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BERNARDSVILLE – Following a lengthy discussion on pedestrian safety issues throughout the community, the Borough Council Monday night unanimously agreed to provide additional crossing guards for students through the rest of the year.
The decision follows an Oct. 13 accident at the intersection of Anderson Hill Road and Olcott Avenue where a Bernards High School student was hit by a car while walking along a crosswalk. The student was transported to a hospital for injuries but was released the same day.
The intersection was called "the perfect storm of bad crosswalks'' by resident Mariel O'Brien, who said her children were nearly hit there as well.
Other parents pressed the council for immediate action.
"What can we do to improve this right now?'' asked Anderson Hill Road resident Paul Wry.
The council authorized Police Chief Kevin Valentine to hire a crossing guard for that intersection, where a girl was also hit by a car last year, and for the center of town, where students cross Olcott Square from Mount Airy Road on their way to school.
Before a small but determined group of parents, the governing body also agreed to pursue a long-term solution for pedestrian safety improvements, including a review of student busing.
The traffic situation has gotten worse, officials said, since the Somerset Hills Regional School District eliminated free "courtesy busing'' of students who live too close to school for the district to receive state reimbursement. Instead, the district now charges families for "safety busing.''
But parents noted that the district's fee for the service has risen from $150 per student to $400 a year, making it financially difficult for some families to afford.
"It's now $800 for two kids,'' noted parent Maggie Bowie of Bernards Avenue. "It's not in their budget. It's not an option.''
As a result, more students are walking to school and more parents drive their children, adding more cars to the roads.
Councilwoman Charlotte Foster proposed establishing an ad hock committee of parents and officials to review busing patterns. She said it might be possible to establish more efficient busing "zones'' or to lower busing costs.
"Maybe we can do better than we are,'' she said.
'Death Trap'
One parent, Christine Zaamarra, suggested putting a cop car at the Anderson Road intersection and ticketing more drivers.
"That corner is like a death trap,'' she said.
Valentine said his officers do ticket violators but "can't just sit there at that intersection'' due to coverage needs throughout the rest of the community.
"We can't be there all the time,'' he said.
The chief reviewed a series of steps that have been taken in recent months to improve safety at the crosswalk such as improved signs and high visibility markings on the roadway.
But he said traffic flow throughout the town "has increased tremendously'' in recent years and has spilled over to many side streets.
"This is not an easy task,'' he said.
Valentine advocated hiring an engineer to conduct a "traffic calming study.'' The idea was discussed in the past but "never came to fruition.''
"That's a funding issue,'' he said.
The need for additional sidewalks in town was also discussed. That, in turn, led to another argument over the ongoing Mullens Lane reconstruction project. For months now officials have debated over how far sidewalks should be extended along that roadway.
Mayor Lee Honecker finally ended the discussion by calling for a motion to hire additional crossing guards, and the council quickly gave its approval.


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Thermal-E Caps from MSA provide head protection for high temperature, electrical/high-voltage, and other dielectric applications requiring NFPA 70E-2009 compliance. Lightweight, durable, slotted caps are ideal for use in utility work, welding, steel mills, mines, and foundries. Thermal-E Caps meet or exceed all applicable requirements for a Type I helmet (top-impact) as outlined in ANSI/ISEA Z89.1-2009, 94.1-2005 (Class E, electrical/high voltage) and NFPA 70E-2009.

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Cindie Adams is executive director of alumni and corporate relations for the Martin J. Whitman School of Management at Syracuse University. In this role, she facilitates and maintains connections with the more than 25,000 Whitman alumni and their various places of business around the world. She is also responsible for coordinating and executing programming events, communications initiatives and other methods of outreach for connecting alumni with faculty and students to develop a comprehensive network of Whitman graduates.
Prior to joining the Whitman School, Adams worked as the director of the Nicholas Center for Corporate Finance and Investment Banking the University of Wisconsin-Madison's School of Business. She has also worked in various management positions in higher education as well as in the private sector. Adams received both her Bachelor's degree and MBA from the University of Wisconsin-Madison, as well as a Master of Science degree in counseling.


text: Search Results Use the search box below to revise your search, or start a new search. Studies (5) Variables Publications Your query returned 3 studies. Series results are grouped under the most relevant study. Ungroup series results to view all results. Sort by: Title A-Z Released/Updated Time Period Most Cited in ICPSR Bib. Released/Updated 1. Northwestern Juvenile Project (Cook County, Illinois), Follow-up 3, 1999-2007 (ICPSR 36651) Teplin, Linda 2 more results in Northwestern Juvenile Project (NJP) Series 2017-07-13 2. Study of Sworn Nonfederal Law Enforcement Officers Arrested in the United States, 2005-2011 (ICPSR 35648) Stinson, Philip 2017-06-30 3. Building Healthy Relationships: An Evaluation of the Fourth R Curriculum with Middle School Students in Bronx, NY (2010-2012) (ICPSR 35255) Cissner, Amanda; Ayoub, Lama Hassoun 2017-06-09


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Monday, March 24, 2014
Sweet Slumber Pillow Review
Getting a good night sleep is crucial, everybody needs a good night sleep to feel rejuvenated, refreshed and ready for another awesome day! It can be hard to get comfortable at night, due to many reasons. Maybe your mattress needs replacing or maybe it's as simple as replacing your pillow. Pillows can be too soft, too hard or maybe just too flat to feel comfortable. Some people sleep with one pillow and others may have two pillows. What do you prefer?
Sweet Slumber Pillow
For this review, I received the Sweet Slumber Pillow! I was very surprised at how big and heavy the pillow was, but it's very comfortable and it supports your head, so your neck is in alignment with your body. The best part of all, is that the pillow has a removable cover that's machine washable! The pillow is made of shredded natural rubber to simulate the feeling of down, providing both comfort and support! It's hypo-allergenic, anti-bacterial and dust mite resistant! I would recommend the Sweet Slumber Pillow!
Reverie was founded in 2003, Reverie is a leading manufacturer of adjustable foundations, mattresses and pillows. Their mission is to help their customers sleep better, with the highest quality sleep systems and a means for living better! Reverie encourages Sleep, as the key factor of living a healthy lifestyle! Sleep Good Tonight and Live Better Tomorrow!
You can connect with Reverie on their social media sites!
Posted by Bonny Sallee at 3/24/2014 06:58:00 PM
Labels: Pillows
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Wednesday, November 19, 2008
Italian Mac and Cheese
Emilie has been raving about this recipe so I figured it was about time to try it. It was fantastic!! I have to say that I liked it better right out of the oven than for leftovers the next day because right out of the oven it was SO creamy and bubbly.
1 pound ziti rigate, penne rigate or cavatappi (ribbed, hollow corkscrews)
1 pound Italian bulk sweet sausage
2 tablespoons extra-virgin olive oil
1 tablespoon butter
3 or 4 cloves garlic, chopped
12 crimini mushrooms, sliced
Salt and pepper
2 tablespoons all-purpose flour
1 cup chicken stock
1 cup heavy cream
1 (10-ounce) sack, 2 1/2 cups, shredded Italian 4 cheese blend
1 can diced tomatoes, drained well
1 teaspoon hot sauce , optional
1/2 cup Parmesan, a couple of handfuls
Bring a large pot of water to a boil. Salt water and cook pasta to a chewy al dente, about 8 minutes.
In a nonstick skillet, brown and crumble the sausage. Drain cooked crumbles on paper towel lined plate. Return pan to heat and add extra-virgin olive oil, butter, garlic and mushrooms. Season liberally with salt and pepper. Saute 3 to 5 minutes, until mushrooms are lightly golden.
Preheat broiler to high.
To mushrooms, add flour and stir, cooking 2 minutes. Whisk in stock, then stir in cream. Bring cream to a bubble, then stir in 2 cups of 4 cheese blend. When cheese has melted into sauce, add tomatoes. When sauce comes to a bubble, remove from heat and adjust seasonings, adding hot sauce if desired.
Combine cheese sauce with sausage and pasta, transfer to baking dish, casserole or oven safe serving platter. Sprinkle remaining 1/2 cup of 4 cheese blend and the grated Parmesan over the top and brown under hot broiler.
Posted by The Heaviland Family at 6:15 PM
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Citywide Banks' next Charity Fan Vote for its $5,000 Quarterly Hand-Up Charity Donation will take place on Facebook from March 1-14, 2012. The Colfax Community Network is one of five nominated charities that will be spotlighted leading up to this quarter's Fan Vote. The general public is invited to participate in the vote. Voters are eligible to win prizes in addition to helping raise awareness for their favorite Front Range charity.
The homeless families that temporarily reside in the motels along Colfax Avenue are, for the most part, in great need of all basic human services from permanent housing and food to toiletries and medical care. Because people usually think these seedy, rundown motels are home to drug addicts and prostitutes, the plight of these transient families often go unnoticed.
Sometimes these families get caught in the "motel trap", where the mother or father is working every day just to pay nightly fee. Or other times these families are using a church or shelter voucher to stay just for the night, or week, without knowing where they're going to sleep after that.
The Colfax Community Network (CCN), founded in 1999, is dedicated to serving these "invisible" homeless children and families by providing food, clothing, information and emergency services to help offer these families some form of stability.
"It's difficult for families to find a shelter," explains CCN executive director Jennifer Herrera. "At most shelters it is necessary to split the husband away from the family because of the difficulties with housing men with women and children."
"In order for families to stay together, most of the time, a hotel is the only place they can go," says Herrera. "There are just not enough shelters for families."
CCN helps these families by providing a variety of programs such as an afterschool program, a six-week summer camp and a parent-child education group (which they recently reinstated after getting partial funding from a foundation grant). Additionally, they offer daily emergency services that include a food pantry, hygiene products, emergency shelter and referral numbers and resources.
"Anything we need to find or dig up for our clients … we'll search the world over to help them get back on their feet," says Herrera. "The children are the real victims and we know that the only real way to help them is to wrap around their families with resources and services that will help them become self sufficient."
When it comes to donating to this charity, there are numerous ways to help – from volunteering for their after school program to donating necessities like non-perishable food items, clothing, and toiletries. Financial donations are always very welcome, needed and appreciated.
A donation of $5,000 would go a long way in helping them provide more kids with access to CCN programs and more families with food and other emergency services. "We like to think of CCN as a home away from homelessness for the children we serve. Unfortunately, the need is greater than we could possibly provide and we need the entire community to help these kids," says Herrera. For more information about the Colfax Community Network, visit www.ColfaxCommunityNetwork.org.
Vote for Colfax Community Network to Receive $5,000 Donation
Each quarter, Citywide Banks spotlights five Front Range charities to raise awareness about their great work, needs, and corporate giving opportunities. The charities are nominated by Citywide employees. Then, during a 14-day vote on the bank's Facebook Fan Page, customers and the local community select the most deserving charity to receive a $5,000 cash donation from Citywide Banks. $500 and $250 runner-up donations will be awarded to the charities receiving the second and third most votes, respectively. Our quarterly Fan Vote on Facebook is a fun way to get the community engaged in our campaign. Regardless of who wins the vote, all the nominated charities will get some valuable exposure.
Voters in Facebook Vote Eligible to Win Prizes
The public is invited to participate in the Charity Fan Vote at Facebook.com/citywidebanks from March 1 -14, 2012. During the March vote, voters will have the option to be entered into a drawing to win one of several prizes, including a $100 gift certificate to Z Cuisine, $25 Starbucks cards, and more.
How to Vote for Your Favorite Nominated Charity
Visit Citywide's Facebook Page at Facebook.com/citywidebanks anytime and become a Fan by clicking the "Like" button. Then, from March 1-14, 2012, Fans will be eligible to cast their vote and be entered into the voter prize drawing. Look for the "Charity Fan Vote" link on the bank's Facebook page. To access Citywide's Facebook Page, you will need to make sure you are logged into your own Facebook account. If you don't have one, it only takes minutes to set up a new account and it's free.


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Anne of Green Gables: The Collection
When I was young I loved loved loved this show! It was like magic. I recommend it for anyone with small kids. The story is of orphan Anne and her adventures in a new home and school. I'd really like to watch this again.
Swoooooon, Johnny Depp!! This movie is awesome. I love Leonardo DiCaprio.Added 9 Years Ago from Amazon.com
This show gave a lot of your favorite actors their beginning! See Northern Exposure as a small town revolves around a doctor from New York's small practice in Alaska! Great show from the 90s!


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"Is the mouth of the canister wide enough that i can dip my measuring cups in? like the 1 cup size for example?"
I read a review before I ordered these that said they could get their 1-cup measuring cup inside. I have two styles of measuring cups, and the largest I can get through the opening is the Pampered Chef 3/4 cup. However, the canisters themselves are roomy and strong. I prefer the glass to metal....
Square Glass Canisters (Pack of 3)by Global Amici
ITEM#: 13576136This set of three glass canisters features a ribbed design with a screw-top lid. These jars are three different sizes to suit all of your kitchen storage needs.
- Materials: Glass, metal lid
- Small capacity: 84 ounces
- Small dimensions: 8 inches high x 6 inches square
- Medium capacity: 104 ounces
- Medium dimensions: 9 inches high x 6 inches square
- Large capacity: 140 ounces
- Large dimensions: 11 inches high x 6 inches square
- Care instructions: Hand wash
|See Details
|Model Number
|Country of Origin
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Customer Reviews
Most Recent
Small mouth/Strong canisters
I read a review before I ordered these that said they could get their 1-cup measuring cup inside. I have two styles of measuring cups, and the largest I can get through the opening is the Pampered Chef 3/4 cup. However, the canisters themselves are roomy and strong. I prefer the glass to metal.Read More
Not well made
The glass on the largest jar was paper thin, brokeRead More
Happy with these
These canisters were exactly what I wanted. The quality was above what I had anticipated and I'm very satisfied with this purchase. Great quality, great price!Read More
Square Glass Canisters
These look great on my kitchen counter top. Easy access and line up well. Great size and quality.Read More
Great purchase! Want some more! :)
These are even larger than they would appear online, and I am finding numerous ways in which to use them. The silicone seal makes them air-tight, and they are very decorative as well as useful. Will be looking to purchase more to use in my sewing room, for notions and threads/etc., to keep them out of dust & cat range, but easily seen & accessed. Great product, good price.Read More
Most Helpful
The glass canisters look great on my counter. I love them. The fact that they are of good quality, heavy glass has just a couple of minor negatives associated with it. First of all, they are a little heavy when filled, especially for someone like myself who has oseoarthritis. Also, the lids are lined with a plastic liner, and if you pick them up by the lids the liner tends to slide out part way. I don't think they would come out all they way, but I am careful to put one hand under them as I pick them up, or slide across the counter to use. They are larger than I had anticipated - which is definitely better than being too small! No problem holding full bags of flour, sugar, and the medium sized one holds several boxes of pasta. I bought two sets so that I could put things like tea, pasta, rice, etc. in them to free up pantry space. The lids seal nicely, and I would certainly recommend them to anyone who wants canisters that will go with any color scheme!Read More
beautiful canisters
I like these canisters. They are heavy (not flimsy) in a good way, with secure screw-on lids. The colors are exactly as they appear on my moniter....clear glass with brushed nickel lids. They blend nicely with my stainless appliances, and I love the look of the ribbed glass. They are large..I can fit an entire 5 lb. bag of sugar in the medium canister. The one word of caution, and I believe this to be true of all canisters, is that you'll need to get narrow measuring cups to fit inside the jar. The inside dimension of the lid openings is about 3 1/2 inches. I'm very pleased with my purchase and like the way they look in my kitchen.Read More
Nice canisters set...
Have enjoyed these canisters on the counter and with the clear glass and clean lines, it will go with any design/color scheme. The square shape makes it a tight fit in the corner and the glass makes it easy to see when ingredients are getting low. Be aware that the opening is ~3.25" and my round 1 cup measuring scoop does not fit (my rectangular and oval scoops works fine). The large canister holds a 5 lb bag of flour, the medium size holds a 5 lb bag of sugar and the small holds two boxes of confectioners or brown sugar. Have stored ingredients for a month and lids seem to keep container airtight (eg. brown sugar is still soft). Easy to wipe down (wash by hand). I ordered a second set to hold pasta/rice/beans in the pantry, with one going to the master bath to hold bath salts. Works well in all cases.Read More
I like them, I am using them in my master bath filled with cotton balls, swaps and bath salts. Looks nice and clean and they are right there when you need themRead More
Just what I was looking for..
I had a difficult time finding canisters that were not too small. These are nice large canisters with tight fitting lids. Measuring cups go easily in and out of the openings. They are made of heavy, quality glass with beautiful tight fitting lids. These canisters look great in my kitchen. They clean easily. I bake bread weekly and use these for my wheat, flour and sugar. It's great being able to go several weeks before needing to refill them. I like them so much I going to order another set for storing items I purchase in bulk and cookies. My daughter is painting her's in bright colors to match her kitchen. They are so versatile and look great anywhere. I love themRead More
Questions & Answers
These canisters are very large. The largest canister holds a 5 lb. bag of flour with quite a bit of room left. The canisters were of good quality and packed very well. Happy shopping with our everyday low prices
The only cup that fits in the openings of all three canisters for me is 1/3 cup, 1/2 cup, and 2/3 cup, all Rubbermaid measuring cups. The 1 cup and 3/4 do not fit through the openings.
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Mid-Century Modern Decorating on a Budget
You don't have to spend a fortune to decorate like a designer. Easily recreate this chic Mid-Century look with budget-friendly items that pack a style punch. From living room to bedroom, our style inspiration will help you achieve this high-end look, no matter your budget.
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Urban Farmhouse Kitchen
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Dear Pastor Steve (Hammer),
As a longtime fan of this column long before I was invited to contribute myself, I want to take a moment to commend your courage in tackling tough issues. When anyone in our community challenges deeply head notions about social issues such as marriage equality, there is always risk of, well, ruffling some feathers. So I hope your recent column was well received.
Still, by the same token, in my mind, you gave voice to those who may feel their way of thinking goes against the grain.
In case our readers missed your piece — I'm making reference to the column published here on Aug. 22, "Oh, for the love of chicken." I've long struggled with the position some in the Christian community have taken in regard to homosexuality and marriage equality. The topic is radioactive, and so I've been, er, chicken to bring it up.
By now, we've all had time — and the benefit of hindsight — to absorb Chick-fil-A CEO Dan Cathy's statement in opposition to marriage equality, the subsequent media firestorm, and the response from all sides. The media may have moved on, but I'm glad Pastor, that you initiated a more thoughtful discussion in the weeks that followed. And I want to keep that dialogue going.
On the day some in the Christian community called for believers to express support of Chick-fil-A by scoring some of those delicious waffle fries, I neither boycotted, nor supported the effort. I believe in Dan Cathy's right to integrate his beliefs into his business, and to steward his profits however he sees fit. I've always admired the decision to close the doors on Sundays.
But I also want to acknowledge that not every Christian holds the same perspective. And I believe we should stand up — respectfully, peacefully — and say so.
Your column helped me to "be not afraid" to proclaim my support for marriage equality for the lesbian, gay, bisexual, and transgender (LGBT) community. I appreciated your encouragement to read and interpret text through the lens of history, context and culture. You made a thoughtful case in challenging the "biblical definition of marriage." There is great diversity among Christians on this and other topics. But that doesn't make for compelling headlines.
When I watched the lines of folks streaming toward Chick-fil-A that day, I understood many people simply wanted to send a message in favor of freedom of speech, or show support in the eye of the backlash that ensued. I think it's a difficult topic for us all, and I realize those opposed to gay marriage do so in accordance with their understanding of scripture. Tolerance goes both ways, and I always welcome varied viewpoints.
Still, I wondered — does the church want to continue to be associated with a divisive issue about which we will likely never achieve consensus? Would we rather be defined by what some in our community are against, rather than what we're all for? Would we rather act as God's watchdogs, or His ambassadors?
Mostly — during the plethora of media coverage that followed the Chick-fil-A controversy I wondered, did they know us by our love? I only wish we could garner a bit more attention for other lines in which Christians so often stand — at shelters to serve the hungry, at prisons and hospitals to visit the lost and the lonely.
Let's keep the conversation going, Pastor, and invite others to lend their voices. My hope and prayer is that in all of it, we seek to "do justice, walk humbly, love mercy."
In Him,
• Diane Meehl contemplates the big questions in Ahwatukee Foothills, where she lives with her husband and their three chicks. They worship at Mountain View Lutheran Church.


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Accountable Care Organizations: The New Player in the Health-Reform Landscape
To assist health plans as they consider and pursue ACOs, Booz & Company conducted extensive primary and secondary research, proprietary economic modeling, and in-depth interviews with academic experts, external vendors, and senior executives of payors and providers. This Perspective reports Booz & Company's findings on the emerging ACO landscape.
Gary D. Ahlquist Sanjay B. Saxena, MD Brett L. Spencer, MD
Accountable Care Organizations The New Player in the Health-Reform Landscape
This report was originally published before March 31, 2014, when Booz & Company became Strategy&, part of the PwC network of firms. For more information visit www.strategyand.pwc.com.
Contact Information Atlanta Ralph Alewine Partner +1-404-519-0184 firstname.lastname@example.com Chicago Gary D. Ahlquist Senior Partner +1-312-578-4708 email@example.com Brett Spencer, MD Principal +1-312-578-4643 firstname.lastname@example.com Abhishek Gopalka Senior Associate +1-312-578-4585 email@example.com New York Gil Irwin Senior Partner +1-212-551-6548 firstname.lastname@example.com Joyjit Saha Choudhury Principal +1-212-551-6871 email@example.com Szoa Geng Associate +1-212-551-6276 email@example.com San Francisco Curt Bailey Partner +1-415-263-3701 firstname.lastname@example.com Thom Bales Partner +1-415-627-3371 email@example.com Paolo F. Borromeo Principal +1-415-627-3387 email@example.com Sanjay B. Saxena, MD Partner +1-415-263-3729 email@example.com
The authors would like to thank Szoa Geng, Abhishek Gopalka, and Phil Lathrop for their valuable contributions to this Perspective.
Booz & Company
Many payors and providers are considering or actively developing accountable care organizations (ACOs) as a result of their inclusion in the U.S. healthcare reform law. At this early stage, however, the long-term success of the ACO construct is not assured: Its value and longevity will be measured by the ability of ACO partners to drive cost reduction while improving care quality and patient experience. To assist health plans as they consider and pursue ACOs, Booz & Company conducted extensive primary and secondary research, proprie tary economic modeling, and in-depth interviews with academic experts, external vendors, and senior executives of payors and providers. This Perspective reports Booz & Company's findings on the emerging ACO landscape, including:
• An assessment of the fast-evolving ACO marketplace • An analysis of the impact of ACOs on payors and providers, as well as competitive implications • Capability recommendations for payors ACOs create both market risks and opportunities for payors. But for payors who are able to provide capabilities that engender accountability to patients, care redesign, and organizational alignment in ACOs, their promise outweighs the risks. These payors will be able to drive urgently needed improvements in medical value, bolster the stability of the private market, and ensure their positions and futures in the shifting healthcare marketplace.
Booz & Company
What does the ACO landscape currently look like? What models and initiatives have appeared in the marketplace? ACO Activity in the U.S. Healthcare Market There is a swelling wave of ACO activity in the U.S. healthcare market in response to the 2010 Patient Protection and Affordable Care Act (PPACA), which included ACO-related provisions and support for demonstration projects. This activity has been further encouraged by state-led reform initiatives. For example, on February 17, 2011, Massachusetts Governor Deval Patrick announced a comprehensive healthcare payment and delivery reform legislation, "An Act Improving the Quality of Health Care and Controlling Costs by Reforming Health Systems and Payments," designed to stimulate ACO development and global payment systems.i Stakeholders throughout the U.S. healthcare system are involved in ACOs: • Virtually every major payor is either involved in, planning, or seriously considering ACOs. Many health plans are actively helping providers, especially integrated systems and primary care physician (PCP) groups, to form ACOs. • Hospitals are cautious but increasingly keen on leading the forma-
tion of ACOs to avoid the risk of being left behind. According to HealthLeaders Media's 2011 industry survey, 74 percent of hospital chief executives say that their organizations will be part of an ACO within the next five years. In addition, 16 percent of the respondents believe they already have the components for ACOs in place and 60 percent say they will have ACO components in place within the next five years.ii • PCPs are interested in ACOs given their focus on managing across the care continuum with a strong emphasis on primary care. Specialists tend to be more wary, because ACOs encourage the shift of services from specialty to preventive care, as well as rationalize the use of expensive procedures and testing. However, even they are pursuing participation in ACOs to replace lost volume and gain a share of the anticipated savings. According to HealthLeaders Media's 2011 industry survey, 52 percent of physician group leaders said that their organizations will be part of an ACO within the next five years and 20 percent say they already have ACO components in place.iii External vendors, such as McKesson and UnitedHealth Group subsidiary OptumInsight, are focused on assisting providers with the analytics and
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infrastructure required to organize and operate ACOs. Third-party administrators see a re-emerging role for themselves as medical management is pushed out to providers. The level and breadth of activity suggests that the most fundamental change that ACOs may bring in the healthcare market is a substantial increase in the levels of collaboration among payors and providers. For example, ACOs that involve the full spectrum of care delivery will require greater plan-provider cooperation to pilot new payment models. Even if fee-for-service (FFS) continues to be the primary chassis for provider reimbursement, outcomes-based rate revisions, performance bonuses, and risk sharing will become increasingly prevalent. Payors and providers will also actively collaborate in specific areas, such as care management—which is expected to become more integrated—with a risk-adjusted, outcomes-based care management fee.
Evolving ACO Models ACOs are a new and ambiguous enough construct in the healthcare landscape to have so far eluded formal definition. Essentially, they are collaborative structures populated by a set of provider partners, often in association with one or more payor partners, who agree to deliver coordinated care and meet performance benchmarks for quality and affordability in order to manage the total cost of care for their member populations. ACOs are the latest attempt to generate medical value by combining HMO-like structural components, enhanced information technology, greater financial risks and rewards for providers, and an emphasis on care redesign processes. The nascent ACO sector is still very early in its development and is changing daily. Although there are a plethora of new ACO initiative announcements, most are still in the pre-launch stage, with ongoing discussions on key aspects such as governance, patient attribution, and
payment structure. Further, their progress is impeded by a lack of formal finalized guidelines from the Centers for Medicare & Medicaid Services (CMS). As of this writing, most in-market ACOs had launched operations only in 2010 or were planning to do so in early 2011. The ACOs that are currently operational are mostly in the pilot phase and very few have reported results to date, although the results that have been reported show glimmers of promise. While the sector is newly emerging, it is safe to say that most payors and providers are either involved in one or more ACOs or are evaluating the economics and feasibility of participation. Some of these projects are more ambitious, while others are simple rebrandings of existing constructs. On the surface it may seem that there are many ACO variations emerging in the marketplace. However, our research suggests that most ACO efforts fit into one of the three forms described on the following pages.
The most fundamental change that ACOs may bring in the healthcare market is a substantial increase in the levels of collaboration among payors and providers.
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Model 1: Adapted Integrated Delivery System These ACOs are organized around existing integrated delivery systems that feature either a single entity that acts as payor and provider or an association of providers with multiple care settings and employed physicians already affiliated with an external payor. Thus, because a complete system is already in place, it is relatively fast and easy for these partners to reorganize into ACOs. In fact, because the ACO concept was in many ways inspired by effective integrated delivery systems, such as Geisinger Health System and Fairview Health Services, ACOs that follow this model have been able to gain a first-mover advantage in the new sector. Adapted integrated delivery system ACOs are typically strongest in the area of organizational alignment— that is, the range of partners in the ACO, the parameters that govern their relationships, and the structures and processes that support them. In most cases, significant alignment existed before the ACO initiative began. They are also experienced in
the management of medical risk and are comfortable with assuming a portion of the financial risk associated with it. The most common large-scale change that adapted integrated delivery system ACOs have undertaken is the implementation of financial incentives aimed at supporting enhanced accountability for patient outcomes. This is the area in which adapted integrated delivery system ACOs are typically lacking, and it is where participation of payors is most useful. Often, the main role of payors is to provide financial incentives in the form of performance bonuses or shared savings that support these ACOs as they seek to take responsibility of the total cost of care of their patient populations. The provider partners in these ACOs are also looking to payors to provide risk management assessment, data analytics, and, in some cases, disease management. Of course, payors also provide an established patient base. In some cases, the adapted integrated delivery systems in the ACO space have also taken steps to incorporate
elements of accountability to patients and care redesign into their operations. Based on our interviews and research, it appears that the leaders of the adapted integrated delivery system ACOs recognize the importance of these two key elements for long-term success and are planning to pursue more fundamental changes in these areas. The following are examples of adapted integrated delivery system ACOs: Norton Healthcare/Humana: The partnership between insurer Humana, Inc. and Norton Healthcare, one of the five participants in the ACO Pilot Project sponsored by The Engelberg Center for Health Care Reform at the Brookings Institution and The Dartmouth Institute for Health Policy and Clinical Practice, is a good example of this model. Norton is an integrated delivery system—a not-forprofit hospital and healthcare system that already has a 44 percent market share in its local area. Humana has a base of local employer plans to populate the ACO. Humana initiated this ACO when it began exploring the concept with
Because the ACO concept was in many ways inspired by effective integrated delivery systems, ACOs that follow this model have been able to gain a first-mover advantage in the new sector.
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Brookings-Dartmouth in 2008. In early 2010, it announced it would partner with Norton Healthcare, which runs five hospitals and 12 clinics in the Louisville, Ky., area. As is typical in this model, the payment structure of the ACO includes a savings plan that will be shared by the provider, payor, and employers. This initiative used prospective patient attribution (i.e., pre-defined allocation of patients to an ACO) to enroll 10,000 members for pre-existing Humana employer plans. Further, the ACO targeted the following areas for improvement and savings: • Preventive screenings, tests, and vaccinations • Chronic illnesses management • Use of generics • Assessment to determine appropriate levels of care The initiative is in its pilot phase and has not yet reported results. However, Humana has stated that it plans to use its experience with this pilot to develop additional ACOs with provider partners in other regions.iv
Additional in-market examples of adapted integrated delivery system ACOs include the following initiatives (see Exhibit 1, page 6, for details): • Blue Cross and Blue Shield of Illinois and Advocate Health System • Monarch Healthcare, HealthCare Partners, and Anthem Blue Cross and Blue Shield in Los Angeles and Orange County, Calif. Model 2: Virtually Integrated ACOs The second ACO model is composed of multiple providers organizing in association with a payor, who contributes the financial incentives that support collective accountability for patient health outcomes and the technological infrastructure used to connect the disparate providers. There are two variations of this model, which we will describe separately: one in which the providers include mainly PCPs and one in which the provider set includes a broader range of partners including specialists, hospitals, and other care settings. Primary Care–Focused Virtually Integrated ACOs: The primary care– focused virtually integrated ACO is designed between a payor and care provider(s) with an emphasis on preventive care. Often these initiatives are built on the chassis of a pre-exist-
ing patient-centered medical home (PCMH), pre-existing pay-for-performance contracts with physician groups, or other settings with an emphasis on primary care interventions. One strength of these ACOs is ease of governance, because only PCPs and payors are involved. Another strength of the model is its primary care redesign potential, due to its evolution from formats, such as PCMHs, that are characterized by strong care coordination and the extensive use of quality data. The primary weakness of this model derives from the limited range of care settings included in these ACOs. While the primary care focus means a larger slice of the savings for the ACO's primary care providers and payor partners, the overall savings is likely to be smaller because specialists and hospitals have little or no incentive to participate. These initiatives must also devote a good deal of attention to determining how they will align their ACOs with external care settings and in developing a payment infrastructure, which typically already exists in hospitals but not in physician groups. Finally, primary care providers are typically reluctant to undertake financial risk. While many physician groups are signing contracts with
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Exhibit 1 Examples of Adapted Integrated Delivery System ACOs
PROVIDER STRUCTURE Large health care system: five hospitals and 12 clinics in Louisville area
PATIENT POPULATION 10,000 Humana Participating members
PAYMENT STRUCTURE Shared savings between provider, payor, and employers
PATIENT ATTRIBUTION Prospective
EARLY RESULTS/ PROGRESS - Early stages of implementation - Identified areas of emphasis include: - Targeting improvements in use of preventive screenings, tests, and vaccinations - Better coordination in management of chronic illnesses - Appropriate use of generics - Improved access to appropriate level of care - Announced on 10/6/2010 - Contract effective from 1/2011 to 12/2013
Norton Healthcare— Humana
- Participant in the BrookingsDartmouth ACO Pilot Project - Humana plans to continue developing more ACO models by partnering with providers in other regions
Advocate— Blue Cross and Blue Shield of Illinois (BCBSIL)
Largest Integrated PPO and health system in HMO Illinois, operating Members 200+ care sites across metropolitan Chicago, including 10 acute care hospitals, two children's hospitals, four Level I trauma centers, a home healthcare company, and a large medical group - Monarch HealthCare: IPA with more than 2,500 independent, privatepractice physicians - HealthCare Partners: more than 1,200 employed and affiliated PCPs, and more than 3,000 employed and contracted physicians overall PPO members in Los Angeles and Orange Counties
- Limits on annual Prospective FFS rate increases with shared upside savings - Total global risk for HMO products - Shared upside and downside on per member/monthbased medical cost trend for PPO products
Savings measured by Advocate's performance compared to other BCBSIL contracting network providers
Monarch HealthCare— HealthCare Partners— Anthem Blue Cross and Blue Shield
- Initially: Shared savings - Some form of global capitation going forward
Currently unknown
- Participant in the BrookingsDartmouth ACO Pilot Project - Led by the two physician organizations
- Five-year pilot launched in January 2011
Source: Booz & Company research, company press releases, Becker's Hospital Review, Brookings-Dartmouth ACO Learning Network
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performance-linked bonuses, they are less likely to enter gain-sharing agreements that include downside risk because they control a smaller percentage of total medical costs and do not have the financial wherewithal to withstand potential catastrophic outcomes. Aetna Medicare Advantage: A good example of the primary care–focused virtually integrated ACO is Aetna's collaboration with providers in its Medicare Advantage program. Aetna has partnered with 36 primary care practices serving 20,000 of its Medicare Advantage plan members. The pilots, which Aetna began launching in 2007, combine personalized care management with electronic patient and evidence-based treatment information to support participating PCPs. Its payment system includes performance-based incentives for doctors, as well as compensation for the additional time and resources that PCPs devote to the ACO's members.vi Aetna provided significant assistance for care delivery redesign. It used ActiveHealth Management's CareEngine System to identify gaps in patient care and nurse case managers to work with doctors in the primary care practices, assist in coordinating patient care, and help members set up personal health records. Aetna also helped the physician groups coordinate with a range of other providers, from specialists to hospitals to community social services, including government agencies for in-home
services, home-delivered meals, and caregiver support. The initiative has been successful. Participating providers are meeting performance goals, such as follow-up office visits within 30 days of discharge and two annual office visits for certain chronic patients. In addition, a September 2010 Commonwealth Fund study showed significant reduction in "duplicate/ unnecessary" services (members in this pilot consumed 43 percent less acute hospital care in 2010 compared to Medicare recipients not in the pilot). A Health Affairs case study also computed an estimated 22 percent reduction in medical costs due to an increase in hospice election and a reduction of acute care services use, compared to a non-participating control group. Finally, physicians participating in the program discovered time savings for themselves and their office staff.vii Aetna continues to work with a variety of providers to create ACOs based on several models, including for their commercial members. In addition, they are leveraging the capabilities of their ActiveHealth Management subsidiary to assist providers with infrastructural capabilities, such as data management and case management. Additional in-market and announced examples of primary care-focused virtually integrated ACOs include the following initiatives (see Exhibit 2, page 8, for details):
• Roanoke, Va.-based Carilion Clinic, with payors to be determined • Tucson Medical Center and UnitedHealthcare Western States Health Plan Full-Spectrum Virtually Integrated ACOs: The full-spectrum virtually integrated ACO involves collaborations between a payor and a broader spectrum of providers than just PCPs, often including specialists, hospitals, and other community care settings. Often, these initiatives are emerging in markets with progressive providers who do not necessarily want to become fully integrated but want to participate in the shared savings that ACOs promise. In this model, the role of the payor is to provide infrastructure assistance and financial incentives for accountability of performance. Payors also help delineate how payment and shared savings will be distributed among participating providers. The inclusion of a wider range of providers enables more comprehensive and effective care delivery redesign, with associated potential for higher savings. Hospitals, for example, can use a variety of additional levers to increase healthcare value that physician groups typically cannot, such as limits on unnecessary testing, development of OBS (observation) units to avoid admissions, enhanced follow-up, and
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Exhibit 2 Examples of Primary Care–Focused Virtually Integrated ACOs
PROVIDER STRUCTURE 600+ physicians in a multi-specialty group practice and eight not-for-profit hospitals
PATIENT POPULATION 60,000 Medicare patients
PAYMENT STRUCTURE Shared savings and financial incentives for employed physicians based on cost and quality performance
PATIENT ATTRIBUTION Currently unknown
EARLY RESULTS/ PROGRESS Anthem, CIGNA, United Healthcare, and Southern Health have expressed interest in partnering
Carilion Clinic
BrookingsDartmouth to provide technical assistance for pilot set up
- Large medical UnitedHealthcenter and affiliated care— physician groups Tucson - ACO includes Medical Center about 12 employed physicians and 50-60 independent physicians
Commercial, managed Medicaid, and Medicare FFS patients
- Shared savings Retrospective - PCPs to receive monthly care coordination fee and bonus for performance based on clinical quality factors - Future might include capitation model
- Based on a PCMH pilot financed by United with major employers such as IBM and Raytheon - United provides data and IT infrastructure - DartmouthBrookings provides "external manager" payment structure design
Preliminary results: - 4.5% decline in necessary emergency department visits - 22.5% drop in unnecessary emergency department visits - Some self-funded employers have expressed interest in joining
Aetna— Medicare Advantage
Aetna-driven ACO model created with 36 participating primary care practices
20,000 Aetna Performance Medicare Advantage (quality)-linked members incentives for facilities and physicians
Currently unknown
- Uses ActiveHealth's - Aetna began CareEngine System testing in 2007 to identify gaps in - Nearly all participatpatient care ing medical groups - Aetna helped form met performance the care team: targets, including doctor groups follow-up office paired with special- visits within 30 ists, hospitals, and days of discharge community social and two office services visits per year for certain chronically ill patients - Reduced acute hospital care by 43% compared to unmanaged Medicare Advantage members, according to a Commonwealth Fund study - Health Affairs study revealed an increase in hospice election and a decrease in acute care services, estimated to reduce medical costs by 22% (compared to control group)
Source: Booz & Company research, company press releases, Becker's Hospital Review, Brookings-Dartmouth ACO Learning Network
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ensuring that all providers have test results readily available. In addition, these initiatives operate along the entire care continuum, enabling them to take greater accountability for overall patient wellness. Finally, hospitals' payment, reporting, and IT infrastructure better enables the transition to a fully-functioning ACO, and, typically, they also have the ability to take on greater financial risk than physician groups. However, full-spectrum virtually integrated ACOs face much larger organizational challenges. These include often difficult decisions on leadership structure, process designs to determine payment and savings distribution among participating providers, and design decisions, such as which specialists to include and how leakage will be handled. Further, although these ACOs are willing to assume a higher portion of the risk, few are interested in managing the total cost of care of patient populations. Hill/CHW/BSC: The partnership of San Ramon, Calif.-based Hill Physicians (with 520 MDs), Catholic Healthcare West (with four hospitals), and Blue Shield of California, serving the California Public Employees' Retirement System (CalPERS), is another good example of this model. The three partners—hospital, physi-
cians, and payor—comprise an adapted integrated ACO in the Sacramento area, one of the earliest and most ambitious entrees in the sector. The initiative, the planning for which dates back to 2007, was officially announced in April 2009. Prospective enrollment was opened in fall 2009, and approximately 40,000 CalPERS members in the Sacramento region, who were already in the Blue Shield HMO and receiving primary care through Hill, joined the ACO. The pilot was launched in January 2010. The partners' goals for the pilot include a full range of objectives, including: • Reducing the cost of healthcare trend to 0 percent in aggregate for members • Building enrollment as a means of increasing the partners' market shares • Creating a sustainable model for continuous improvement in cost, quality, and service that can be expanded to other geographic markets To achieve these goals, the ACO pilot is employing integrated processes, data, and quality metrics, as well as
clinical best practices and member and physician engagement. Further, incentives are aligned so that each partner shares in the savings but is at financial risk if targets are not met. This pilot is one of very few that has announced results, all of which are encouraging, according to executives within the partner organizations.v Results include: • Membership growth by more than 2,500 members since open enrollment • A 30 percent reduction in re-admissions • A reduction in average length of stay by 0.72 day for all admissions • A 7.6 percent reduction in ER/ Urgent Care admissions • A 15 percent reduction in total bed days Vermont ACO: Another example of the full-spectrum virtually integrated ACO is the Vermont Accountable Care Organization, which is spearheaded by Vermont's Health Care Reform Commission. Its participants include three payors (Blue Cross and Blue Shield of Vermont, MVP Health Care, and CIGNA) and
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provider partners including three community hospitals (Northeastern Vermont Regional Hospital, Southwest Vermont Medical Center, and Springfield Hospital). Other stakeholders include the state hospital association, state medical society, the business community, state health reform staff, the Vermont Department of Health, the state legislature, and the Department of Banking, Insurance, Securities, and Health Care Administration. In 2008, Vermont's Health Care Reform Commission began examining how ACO-like models could be piloted as part of the state's comprehensive health program. With assistance from the Dartmouth-Brookings ACO Learning Network, three pilots are now being implemented across the state. The payors in these pilots are providing financial incentives designed to support collective patient accountability, and a common payor database to determine the allocation of payments among participating providers. Global budgets for each ACO are based on historical trends and adjusted for patient mix, with cost and quality incentives for providers to drive accountability. The level of risk undertaken by providers varies based on their level of sophistication and their degree of integration. "Newly formed entities with little experience managing care or risk" have entered into shared savings agreements,
while more sophisticated providers have taken on more risk in partnerships with two-sided gain sharing, in which providers reimburse payors for a portion of above-target medical expenses but also receive a larger portion of any savings.viii To prevent underutilization of medical services, performance measurement is not only limited to medical expenses but also includes clinical process measures, outcome measures, and patient experience data. Patient attribution in the Vermont ACO pilots follow a retrospective methodology developed by Dartmouth, in which patients' primary care physician usage patterns are analyzed. Since primary care physicians are used for patient assignment, they can only participate in one ACO, while specialists and hospitals are allowed to partner with multiple ACOs. The goal of the Vermont pilot program is to "achieve delivery system reform based on the development of a true community health system that both improves the health of the population it serves and manages medical costs at a population level," in which providers are required to manage the "full continuum of care settings and services for its assigned patients."ix Toward this end, the pilots are using the patient-centered medical home model as the basic building block of care coordination. Community health
teams that support approximately 20,000 patients and typically include a nurse care coordinator, mental health staff, and nonclinical community health workers are being developed. The Vermont ACO pilots are expected to become operational in 2011. Additional examples of in-market and announced full-spectrum virtually integrated ACOs include the following (see Exhibit 3 for details): • CIGNA Healthcare's Collaborative Accountable Care initiative, which includes separate ACOs with providers in various regions of the country, including ProHealth Solutions in Connecticut, Holston Medical Group in Tennessee, and Medical Clinics of North Texas • Dartmouth-Hitchcock Health, the largest healthcare provider in New Hampshire, and Anthem Blue Cross and Blue Shield Model 3: Provider-Led ACOs The third ACO model is formed and led by provider group collectives. These ACOs are typically composed of physicians, with or without hospital participation, and often they substitute payors with third parties that provide support functions, such as middle office operations and claims. Due to the lack of payor involvement in many provider-led ACOs, payment reform is often not a highlight of
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Exhibit 3 Examples of Full-Spectrum Virtually Integrated ACOs
PROVIDER STRUCTURE Large primary care groups, multispecialty groups, and integrated delivery systems of physicians and hospitals
PATIENT POPULATION Members in all types of products, including PPO
PAYMENT STRUCTURE - Bonus for meeting performance targets (quality and lower costs) - Eventually expected to move toward two-sided gain sharing
PATIENT ATTRIBUTION Retrospective, based on CIGNA analysis of which PCP last treated the patient
EARLY RESULTS/ PROGRESS - CIGNA expecting savings from efficiencies - No results available yet
CIGNA Collaborative Accountable Care
- ACO enabled by CIGNA - CIGNA provides claims data and informatics to identify high-risk patients, funds nurses for outreach programs, and produces management reports - Provider practices to determine care redesign opportunities Anthem and DartmouthHitchcock to collect and analyze data to "identify and implement efficiencies and improvements in healthcare delivery"
- DHMC is New Dartmouth Hampshire's Hitchcock only academic Medical Center medical center (DHMC)— - 900-physician Anthem Blue group practice, Cross and with strong Blue Shield background in ACOs
urrently unknown C (Anthem members)
Dartmouth Hitchcock to manage cost and quality of care
Currently unknown
- ACO yet to be implemented - DartmouthHitchcock has earned $13M to date in the Medicare Physician Group Practice Demonstration, the model for ACOs Early results include: - Added 2,500+ members since open enrollment - 30% reduction in readmissions - Reduction in average length of stay by 0.72 day - 7.6% reduction in ER/Urgent Care admissions - 15% reduction in total bed days - Started in 2008 to "achieve delivery system reform based on the development of a true community health system that both improves the health of the population it serves and manages medical costs at a population level"
Blue Shield of California (BSC)— Catholic Healthcare West (CHW)— Hill Physicians
- CHW: large hospital system - Hill Physicians: large physician multi-specialty group practice
About 40,000 California State employees in Greater Sacramento
Shared savings
- Prospective - Initiated a program to identify and enroll patients who have gone out of network
Hill and CHW are collaborating on alternatives, including pursuing evidence-based approaches to therapy and treatments prior to recommending surgery
Vermont ACO Pilot
Three Vermontbased ACO pilots
Currently unknown
Variable shared savings model based on level of provider's integration and sophistication: - One-sided shared savings (no risk) for new providers - Shared savings with risk for more sophisticated providers
Retrospective, using historical patient patterns
- Key stakeholders: Vermont's three major commercial insurers, three community hospitals, a tertiary hospital, state hospital association, state medical society, business community, state health reform staff, Vermont Department of Health, the legislature, and the Department of Banking, Insurance, Securities, and Health Care Administration - Pilot created with assistance from DartmouthBrookings
Source: Booz & Company research, company press releases, Becker's Hospital Review, Brookings-Dartmouth ACO Learning Network
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the structural design. As such, many of these ACOs continue to be built around an FFS chassis, and they are focused on capturing shared savings without necessarily sharing gains with payors. While most of these ACOs are based on contract arrangements among a community of providers, they can also form as the result of acquisition. For instance, in 2010, St. Joseph Mercy Health System acquired IHA, a 150-physician organization in Ann Arbor, Mich., with the express intent of forming an ACO. IHA plans to recruit independent doctors and double in size.x Unsurprisingly, these provider-led ACOs tend to focus more heavily on care delivery improvements than any of the other models. In particular, they seek to coordinate care delivery across multiple provider settings, including aggressive management of the referral process, patient information share, and outcome tracking across the care continuum. This is a major strength of providerled ACOs: Because providers tend to have better insight into care process inefficiencies and physician practice motivators, they can generate the savings needed to compensate for lost revenue and increased effort, and modify behavior accordingly. The main obstacle that provider-led ACOs face is the lack of organizational expertise and bandwidth to engage in functions that traditionally fall within the purview of payors, such as network, medical, and
financial risk management. Provider executives leading the charge on provider-led ACOs recognize the challenge of defining the correct patient population for inclusion in an ACO, as well as the challenge of evaluating care outcomes across a system of providers in an actionable manner. Significant organizational efforts in governance and partner selection are thus required for these ACOs to succeed. A few sophisticated provider-led ACOs engage third-party vendors to oversee these important functions, as is the case with United Outstanding Physicians in Michigan. United Outstanding Physicians: United Outstanding Physicians (UOP), a Dearborn, Mich.-based physician organization with approximately 1,000 private and employed physicians, launched its ACO in 2010 in partnership with Automated Benefit Services Inc., a third-party administrator that will process medical claims; Continuum Management Services, an information technology and medical management company; and CIG Corp., a financial and regulatory management company. Under the UOP ACO, physicians are individually responsible for improving the outcomes and affordability of care provided to patients. They are incented through a unique stockbased reimbursement system, with 1,020 shares of stock distributed to 720 physicians. The distribution ratio reveals an emphasis on preventive care and recognizes the greater influ-
ence and responsibility of primary care physicians in providing it: 291 primary care physicians were each given two shares of the ACO stock, while specialists were each given one share. The remainder of the 60,000 shares will be available to new physicians or retained by the company. UOP was founded on the basis of strong physician leadership to monitor and improve peer performance and has continually emphasized evidence-based medicine as a tool for improving utilization performance. Physicians who participate in the UOP ACO will have access to electronic prescribing and electronic registry technology to better track their patients. Further, the ACO expects to contract with several hospitals for inpatient care and has approached healthcare systems in its primary service area in western Wayne County, including Oakwood Healthcare, St. Mary Mercy Livonia, Garden City Hospital, Detroit Medical Center, and Henry Ford Wyandotte. Additional in-market and announced examples of provider-led ACOs include the following initiatives (see Exhibit 4 for additional details): • Hyannis, Mass.-based Cape Cod Healthcare, Inc. • Optimus Healthcare Partners, a joint venture of two independent practice associations in New Jersey: VISTA Health System and Central Jersey Physician Network
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Exhibit 4 Examples of Provider-Led ACOs
PAYMENT STRUCTURE Shared savings; specifics not disclosed
PATIENT ATTRIBUTION Currently unknown
United Outstanding Physicians (UOP)
Detroit-based UOP patients physician organization (with more than 1,000 physicians) partnering with several local health systems for inpatient care
- United Outstanding Goal: contract with Physicians will man- Medicaid or private age the ACO and payors as an ACO doctors will own it - Designated 1,020 stocks to 720 physicians: - 291 PCPs given two shares each - Specialists given one share - Remainder shares kept for new physicians - Contracts signed with: - Third-party administrator that will administer medical claims (Automated Benefit Services) - Medical management company (Continuum Management Services) - Financial management company (CIG Corp) - Two organizations - Objectives: to be formed: to strengthen - Physician Orgathe working nization (PO): relationships physician-owned, among local physicianphysicians and governed hospitals, and to - Physician-Hospiimprove quality, tal Organization efficiency, and (PHO): joint vencoordination of ture of the PO patient care and Cape Cod - Long-term goal: Healthcare sysevolve into an ACO tem—to pursue risk contracts with joint governance - CCNS to contribute ACO knowhow and IT infrastructure - ACO (Optimus Healthcare Partners) will enroll physicians from combined 650 membership of VISTA and CJPN before expanding to rest of New Jersey - ACO to adopt evidence-based medicine, care coordination, and whole-person orientation Goal: to provide an alternative to hospitals or larger groups for physicians who wish to remain independent
Cape Cod Healthcare
Two hospital, Currently unknown physician–owned system partnering with local Cape Cod physician community
Contract with Caritas Christi Network Services (CCNS), a large Boston-based physician network, to manage patient budgets and healthcare quality
Currently unknown
Optimus Healthcare
Two IPAs: Vista Currently unknown Health (Summit) and Central Jersey Physician Network
"New compensation models rewarding good outcomes"
Currently unknown
Source: Booz & Company research, company press releases, Becker's Hospital Review, Brookings-Dartmouth ACO Learning Network
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STAKEHOLDER IMPACT AND COMPETITIVE IMPLICATIONS OF ACOs
ACOs offer both volume and margin stabilization opportunities for procedural specialists. Specialists who are facing impending volume declines, driven by more aggressive utilization controls in the post-reform environment, can participate in ACOs to gain new volume. Such participation will also help them stabilize their margins by gaining a share of the ACO savings that would likely accrue with or without their participation. In a time when shifts in the healthcare model will make volume increasingly difficult to generate, ACOs present a valuable opportunity for hospitals to preserve and expand their volume. Hospitals that take leading roles in ACOs can gain market share, enhance their negotiating positions vis-à-vis payors, and develop key capabilities such as data analytics. ACOs can also be used to support the vertical integration efforts of hospitals; they can use them as "burning platforms" to acquire physician groups and a means of establishing direct contract
with self-insured employers, cutting payors out of the process. ACOs represent an opportunity for first-movers and low-cost, high-quality providers to define their brands and build valuable equity in the local market. Such brands will be key to creating and gaining market share in the post-reform era. Finally, over the long term, ACOs can enable providers to streamline their claims processing and eliminate obstacles to reimbursement. This can improve their cash flow and reduce their dependence on revenue-cycle management vendors. Provider risks: The primary ACO risk for providers is that they will lose volume if they cannot successfully position themselves in this emerging market. The ACO market scenario is based on the assumption that the total amount of care delivered to patients will decrease as the quality of care improves. This suggests that there will be a significant amount of
What is the potential impact of the ACO construct on the competitive positions of providers and payors? ACO Impact on Providers Provider opportunities: PCPs can derive significant benefits from ACOs due to their role as lynchpins in ACO structural design. This position increases the negotiating power of PCPs relative to specialists, hospitals, and payors. In addition, ACOs create the opportunity for PCPs to gain reimbursement or subsidies for medical management work, which many physicians already do or would like to do but cannot afford to undertake.
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unused capacity in the health system (e.g., specialists, inpatient settings). As a result, providers that are late or unsuccessful in pursuing ACOs could potentially lose even more volume as they lose market share to first-movers and low-cost, high-quality providers. Another major potential challenge for providers is the risk that ACOs may not even provide the economic returns necessary to support their participation. For instance, Steven Lieberman, a Brookings Institute visiting scholar, concluded that the shared savings plan in the Brookings-Dartmouth ACO
model, which is being piloted in five sites, may be inadequate. Lieberman calculated that the shared savings could constitute a significant portion of the primary care budget, but as little as 2 percent of the total hospital and specialist budget—a percentage that may not be enough to compensate them for the revenue reduction from decreased utilization and infrastructure investments associated with ACOs.11 There are also potential drawbacks in the various ACO payment models. Shared savings is particularly effective as a means to flatten the cost curve
in areas with high rates of healthcare inflation. However, in areas that are already relatively efficient or have lower rates of inflation, such saving may not materialize (see Exhibit 5).xii Further, since the U.S. healthcare system is largely built around a volume-based business model, there is a risk that ACOs and their associated care redesign strategies, such as prevention and lifestyle management, could reduce the economic viability of hospitals and large provider groups. "Most hospitals are carrying huge fixed cost overhead and we're talking
Exhibit 5 Varying Impact of Shared Savings Models
IMPACT OF "SHARED SAVINGS" MODELS IN HIGH-SPENDING VS. LOW-SPENDING REGIONS Savings Potential
Healthcare Spending
High-Cost, High-Inflation Regions
Low-Cost, Low-Inflation Regions
No reward for lower spending than other regions if it is higher than previous levels
Source: Center for Healthcare Quality & Payment Reform
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about reducing the patient population," said one provider executive. "[It's like] asking them to root for a weak flu season as opposed to for a strong one… it's a sea change."xiii In an ACO environment, providers will have to shift from a volume-based to a margin-based business model. One reason some ACO pilots have focused on PCPs is that these providers are in some ways better positioned to make this shift due to the fact that they currently provide services such as preventative care and disease management, albeit sub-optimally, with no reimbursement. Hospitals and other large providers will need to actively pursue ways to develop more dynamic modes of operation in which they can scale up or down based on demand and provide the appropriate level of care based on patient needs. Finally, to successfully develop and operate ACOs, providers will need to lead change within the organization and across stakeholders; drive the commitment to reduce costs, improve quality, and accept accountability for results; and identify, invest in, and develop a host of new capa-
bilities required to successfully plan and operate ACOs. Until ACOs are fully defined and their guidelines are established, the full extent of these capabilities is not known. Even when the capabilities are known, providers typically do not possess and have little experience with them (see "ACO Capabilities Needed by Providers"). ACO Impact on Payors Payor opportunities: First and foremost, ACOs offer payors an opportunity to reduce medical costs from more efficient utilization, lower unit costs, and improved outcomes. With the increasing willingness of providers to accept two-sided gain sharing, ACOs also offer payors an opportunity to transfer some of the financial risk of care when incurred expenses exceed agreed-upon total cost-of-care amounts. Although payors will continue to bear the burden of insurance risk, providers in ACOs (and especially those in an adapted integrated delivery model) are assuming an increasing share of the clinical risk. Second, although helping to establish ACOs will likely cause payors' admin-
istrative costs to rise in the short-term, over the long-term, there may be an opportunity to reduce these dramatically. Incremental savings could accrue from consolidated billing based on the collectivization of providers and treatments that currently require separate payments. And eventually, if the shift to global payment is successful, ACOs could help eliminate a major portion of back office functions. Third, ACOs offer payors an opportunity to capture new revenue streams by packaging and selling medical management and reporting capabilities (especially for care delivered outside the ACO network). These include opportunities to create new businesses to assist ACOs with population health management, overall administration, and turnkey solutions. Payor risks: The primary ACO risk for payors relates to their relationships with providers and the associated threat of marginalization in the marketplace. Since payors will compete to contract with ACOs that offer the lowest total cost of care, it will be more difficult for all payors to
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ACO Capabilities Needed by Providers To successfully develop and operate ACOs, providers will require five broad sets of capabilities. These include: Technological infrastructure capabilities, including tools for outcome measurement and reporting, baseline databases from which to evaluate savings, analytics capable of mining clinical data for care delivery redesign insights, health information technologies supporting electronic medical and patient health records, and claims processing. Risk management capabilities, including population health management and actuarial cost assessments, savings/income distribution infrastructure, and predictive trend analysis and indicators. Care coordination, support, and wellness capabilities, including integrated care management, care leakage management, patient engagement tools (especially for non-compliant patient populations), and care coordinator/ navigator provisioning. Sales and marketing capabilities, including ACO product development, payor and employer-facing sales force development and management, and promotions and brand management. Finance and business development capabilities, including contract negotiation skills, and compensation design and management.
maintain relationships with low-cost, high-quality providers. This risk could be exacerbated if patient attribution processes and regulations prevent physician groups from aligning with more than one ACO, in which case payors that are unable to secure key partnerships could be cut out of low-cost ACOs or, in cases in which a provider group dominates a specific market, the ACO market itself. To the extent that ACOs drive quasiprovider consolidation, they are also likely to increase the negotiating leverage of providers. That said, this risk is expected to be countered to some extent by the expansion of government oversight on the part of the Federal Trade Commission and Department of Justice, which will likely monitor rates closely for power abuses associated with provider consolidation. The central role that providers can play in establishing ACOs can also create a risk for payors. Providers who take a lead in ACOs could gain an advantage by, for instance, setting reimbursement standards and dictating the amount of payor infrastructure that is used
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versus outsourced in ACOs. This threat is increased in markets where there is already a substantial level of care delivery integration and payors are poorly positioned to provide the "connective tissue" for ACOs. However, the worst-case scenario would entail provider-led ACOs disintermediating payors entirely. Large, self-insured employers, for example, could join ACOs directly, obviating the need for payors. If the health insurance exchanges mandated by the reform act are successful and they actively
set the terms of benefit packages, they could contract directly with potentially lowest-cost ACOs, leaving out traditional payors. Finally, provider-led ACOs could eliminate external payors by developing or outsourcing their medical management and administration functions, and using alternate payment methodologies. In fact, specialized vendors are already seeking to assist providers with the technological infrastructure, risk-management, and medical management capabilities they will need to operate ACOs (see "External Vendors in the ACO Space").
In summary, ACOs represent a new basis of competition for payors and providers. As ACOs gain scale— indeed, if they are to successfully gain scale—they will accelerate the shift to a healthcare system that runs on a margin-based financial model in which both payors and providers will prosper by becoming ever more collaborative in their drive to improve the quality of care and reduce its total cost. These goals will be supported by a high-quality, cost-effective care delivery model that is patient-centric in its approach (see Exhibit 6).
Exhibit 6 Competitive Implications of ACOs
THE BASIS OF COMPETITION From To
Revenue - Focus on higher volumes in an FFS environment Competition - Payors and providers debating approvals and negotiating contract rates, with general lack of trust Institution-centricity - Limited exchange of data; disjointed patient outreach State-of-the-art care - Marketing differentiation built on newest technology and latest procedure, even if little clinical difference
Margin - Focus on higher profitability (e.g., by reducing "controllable costs") Collaboration - Payors and providers working together to create true healthcare value, with mutual "skin in the game" Patient-centricity - Full transparency; increased patient engagement High quality, cost-effective care - Marketing differentiated on quality of care supported by results at a better price
Source: Booz & Company
Booz & Company
External Vendors in the ACO Space A review of the market reveals the following external players offering solutions in the ACO space: Ingenix, a subsidiary of UnitedHealth Group: Ingenix offers "comprehensive data analytics and reporting capabilities to deliver insights that inform strategies to improve patients' health outcomes" to providers. In February 2011, Boston-based Beth Israel Deaconess Physician Organization announced it was using the Ingenix Impact Suite software in a pilot program that will integrate performance measurement data from its 1,800 providers and physicians and analyze it for insights aimed at improving medical outcomes. McKesson Corporation: McKesson provides advice and technology solutions designed to support payment reform strategies. The company, which is actively engaged with a number of providers in the ACO space, is seeking to offer comprehensive solutions for provider-based ACOs, including data and analytics, support for health information exchanges, and patient engagement support. Treo Solutions: Troy, N.Y.-based Treo Solutions, in association with 3M Health Information Systems, offers an ACO solution that includes analytics, strategies, and technologies to redesign payment structures. Its aim is to help align payment to quality outcomes, support the move to patient-centered episode and bundled payments, and achieve accountable care. Zynx Health: Zynx Health, a subsidiary of Hearst Corporation, is a developer of evidence- and experience-based clinical decision support solutions designed to improve the quality, safety, and efficiency of patient care. In October 2010, Zynx announced the launch of a pilot program with five healthcare provider organizations, including Cedars-Sinai Medical Center in California, Memorial Hermann Healthcare System in Texas, Northwest Hospital & Medical Center in Washington, St. Joseph Health System in California and Texas, and WellStar Health System in Atlanta. The pilots will use the company's service and software solutions to assess existing clinical processes and workflows, determine how they can become more efficient and effective, and identify potential barriers to clinical decision support adoption.
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ties: capabilities that support accountability to patients; capabilities that support care redesign; and capabilities that support organizational alignment. "Accountability to patient" capabilities: To succeed, ACOs must demonstrate their value to patients. HMOs lost favor in many markets in large part because they were perceived by consumers as sub-optimal health plan options. In some cases, this perception was based on false information; to this day, some HMOs enjoy higher patient satisfaction and achieve better outcomes than their PPO counterparts. Yet, as the health insurance market generally becomes more retail-oriented, patient perception will become even more important in determining the success—and failure—of insurance products. For this reason, it is crucial that any health plan embarking on the development of an ACO emphasize the importance of accountability to patients and communicating the benefits of ACOs to consumers. Doing so is critical both to the success of the ACO and, by extension, to the success of any strategy built around ACOs. So how should accountability to patients be pursued? There are three potential means for establishing accountability to the patient: 1. Incorporate performance on patient experience metrics in financial incentive structures and creatively pursue additional ways to understand and incorporate patient input into ACO design and associated product development.
What issues must payors consider and what capabilities must they develop to capture the opportunities in ACOs? Most payors, including national and regional plans and the Blue Plans, are already moving to capture the opportunities and counter the competitive challenges inherent to ACOs. They are navigating the changing basis of competition that ACOs represent by pursuing increasingly collaborative initiatives with providers. They are preparing for the shift to margin-based financial model, as well as the increased negotiating pressure that ACO development could bring to bear, by selecting provider partners who can utilize significant market shares and a deep understanding of local markets to generate meaningful savings. They are also striving to deliver strong technological and data analytics capabilities to the ACO space to support a primary care– driven delivery model that is focused on accountability to patients and to counter the risk that someone else will set the standards in this emerging sector. Three ACO Capability Sets To further these efforts, payors should consider the following issues and develop three sets of ACO capabili-
In this nascent stage of development, most ACOs are not yet adequately measuring patient experience. While most ACO pilots cite improved patient experience as a program objective, few feature experience metrics in a prominent way. For example, only one of the approximately 100 performance metrics proposed by the National Committee for Quality Assurance (NCQA) for ACO accreditation directly measures patient experience. xiv Without targeted assessment, many dimensions of the patient experience that lie outside quality and affordability metrics will be unaccounted for, including experience of facilities and processes (e.g., care environment, wait time, administrative efficiency), emotional support (e.g., communication, empowerment, compassion), and overall brand impression (e.g., brand loyalty, willingness to refer). 2. Dramatically increase the transparency and ease of use of consumer-facing provider evaluation systems. Payors usually have a significant market advantage in this regard due to the breadth and depth of the provider and patient data they possess. The development and expansion of existing transparency systems should start immediately so that consumers have time to become familiar with them before ACOs become more dominant in the marketplace. Toward this end, payors should actively market the transparency tools and the benefits and successes of ACOs. If ACOs do achieve the superior outcomes that their framers envision, effective marketing coupled
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with robust and accessible transparency systems will enable patients to become immediately aware of ACOs' successes and proactively choose high-performing ACOs over other options. 3. Balance the benefits of a closed network with patient desire for open networks. A third important element of accountability to patients is establishing and maintaining the balance between closed-network structures that facilitate performance measurement and opennetwork access that patients prefer. This aspect has become an important consideration as CMS debates the tradeoffs of prospective patient assignment to ACOs versus retrospective attribution. Notwithstanding the question of attribution, to avoid the pitfalls that weakened the reputation and appeal of HMOs, ACOs should allow patients to access providers outside the ACO and use other benefit design strategies as an alternative to closed networks. Payors can employ a broad range of benefit design strategies. These
strategies include differential copayments or coinsurance for care inside and outside the ACO, the addition of auxiliary services (such as a populated and comprehensive Patient Health Record) for those who receive the majority of their care within the ACO, and the broader use of valuebased benefit design, such as lower co-payments for evidence-based services that promote efficiency (e.g., X-rays versus CT scans as an initial diagnostic tool.) Value-based benefit design can also help tackle the ongoing challenge that physicians face in navigating the sometimes conflicting goals of meeting patient expectations and delivering evidence-based care. The rise of directto-consumer advertising and online information has led to an increasingly informed and, in many cases, demanding patient population. However, patients are less informed about the risks of overutilization. A renewed emphasis on shared decision making, and a commitment on the part of caregivers to communicate the relative risks and benefits of different treatment meth-
ods, will be essential in avoiding the perception among patients that increased efficiency means less optimal care. Care redesign capabilities: To achieve better outcomes, ACOs must significantly redesign care processes, including workflow design, communication pathways, team structures, and the relationships among providers, payors, and patients. A fundamental re-architecting of care delivery is necessary to generate efficiencies for providers and reduce their costs and, in turn, yield savings for payors. Specific examples of care redesign include new scheduling and access arrangements, development of teambased care, and quality improvement activities to reduce errors and readmissions (see Exhibit 7 for additional examples). Considering the central importance of care redesign in enabling the success of ACOs from the perspectives of payors and providers, too little attention is being paid to it in current initiatives. Among those providers who are actively experimenting
Exhibit 7 Selected Examples of Care Redesign
SELECTED EXAMPLES OF CARE REDESIGN Process Improvements - New scheduling and access arrangements - New ways of bringing evidence to the point of care - Institution of more point-of-care services Teamwork Focus - Development of team-based care - New coordination arrangements with other parts of the healthcare system - Data and information sharing across provider types Waste Reduction - Changes in practice management to eliminate redundancies - Quality improvement activities to reduce errors and readmissions - Implementation of EBM guidelines to establish protocols for appropriate use
Source: Booz & Company
Booz & Company
with care redesign, most are in the early stages of this work, such as creating quality documentation and procedural checklists in order to standardize care delivery and establish a baseline for measurement and future improvement. As yet, few providers are taking more ambitious steps, such as redesigning workflows and engaging patients in their own care. The extent of the change that must occur ensures that care redesign will not be easy. In pursuit of care redesign, ACOs will require partnerships across payors, hospitals, physicians, and patients. We recommend that payors work collaboratively with providers on three key actions to support care redesign: 1. Development of a strategic plan for care redesign Payors, providers, and patient representatives should work in concert to prioritize and plan care redesign initiatives. This planning should include scheduling of specific care redesign activities, and the identification and adoption of methods for evaluating the impact of care redesign initiatives. 2. Structuring and implementation of financial incentives for improving care practices
In the first stage of ACO development, financial incentives should directly reward and/or fund care redesign activities. Over time and as outcome measures become more sophisticated, incentives can support care redesign indirectly by rewarding performance. 3. Provision of enabling capabilities for care redesign such as data analytics, wellness programs, identification of redundant or unproductive processes, and care coordination support Payors will need to provide sophisticated data to help providers pinpoint process inefficiencies and identify the causal relationships between procedures and outcomes. Further, they will often need to reconfigure these data for use in specific provider settings. One provider interviewee expressed frustration at the slow pace of this work to date: "We've been trying for two years to get the data [from our payor] that we need to improve critical processes… They don't yet have the capability to adapt data systems to share the relevant information." Particularly in cases where an ACO does not include the full spectrum of providers, payors can also play a rol


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New Reader with great pdf-support: Mantano Reader (like aldiko+ezpdf)
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Hi, I am also currently trying out your readerapp, and I have a couple of questions.
When I use the explorer to navigate to a folder containing some files, I don't see the txt or html files, which I use for some texts. Yet when I go to the library, some txt and html files are there, and I am able to open them. When it comes to styling, there is absolutely none for txt. Reducing the default font size for epub will automatically change font size for txt and html, making the font too small and barely readable. Can these be handled separately? I know it's possible to apply styles to txt because CoolReader does it, and I would prefer having one app to read most files than a separate app for every file format.
I agree with
that having a list of books is not very helpful, and that it would be good if the books can be organized in some way, especially series. Re: tags, I see I can create a tag and apply it to a book, but is it possible to select several books and apply a tag to all of them? I was unable to find anything about that in the user manual. (In fact, is it possible to edit metadata directly in the app instead of in an outside application?)
Re: paging, I noticed that there is a kind of a "click" sound when I use volume buttons to go forward and backwards; is there a way to turn this behavior off? Also, I can go forward by tapping the right side of the screen but tapping the left to go back only brings up the settings. Is it possible to address this issue?
This seems like a fine reader, and I like the way it handles pdf. While I do prefer a single app for multiple formats, I wasn't very satisfied with the way pdfs are handled in other apps. I like the note, annotation and highlighting options, and am interested in finding out more about text to speech. I have the next 7 days to try it out. I will post in this thread again if I have any more questions.
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