The implementation of accountable care organizations (ACOs), a new health care payment and delivery model designed to improve care and lower costs, is proceeding rapidly. We build on our experience tracking early ACOs to identify the major factors-such as contract characteristics; structure, capabilities, and activities; and local contextthat would be likely to influence ACO formation, implementation, and performance. We then propose how an ACO evaluation program could be structured to guide policy makers and payers in improving the design of ACO contracts, while providing insights for providers on approaches to care transformation that are most likely to be successful in different contexts. We also propose key activities to support evaluation of ACOs in the near term, including tracking their formation, developing a set of performance measures across all ACOs and payers, aggregating those performance data, conducting qualitative and quantitative research, and coordinating different evaluation activities.T he implementation of accountable care organizations (ACOs), a new payment and delivery model designed to improve health care and lower costs, is proceeding rapidly in both the public and private sectors. As of August 2012 we had identified 227 provider organizations that have established ACO contracts with Medicare, Medicaid, private payers, or some combination thereof.The ACO concept originated in response to a growing recognition that fee-for-service payment was a major contributor to the rapidly rising costs and poorly coordinated care that characterize the US health care system. 1 Under this new payment model, provider groups willing to be accountable for the overall costs and quality of care for their patients are eligible for a share of the savings achieved by improving care.Proponents believe that ACOs will encourage providers across the full range of practice settings-from individual office-based practices to integrated delivery systems-to improve quality and slow spending growth. Under this model, payers establish quality benchmarks and riskadjusted spending targets for the patients cared for by the physicians in the ACO. If the organization meets the quality benchmarks, it is then eligible for a share of the savings achieved below the set spending target. In some models, the organization is also at risk for a portion of any spending that exceeds the target. Early evidence on ACO performance is promising. [2][3][4] Challenges to the success of the model remain, however. Little is known about what capabilities and activities are most important to the longterm success of these new organizations. Also, the optimal design of accountable care contracts between providers and payers is uncertain.In addition, many stakeholders are concerned about the complex interactions among public and private reform initiatives based on ACOs. For example, some economists wonder whether implementation of ACOs in the Medicare popu- lation will lead to provider consolidation and thus higher prices for private payers...

Accountable care organizations (ACOs) are a promising payment model aimed at reducing costs while also improving the quality of care. However, there is a risk that vulnerable populations may not be fully incorporated into this new model. We define two distinct vulnerable populations, clinically at-risk and socially disadvantaged, and we discuss how ACOs may benefit each group. We provide a framework to use in considering challenges for both vulnerable patients and health systems on the path to accountable care. We identify policies that can help overcome these obstacles: strategies that support ACO formation in diverse settings and that monitor, measure, and reward the performance of providers that reach all patients, including vulnerable populations.

This cross-site comparison of the early experience of four provider organizations participating in the Brookings-Dartmouth Accountable Care Organization Collaborative identifies factors that sites perceived as enablers of successful ACO formation and performance. The four pilots varied in size, with between 7,000 and 50,000 attributed patients and 90 to 2,700 participating physicians. The sites had varying degrees of experience with performance-based payments; however, all formed collaborative new relationships with payers and created shared savings agreements linked to performance on quality measures. Each organization devoted major efforts to physician engagement. Policy makers now need to consider how to support and provide incentives for the successful formation of multipayer ACOs, and how to align privatesector and CMS performance measures. Linking providers to learning networks where payers and providers can address common technical issues could help. These sites' transitions to the new payment model constitutes an ongoing journey that will require continual adaptation in the structure of contracts and organizational attributes. I nterest in accountable care organizations (ACOs), a payment model designed to improve quality while reducing costs, is accelerating. Section 3022 of the Affordable Care Act established the Medicare Shared Savings Program. Draft regulations initially proposed were sharply criticized, but in the final rule, the Centers for Medicare and Medicaid Services (CMS) addressed many key stakeholders' concerns. As of now, a total of 116 organizations are participating in that program. 1The Center for Medicare and Medicaid Innovation, a newly created center within CMS, has also established several complementary programs. These include the Advance Payment Initiative 2 to test approaches for providers with limited resources, and the Pioneer ACO Program, 3 designed for providers whose ability to embrace the ACO model is far more advanced. The private sector, too, has moved forward to create a substantial number of commercial ACOs, 4 and several learning networks have emerged to support providers and payers.Despite the extent of ongoing ACO activity in the public and private sectors, there is limited evidence from the field about what factors may contribute to successful progress toward ACO formation. Although some studies have described early results of ACO or ACO-like implementation, 5,6 little is known about the early phases of ACO development and formation. Our research aimed to do the following: document approaches to developing ACO organizational structures and payer agreements; identify factors that may facilitate ACO formation; and analyze the potential policy implications of these emerging ACO arrangements.

Context:It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together?Methods: Using the lens of the social identity approach, this qualitative study examined how four nascent ACOs engaged with the concept of integration. During multiday site visits, we conducted interviews (114 managers and physicians), observations, and document reviews. Findings:In no case was the ACO interpreted as a new, overarching entity uniting disparate groups; rather, each site offered a unique interpretation that flowed from its existing strategies for social-identity management: An independent practice association preserved members' cherished value of autonomy by emphasizing coordination, not "integration"; a medical group promoted integration within its employed core, but not with affiliates; a hospital, engaging community physicians who mistrusted integrated systems, reimagined integration as an equal partnership; an integrated delivery system advanced its careful journey towards intergroup consensus by presenting the ACO as a cultural, not structural, change.

High-throughput (HT) crystallization experiments were conducted with sertraline free base in the presence of mono-, di- and triacidic salt formers. Over 3600 crystallization trials were conducted, leading to the identification and characterization of 18 crystalline salt forms. Due to the large number of crystallization conditions for a given salt type, it was possible to gauge the propensity of a given salt form to exhibit polymorphism. Four salt forms were found to exist (in this limited screen) as monomorphic materials. Unlike the HCl salt in the marketed drug product, the HBr salt appears resistant to polymorphism, crystallizing as a single form from over 140 discrete trials. This observation underscores the lack of predictability of polymorphic behavior of pharmaceuticals even when seemingly minor changes to the composition are made. The experiments highlight the importance of coupling salt selection studies with simultaneous polymorph screening to gain a more comprehensive understanding of solid form diversity as part of the form selection process for pharmaceutical development.