Policy Points:r For accountable care organizations (ACOs) to be successful they need to change the behavior of their physicians. To stimulate this change, a broad range of motivators are being used, including ways to see a greater impact on patients (social purpose) and opportunities to be a more effective physician (mastery), in addition to personal financial incentives.r From our analysis of case studies, it does not appear that the full range of motivators is being deployed by ACOs, which suggests an opportunity to develop more sophisticated and wider-ranging portfolios of motivators for greater impact. Context:There are approximately 800 accountable care organizations (ACOs) in the United States. In order to achieve the ACO goals of reduced cost, improved outcomes of care, and better population health, it is critical to change how physicians within ACOs deliver care. While knowledge of ACO development and evolution is growing, relatively little is known about the motivational drivers that are being used to effect change among participating physicians. Methods:We synthesized 9 well-established and empirically tested theories of motivation into an overarching framework of 6 motivator domains. This framework was then used to explore the types of motivators that leaders use to stimulate change within 4 case study ACOs. We explored the organizational characteristics, strategies, and motivators for changing physicians' behaviors through in-depth interviews and document review. Findings:The case study ACOs more strongly emphasized nonfinancial motivators for changing physician behavior than financial incentives. These

Accountable care organizations (ACOs) have diverse contracting arrangements and have displayed wide variations in their performance. Using data from national surveys of 399 ACOs, we examined differences between the 228 commercial ACOs (those with commercial payer contracts) and the 171 noncommercial ACOs (those with only public contracts, such as with Medicare or Medicaid). Commercial ACOs were significantly larger and more integrated with hospitals, and had lower benchmark expenditures and higher quality scores, compared to noncommercial ACOs. Among all of the ACOs, there was low uptake of quality and efficiency activities. However, commercial ACOs reported more use of disease monitoring tools, patient satisfaction data, and quality improvement methods than did noncommercial ACOs. Few ACOs reported having high-level performance monitoring capabilities. About two-thirds of the ACOs had established processes for distributing any savings accrued, and these ACOs allocated approximately the same amount of savings to the ACOs themselves, participating member organizations, and physicians. Our findings demonstrate that ACO delivery systems remain at a nascent stage. Structural differences between commercial and noncommercial ACOs are important factors to consider as public policy efforts continue to evolve.

Objective:To compare cost-related non-adherence (CRNA), serious problems paying medical bills and average annual out-of-pocket cost over time in five countries.Methods:Repeated cross-sectional analysis of the Commonwealth Fund International Health Policy survey from 2004 to 2014. Responses were compared between Canada, the UK, Australia, New Zealand and the US.Results:Compared to the UK, respondents in Canada, Australia and New Zealand were two to three times and respondents in the US were eight times more likely to experience CRNA; these odds remained stable over time. From 2004 to 2014, Canadian respondents paid US $852–1,767 out-of-pocket for care. The US reported the largest risks of serious problems paying for care (13–18.5%), highest out-of-pocket costs (US $2,060–3,319) and greatest rise in expenditures.Interpretation:Over the 10-year period, financial barriers to care were identified in Canada and internationally. Such persistent challenges are of great concern to countries striving for equitable access to healthcare.