Assessment of Accountable Care Organization Strategies: A Qualitative Approach ()
1. Introduction
1.1. Background of the Study
Accountable care organizations (ACOs) are a major reform initiative that has grown substantially in recent years. Despite the rapid diffusion of the model, little is known about how ACOs are working to transform care on the ground (Lewis et al., 2019) . An ACO is an association of hospitals, healthcare providers, and insurers in which all parties voluntarily assume financial and medical responsibility for a patient population. An ACO is accountable and responsible for their patients’ care by implementing a holistic approach (therapeutic and preventive). This involves the deployment of care coordination that allows a patient to receive the right care at the right time while reducing the risk of medical errors and duplicate services (Mishra et al., 2018; Shortell et al., 2015) .
1.2. Saudi Healthcare Reform
In the Kingdom of Saudi Arabia, the Ministry of Health (MOH) has been tasked with delivering this strategy as part of “Vision 2030”. Previous research confirmed Saudi Arabia’s readiness to adopt the ACO healthcare system as part of the transformation and Vision 2030 (Alharbi et al., 2022) . In the new system, all providers under the MOH are brought together under a single management structure, with specified geographic and population boundaries, to create 20 “Clusters.” Clusters are working towards becoming autonomous ACOs. Each ACO will also have to take responsibility for allocating resources for their population (Lewis et al., 2013a, 2013b) .
Commercial ACOs were based on three main principles: accountability for quality, shared savings and performance measurement. Commercial ACOs tended to have a higher degree of engagement in disease-monitoring activities, reflecting the main ACO principles in taking action in care practices, unnecessary hospitalizations, and specialist referral processes. Additionally, commercial ACOs were allocating resources towards implementing procedures to reduce emergency department utilization and curb the excessive utilization of healthcare services (Farmanova et al., 2019; Peiris et al., 2016) . Reduction in hospitalizations may indicate that hospitals linked with ACOs are more successful than other hospitals or better at targeting interventions for high-risk patients (Winblad et al., 2017) .
1.3. The Need for Effective ACO Strategies
ACOs have been established to improve healthcare quality, reduce costs, and enhance patient outcomes. However, implementing ACO strategies is a complex process that requires careful planning, collaboration, and effective communication among stakeholders. This is to fit the needs of patients and providers better (Fraze et al., 2021) . To successfully implement an ACO strategy, healthcare organizations need to establish a comprehensive framework that includes the identification of relevant metrics, the development of care management processes, the integration of technology, and the alignment of incentives. This requires a deep understanding of the organization’s existing processes and capabilities and a clear vision for the future (McClellan et al., 2010) .
One of the critical challenges in the implementation of ACO strategies is ensuring that all stakeholders are aligned and committed to the goals and objectives of the organization. This includes healthcare providers, payers, patients, and community organizations. Effective communication and collaboration are critical for building trust and ensuring everyone works together to achieve the same outcomes (DeCamp et al., 2014) . Another important factor in implementing ACO strategies is the use of data and analytics to identify areas for improvement and measure progress. This requires a robust technology infrastructure and skilled data analysts and IT professionals who can help identify trends and patterns in the data (Razzak et al., 2020) .
Organizations devise strategic plans to accomplish diverse goals, including but not limited to countering various pressures exerted on them, seizing novel opportunities, surmounting significant challenges, meeting stakeholders’ expectations, gaining a competitive edge over rivals, and enhancing the resources and competencies of the firm. In this context, a strategy is a set of actions and resource allocations intended to help an organization reach its goals. Overall, the implementation of ACO strategies requires a significant investment of time, resources, and expertise. However, the potential benefits are substantial, including improved patient outcomes, reduced costs, and increased efficiencies. Therefore, healthcare organizations that are able to successfully implement ACO strategies will be well-positioned to succeed in the rapidly changing healthcare landscape.
1.4. Aim and Objectives of the Study
The main aim of this study is to assess the ACO strategies employed by hospitals, primary healthcare centers (PHCs), and other healthcare providers of Cluster One located in the Riyadh region and determine how these strategies contribute to improving access to care and enhancing the quality of healthcare services while also reducing costs.
The study’s objectives are:
• To evaluate the perceptions and experiences of employees of Cluster One to gain further understanding of effective strategies that help attain the ACO goals of improving access to care and enhancing the quality of healthcare services while reducing costs.
• To recommend practical solutions to help develop appropriate strategies that help achieve the ACO goals of improving access to care, enhancing the quality of healthcare services, and reducing costs.
This study will identify the role of ACOs in ensuring the best patient care and providing higher quality healthcare at a lower cost.
2. Method
This qualitative cross-sectional study focuses on the implementation of ACO strategies among hospitals, PHCs, and other healthcare providers.
2.1. Data Collection and Sampling
For data collection, semi-structured interviews were performed. The use of semi-structured interviews made it possible to collect comprehensive data about the context being studied. The study employed purposeful sampling as a means of collecting comprehensive data from appropriate participants.
Eight senior strategic managers from different healthcare facilities in the Riyadh region in Cluster One of the Saudi MOH participated in interviews. These individuals are responsible for designing and implementing strategies for the organization. They were asked five questions related to future strategies of ACOs in the Kingdom of Saudi Arabia.
2.2. Piloting
Prior to conducting the main interviews, a piloting phase was carried out to ensure the suitability of the interview questions and to improve the qualitative analysis process. A Thematic Analysis process was utilized to analyze two piloting interviews conducted with senior managers from Cluster One. The study utilized the NVivo 12 software, a computer-aided qualitative data analysis system, to facilitate the coding and thematic development of the dataset. The piloting analysis helped to refine the questions and evaluate the themes related to an ACO in the Riyadh region.
The results of the piloting phase underlined the need for the researcher to have a solid understanding of the themes to guarantee successful data collection and the significance of modifying and expanding certain themes to enhance the analysis output.
2.3. Data Analysis
This is a qualitative cross-sectional study with a sample of eight senior strategic managers from different healthcare facilities in Cluster One’s Riyadh region who participated in interviews. The participants were presented with a set of five questions about the future strategic plans of the ACO within the Kingdom of Saudi Arabia. As previously indicated, the data underwent analysis utilizing NVivo 12 software. The process of data analysis involved six main stages:
• The initial phase entailed an examination of the data source, namely the transcripts of interviews conducted with senior strategic managers within Cluster One’s Riyadh region.
• The transcripts underwent a dual reading process, wherein an initial impression was formed, and significant keywords and phrases were identified for use in NVivo.
• The subsequent stage entailed the identification of overarching themes, which were subsequently employed as codes to guide the analytical procedure.
• The third phase involved the evaluation and identification of theme nodes. Nodes refer to a set of curated resources that are thematically or relationally related.
• The fourth step entailed coding based on the nodes. This task was performed through manual means to ensure accurate results.
• In the fifth phase, repeated statements were extracted by identifying the themes using a number of criteria, such as quantity, repetitions, and connections between ideas.
• The ultimate phase entailed determining the presence of connections among the identified themes that were associated with ACO strategies.
The process of data analysis entailed taking into account the key elements of the strategic approach of ACOs, including the challenges facing healthcare transformation, ACO priorities, benefits of the healthcare system from ACO, and ACO contributions to fill the gaps in the quality of services, as well as the impacts of a successful implementation of ACO. These elements were essential in understanding the future strategies of ACO in the Riyadh region and their role in ensuring access to care and quality healthcare at lower costs. The use of Nvivo software facilitated the data analysis process and enabled the identification of key themes and connections between them. The analysis provided valuable insights into the future strategies of ACOs in the Riyadh region and can inform healthcare policy and decision-making.
3. Results
3.1. Key Themes
The study identified five main themes related to ACO strategies in the Saudi healthcare system: 1) The greatest challenges facing healthcare transformation; 2) The priorities that an ACO should concentrate on; 3) The changes in healthcare systems that would yield the greatest benefits for ACOs; 4) How the ACOs contribute to enhancing the cost-effectiveness and quality of healthcare services, as well as addressing the gaps in service quality that exist within current healthcare systems; and 5) The factors and consequences that will motivate the successful implementation of ACO. This analysis identified valuable insights into the challenges and opportunities facing the implementation of ACO strategies in the Kingdom of Saudi Arabia’s healthcare system.
3.2. Analysis of Interviews
The analysis of the interviews conducted with eight senior strategic managers in Cluster One of the Riyadh region was intended to identify the ACO strategies to improve healthcare delivery. Five main questions were asked to find the best strategy for developing a successful ACO as were briefed in Table 1, showing participants’ comments in the analysis. The results are presented per the identified themes.
1) The greatest challenges facing healthcare transformation
The majority of the participants agreed regarding identifying the most significant challenges in developing an effective strategy for establishing an ACO. Most of the senior managers who participated in the study offered comparable responses concerning the primary obstacles involved in developing an optimal strategy for establishing an ACO. The following main challenges were:
a) Establishment of the infrastructure and the ability to identify new standards.
b) Resistance to change.
c) Awareness and the ability to identify new concepts for a new organization and the methodology on how to change the population mentality.
d) Establishment of a unified and computerized medical record system.
e) Challenges such as outdated technological infrastructure and human resource management.
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Table 1. Summary of participants’ comments identified in the analysis.
2) The priorities that an ACO should concentrate on
Different approaches were proposed for prioritization, but there was consensus among the participants that ACOs should prioritize the following strategic areas.
a) Value-based care (best outcome for the best cost), high quality at lowering cost.
b) Create financial sustainability (through a health insurance system).
c) Enhance operational efficiency by enhancing the care experience by establishing an ACO as a service provider.
d) Enhance the quality of the workforce through education and training interventions aimed at the existing employees.
e) Improve the community’s well-being by improving the population’s overall health, thereby ensuring patient satisfaction.
f) Establish an ACO manual that helps with adherence to the guidelines.
g) Developing a unified Health Informatics System (HIS) is a means of establishing a technology infrastructure.
h) Develop a mechanism to enable each cluster to operate autonomously.
3) The changes in healthcare systems that would yield the greatest benefits for ACOs
The participants thought that the following were the primary changes that the ACO might bring about:
a) The integration of all means, properly trained personnel, electronic data, and patient-centered care.
b) Utilization of resources through improved and efficient operations.
c) Better health management with community-based requirements is reflected in increased patient satisfaction and care access.
d) Provision of better healthcare in a cost-effective way.
e) Proper training for staff in primary healthcare centres.
4) How the ACOs contribute to enhancing the cost-effectiveness and quality of healthcare services, as well as addressing the gaps in service quality that exist within current healthcare systems
The primary objective of the concept of ACO is to establish a comprehensive and integrated system. The factors that can contribute to filling the current gaps in service quality are:
a) The integration within the ACO can potentially enhance the capabilities of healthcare services.
b) Establishment of a network to effectively utilize available resources.
c) Provision of holistic healthcare.
d) Quantification of all financial resources.
e) Establishment of mega healthcare centers.
f) Accountability.
5) The factors and consequences that will motivate the successful implementation of ACO
The following are the participants’ responses regarding the factors and consequences that can support the successful implementation of the ACO system, which will result in improved healthcare in the future:
a) Recently established organizations operating under a capitation payment model (national insurance system).
b) Mega electronic healthcare.
c) High level of alignment, including communication.
d) Better experience of care, cost-effectiveness, and population health.
e) Better utilization of both human and financial resources.
f) Value-based compensation.
g) Full financial support with complete autonomy.
h) Culture of transparency.
i) Transformation is a part of Saudi Vision 2030.
4. Discussion
The healthcare system is an essential element of any given society, and it is imperative to ensure that it delivers healthcare services that are of superior quality, easily accessible, and affordable to all members of the population and communities. This section covers the discussion of the empirical results.
4.1. The Greatest Challenges Facing Healthcare Transformation
The implementation of an ACO strategy has the potential to enhance the healthcare system by adopting a holistic approach to therapy and prevention. Healthcare practitioners have identified the infrastructure as a notable obstacle in the healthcare transformation process, as its implementation is not straightforward. There is evidence that the implementation of effective ACO infrastructure has provided valuable support to clinical practices throughout the country by offering proactive guidance to enhance their operations (Amon et al., 2022) .
The majority of the study’s participants have put forth the notion that the allocation of resources towards the development of infrastructure to facilitate healthcare transformation is imperative in realizing the objectives of providing healthcare services that are both cost-effective and of high quality. This includes the implementation of health information systems and infrastructure to support the financial sustainability of healthcare systems. One of the challenges encountered in healthcare transformation is the resistance to the implementation of ACO requirements. The potential consequences of reinforcing negative behaviors and lack of coordination may result in a significant and detrimental impact on the ACO strategy (Fisher et al., 2006) . ACOs have encountered resistance from healthcare providers, who feel they are being unfairly burdened with the responsibility for cost containment. This has led to difficulties in implementing ACO requirements, and the results have been mixed. Some ACOs have been successful in achieving their goals of delivering high-quality, cost-effective care, while others have struggled. The resistance of some healthcare providers to the ACO model underscores the need for greater engagement and collaboration with these providers to help them understand the benefits of the ACO model and overcome their resistance.
ACOs are a complex model of healthcare delivery that can be difficult to understand. Many people and some healthcare professionals have struggled to grasp the concept, which involves a network of providers coordinating to deliver better quality care while reducing costs. One of the challenges in understanding ACOs is that they operate differently depending on the region and population they serve. Establishing a unified and computerized medical record system is an important aspect of ACOs. ACOs require collaboration between various healthcare providers to ensure patients receive coordinated care. A unified medical record system allows for the seamless sharing of patient health information across different healthcare providers, which is essential for providing high-quality and efficient care.
Additionally, a computerized medical record system increases the accuracy and accessibility of patient data, reducing the likelihood of medical errors and improving patient outcomes. By implementing a unified and computerized medical record system, ACOs can strengthen their ability to improve care coordination, reduce costs, and enhance patient satisfaction. Barrier in reporting electronic healthcare records could have a potential risk of causing severe delays and affect ACO quality measures (Perloff & Sobul, 2022; Lakbala & Dindarloo, 2014; Ginter et al., 2018) .
As the healthcare industry continues to shift towards value-based care, it is vital to increase education and awareness about ACOs to ensure this model’s widespread adoption and success.
4.2. The Priorities That an ACO Should Concentrate On
ACOs have emerged as a promising model for delivering high-quality, cost-effective care in healthcare. ACOs are networks of healthcare providers that work together to coordinate care for a defined patient population. ACOs are responsible for the health outcomes of their patients and are incentivized to deliver high-quality care while minimizing unnecessary costs. However, developing a successful ACO strategy is no easy task, and there are a number of priorities that must be considered.
Value-based care is a cornerstone of any successful ACO strategy. Value-based care is a healthcare delivery model that rewards healthcare providers for delivering high-quality care that achieves positive patient health outcomes. Value-based care is a departure from the traditional fee-for-service model, which incentivizes healthcare providers to perform more tests and procedures, regardless of whether they are necessary or effective. Value-based care encourages healthcare providers to focus on the health outcomes of their patients, rather than the volume of services they provide. By prioritizing value-based care, ACOs can ensure that their patients receive high-quality care tailored to their needs (Porter & Teisberg, 2007; Badash et al., 2017) .
Another priority in ACO’s strategy is financial sustainability. ACOs are responsible for managing their patients’ care costs, and they must do so while delivering high-quality care (Bodaken et al., 2016) . ACOs must be financially sustainable in order to continue providing care to their patients over the long term. This requires careful management of resources, including personnel, equipment, and supplies. ACOs must also be able to negotiate favorable contracts with payers and suppliers to ensure they can deliver high-quality care at a reasonable cost.
Service provider (ACO) education and training are also prioritized in ACO strategy. ACOs are composed of various healthcare providers, including physicians, nurses, and other healthcare professionals. These providers must be trained to work together effectively to deliver coordinated care that achieves positive patient health outcomes (Rutledge et al., 2019) . ACOs must invest in education and training programs that help providers understand the ACO model, the importance of value-based care, and the need for effective communication and collaboration.
Patient satisfaction is also a key priority in ACO strategy. ACOs are responsible for the health outcomes of their patients, and patient satisfaction is a crucial component of those outcomes. ACOs must work to ensure that their patients are satisfied with the care they receive, including the quality of care, the level of communication, and the overall experience of receiving care. Patient satisfaction is important not only for the health outcomes of patients but also for the financial sustainability of the ACO (Rodriguez et al., 2019) .
ACO manuals are also an essential priority in ACO strategy. ACO manuals are documents that outline the policies and procedures of the ACO, including the roles and responsibilities of healthcare providers, the processes for delivering care, and the methods for measuring and improving health outcomes. ACO manuals are essential for ensuring that all providers within the ACO are working together effectively and that the ACO delivers high-quality care that achieves positive health outcomes for patients (Fisher et al., 2009; Burke & Rosenbaum, 2010) .
Finally, a unified Health Informatics System (HIS) is a crucial priority in ACO strategy. HIS is a system that allows healthcare providers to share patient information securely and seamlessly. This is essential for delivering coordinated care that achieves positive patient health outcomes. HIS enables healthcare providers to access patient information quickly and easily, which is essential for making informed decisions about patient care (Balio et al., 2019) .
Developing a successful ACO strategy requires careful consideration of a number of priorities. Value-based care, financial sustainability, service provider education and training, patient satisfaction, ACO manuals, and a unified HIS are all essential components of a successful ACO strategy. By prioritizing these areas, ACOs can deliver high-quality, cost-effective care that achieves positive health outcomes for patients.
4.3. The Changes in Healthcare Systems That Would Yield the Greatest Benefits for ACOs
In developing an ACO strategy, it is important to consider how to integrate with other systems of care. Integration can help you achieve better outcomes for patients and lower costs. The benefits of integration include the following:
• Improved coordination between providers in different settings (e.g., hospitals and outpatient clinics). This can reduce duplication of services or laboratory tests already performed elsewhere.
• Reduced duplication of services or tests that are already being performed elsewhere. Integration can also reduce the administrative burden on providers by eliminating unnecessary paperwork and allowing them more time for patient care activities such as face-to-face visits or phone calls instead of completing paperwork on every visitor test ordered by another provider in another setting (Burns et al., 2022) .
ACOs are healthcare delivery systems that coordinate care for their patients. They are accountable for the quality and cost of the services they provide, which means they must integrate all aspects of patient care—from hospitalization to primary care visits--to ensure that it meets established standards.
4.4. How the ACOs Contribute to Enhancing the Cost-Effectiveness and Quality of Healthcare Services, as Well as Addressing the Gaps in Service Quality That Exist within Current Healthcare Systems
ACOs are healthcare delivery systems that coordinate care for their patients. They are accountable for the quality and cost of the services they provide, which means they must integrate all aspects of patient care-from hospitalization to primary care visits-to ensure that it meets established standards.
Integration is a critical component of the ACO strategy. ACOs work to integrate care across different providers and settings, such as hospitals and clinics, to ensure that patients receive the best possible care (Korenda & Thomas, 2016) . ACOs can establish networks of providers that work together to deliver care to patients. These networks can include hospitals, clinics, primary care providers, and specialists. By working together, providers can coordinate care more effectively, reducing duplication of services and improving patient outcomes.
ACOs should take a holistic approach to healthcare that considers the physical, mental, appropriate educational, management systems and promotes religiousness, encouragement, and patients’ social needs. This approach ensures that patients receive care that addresses all aspects of their health (Zamanzadeh et al., 2015) .
ACOs must also quantify their financial resources to ensure that they’re cost-effectively delivering care. This requires careful tracking of expenses and revenues, as well as a focus on reducing unnecessary costs wherever possible (Lloyd, 2017) .
ACOs can establish mega primary health centers (PHCs) that provide a comprehensive range of services. These centers can include primary care providers, specialists, diagnostic services, and other resources necessary to provide high-quality care to patients (Tashkandi et al., 2021) .
ACOs must be accountable for the care they provide. This means measuring and reporting on key performance indicators, such as patient outcomes, patient satisfaction, and cost of care. ACOs should also establish processes for continuous quality improvement, ensuring they always strive to provide the best possible care to their patients (Nyweide et al., 2015) .
ACOs are an important part of healthcare delivery systems. They provide a coordinated approach to care that ensures patients receive the best possible treatment. ACOs must focus on integration, network utilization, holistic healthcare, quantifying financial resources, establishing mega PHCs, and accountability to be successful. By doing so, they can improve patient outcomes, reduce costs, and deliver high-quality patient care (Meret-Hanke & Barney, 2016) .
4.5. Factors and Consequences That Will Motivate the Successful Implementation of ACO
The implementation of ACOs is a complex process that requires careful planning, collaboration, and effective communication among stakeholders. The success of this implementation depends on several factors that need to be considered carefully (D’Aunno et al., 2018) . One of the most critical factors is the establishment of new entities with capitation. This means that providers are paid a fixed amount per patient, encouraging them to provide high-quality, cost-effective care. This incentivizes providers to focus on preventative care measures and coordinate care across specialties, ultimately improving patient outcomes (Sharan & Prasad, 2019) .
Adopting mega electronic health care is another critical factor in the success of ACO implementation. Electronic health records (EHRs) allow providers to access patient information seamlessly and provide coordinated care across specialties. This results in better care management, improved patient outcomes, and lower costs (Bodenheimer, 2008; Kataria & Ravindran, 2020) .
Alignment and communication among stakeholders is also a crucial factor in the success of ACO implementation. All stakeholders must be aligned and committed to the goals and objectives of the organization. Effective communication and collaboration are critical to building trust and ensuring that everyone is working together to achieve the same outcomes (Hilligoss et al., 2017) .
The implementation of ACOs can lead to a better experience of care for patients. By focusing on preventative care measures and coordinated care, patients receive more personalized care that is tailored to their specific needs. This ultimately leads to better outcomes and higher patient satisfaction. Better utilization of resources is also a critical factor in the success of ACO implementation. By providing high-quality, cost-effective care, ACOs can reduce waste and improve efficiency, leading to better utilization of resources.
Value-based compensation and financial support are also essential to the success of ACO implementation. Providers must be incentivized to provide high-quality, cost-effective care, and financial support must be provided to help organizations make the necessary investments in infrastructure and technology (Gaffney et al., 2016) .
Finally, culture transparency and transformation are critical factors in the success of ACO implementation. Organizations must be committed to transparency and transformation, embracing new technologies and processes that allow them to provide high-quality, cost-effective care. This requires a cultural shift that values innovation and continuous improvement (Peckham et al., 2019; Han & Deng, 2018) .
The successful implementation of ACOs requires careful consideration of several critical factors, including new entities with capitation, mega electronic health care, alignment and communication, better experience of care, better utilization, value-based compensation, financial support, culture transparency, and transformation. By focusing on these factors, organizations can improve patient outcomes, reduce costs, and enhance the overall quality of care.
5. Conclusion
Establishing ACOs is a complex process that requires careful planning, collaboration, and effective communication among stakeholders. The most significant challenges facing healthcare transformation include the establishment of infrastructure and identifying new standards, resistance to change, and the ability to identify new concepts for a new organization. However, ACOs should focus on priorities such as value-based care, financial sustainability, and improving the quality of care by educating and training employees. By integrating staff and electronic data, and delivering patient-centered care, ACOs can achieve cost-effective, quality healthcare services and fill the gaps in the current healthcare systems. Factors such as the implementation of the capitation payment model, the provision of mega electronic healthcare, high levels of alignment of healthcare facilities and communication, better experience of care, and value-based compensation can motivate the successful implementation of ACOs. By prioritizing these factors and addressing the challenges, ACOs can improve patient outcomes, reduce costs, and enhance the overall quality of care in the healthcare sector.
6. Ethical Consideration
All the processes of this study were conducted in accordance with the Good Clinical Practice standards and regulations, and in consistence with the declaration of Helsinki. This is qualitative research to evaluate the ACO strategy in the Kingdom of Saudi Arabia. Confidentiality of participants’ names, records, identity, and related communication numbers was the most important consideration. Ethical approval was granted with a proposal reference No.: H1RI-11-Jul21-01 from the institutional review board of the King Saud Medical City.
Acknowledgements
Authors would like to thank all the eight senior strategic managers in Cluster One in the Riyadh region.