adopters or laggards. Late adopters are slower to adopt changes and their results can pull down the group’s overall performance. Each group requires different amounts and types of adoption support. A strategy to gain adoption must reach each group, providing the appropriate support to gain more rapid, sustainable adoption.
Promoting adoption is not a “one-shot” deal. Research also suggests that there are five stages in the adoption of innovations:
- knowledge
- persuasion
- decision
- implementation and
- confirmation.
From this perspective, many organizations miss the mark. They present new knowledge or expectations in newsletters or large group meetings with the expectation that knowledge will be sufficient. But that is rarely the case. To avoid performance problems, leaders must spend time ensuring that each physician is prepared to achieve the group’s goals and expectations. Start by assessing each individual’s understanding and readiness to implement the necessary changes. Individuals may need to be persuaded by addressing their concerns or assisted in thinking through how they will implement new practices.
Even after individuals are engaged and agree to try implementation, adoption cannot be assumed. Research also shows that some implementers decide to discontinue the adoption if they encounter problems, so it is important to confirm that the change has not been rejected after it has been tried. If you wait for performance data analysis, you will catch the problem after damage has been done. So it will be necessary to maintain an ongoing dialogue (not one way communication) to ensure engagement. Organizations that fail to address these issues in planning, run the risk of inconsistent adoption.
When faced with the need for rapid change, it’s natural to focus on the technical changes, such as building analytics, hiring case managers, and modifying compensation. But healthcare is more about people (the care team) working with people (patients and families) than it is about technical systems. Resources must be committed to getting people aligned with a new mission, new norms, practices and habits. With the right leadership and plan for change, organizations can achieve sustainable success quickly. Setting up policies and procedures and building management systems are not sufficient to achieving success, especially when the goals are new to the organization’s members. Knowledge and financial incentives also are insufficient (consider the large percentage of the population that smokes). Attention to the adoption of change is the critical success factor.
