The fine print in a health insurer contract can be trying to begin with, but this only intensifies when hospitals enter several risk-based contracts for accountable care organizations.
ACOs used to be so rare, they were likened to unicorns. Now, however, there are more than 700 commercial and government payer ACO contracts spread throughout the country.
As the model gains traction, provider entities have begun signing pay-for-performance and risk-based contracts with more than one payer to capitalize on savings achieved in the model. Pioneer ACOs are actually required, through their contract with CMS, to negotiate outcomes-based contracts with other payers to remain in the program.
Multiple ACO contracts can benefit provider organizations, since many activities related to success as an ACO can decrease patient volume and therefore reimbursement in a fee-for-service situation. If a provider has ACO contracts with a growing number of its payers, then they reap the benefits of reducing patient volume, rather than suffering from lost revenue in a FFS contract. However, having multiple ACO contracts can also be a curse in disguise, says Laura Beerman, director of customer segment analysis for Decision Resources Group. That's because multiple ACO contracts are leading to what Ms. Beerman has dubbed "multi-ACO fatigue" — a topic she addressed at the Managed Markets Summit in Orlando in February. 
Multi-ACO fatigue occurs when provider organizations pursue multiple accountable care contracts, which rarely have perfectly aligned metrics, benchmarks or reporting processes. The organizations with multiple contracts are "struggling from the dilemma of how to align their metrics [and from the] infrastructural demand it takes to contract with more than one payer at a time in an ACO," Ms. Beerman explains.
Even ACOs that make concerted efforts to synchronize several payer contracts can run into difficulties. Ms. Beerman gives the example of an experienced ACO that lined up its payer contracts side-by-side to identify commonalities and simplify reporting, but "they were having a tough time finding alignment," she says. "We were surprised to hear that, coming from a larger, more sophisticated player."
Though many commercial payers' quality metrics are somewhat in line with the 33 measures Medicare is concerned with for ACOs, there is no standardization in the particulars of ACO contracts. When it comes to what payers look for from provider organizations in an ACO, or how they want providers to report results, providers are looking at a diverse set of demands. Several ACO contracts include metrics around populations like diabetics or patients with COPD or heart failure, for instance, but there are still few common ways for provider organizations to align not only metrics but also those metrics' benchmarks, reporting periods and other dimensions.
Since larger, more experienced provider organizations are having trouble juggling multiple ACO contracts, it does not bode well for the future of less experienced hospitals and physician groups just wading into the pool of accountable care.
"There are going to be some providers who choose to start with one [contract] and see where it goes," Ms. Beerman says. However, providers' actions should be based on their respective markets. "I think providers are saying you have to try to accomplish more at one time than you might want to," she says, because "the market is driving some pretty aggressive activity."
There is no quick fix for the competing demands facing multi-contract ACOs. But as the number of organizations suffering from multi-ACO fatigue grows, some organizations are positioning themselves to bring increased standardization to ACO benchmarks and ease fatigue. For instance, the National Committee for Quality Assurance has developed a framework for ACO accreditation. Additionally, one of the stated goals of the National Association of ACOs is to "provide industry-wide uniformity on quality and performance measures." Over time, initiatives such as this may bring some consistency to measures and reporting standards so ACOs at least have a more stable idea of what to expect.
Do you have thoughts on this topic? Are you part of an ACO that is familiar with this type of fatigue? If so, please email hpunke@beckershealthcare.com with your thoughts.