Although overuse in medicine is gaining increased attention, many questions remain unanswered. Dan Morgan and colleagues propose an agenda for coordinated research to improve our understanding of the problem Daniel J Morgan associate professor 1 , Shannon Brownlee writer 2 , Aaron L Leppin postdoctoral research fellow

Accountable care organizations (ACOs) have attracted interest from many policy makers and clinical leaders because of their potential to improve the quality of care and reduce costs. Federal ACO programs for Medicare beneficiaries are now up and running, but little information is available about the baseline characteristics of early entrants. In this descriptive study we present data on the structural and market characteristics of these early ACOs and compare ACOs' patient populations, costs, and quality with those of their non-ACO counterparts at baseline. We found that ACO patients were more likely than non-ACO patients to be older than age eighty and had higher incomes. ACO patients were less likely than non-ACO patients to be black, covered by Medicaid, or disabled. The cost of care for ACO patients was slightly lower than that for non-ACO patients. Slightly fewer than half of the ACOs had a participating hospital. Hospitals that were in ACOs were more likely than non-ACO hospitals to be large, teaching, and not-for-profit, although there was little difference in their performance on quality metrics. Our findings can be useful in interpreting the early results from the federal ACO programs and in establishing a baseline to assess the programs' development.

The rate of growth in national health expenditures is projected to fall to 7.8 percent in 2003 because of slower private and public spending growth. However, during the next ten years health spending growth is expected to outpace economic growth. As a result, the health share of gross domestic product (GDP) is projected to increase from 14.9 percent in 2002 to 18.4 percent in 2013. The recently passed Medicare drug benefit legislation (not included in these projections) is not anticipated to have a large impact on overall national health spending, but it can be expected to cause sizable shifts in payment sources.

In addition to its expansion and reform of health insurance coverage, the Affordable Care Act (ACA) contains numerous provisions intended to resolve underlying problems in how health care is delivered and paid for in the United States. These provisions focus on three broad areas: testing new delivery models and spreading successful ones, encouraging the shift toward payment based on the value of care provided, and developing resources for systemwide improvement. This brief describes these reforms and, where possible, documents their initial impact at the ACA's five-year mark. While it is still far too early to offer any kind of definitive assessment of the law's transformation-seeking reforms, it is clear that the ACA has spurred activity in both the public and private sectors, and is contributing to momentum in states and localities across the U.S. to improve the value obtained for our health care dollars. OVERVIEWIn addition to its more familiar health insurance coverage reforms, the Affordable Care Act (ACA) contains numerous provisions that directly target how health care is organized, delivered, and paid for in the United States. These provisions take aim at the well-known shortcomings of the U.S. health system, from the inefficiency and high cost of our predominantly fee-for-service system to the extreme variability in the quality of care patients receive from region to region.Building on existing reform models in the private and public sectors, the law takes multiple, complementary approaches to addressing the health system's longstanding problems. These center on:• testing new models of health care delivery • shifting from a reimbursement system based on the volume of services provided to one based on the value of care• investing in resources for systemwide improvement.MAY 2015

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