• Rachael Addicott and Stephen M Shortell.
• Rachael Addicott, PhD, is Senior Research Fellow, King's Fund, London, United Kingdom. E-mail: r.addicott@kingsfund.org.uk. Stephen M. Shortell, PhD, MPH, MBA, is Dean Emeritus, School of Public Health, Blue Cross of California Distinguished Professor of Health Policy and Management, and Professor of Organization Behavior, University of California, Berkeley. E-mail: shortell@berkeley.edu.
• Health Care Manage Rev. 2014 Oct 1; 39 (4): 270-8.

BackgroundThe establishment of accountable care organizations (ACOs) in the Affordable Care Act (ACA) was intended to support both cost savings and high-quality care. However, a key challenge will be to ensure that governance and accountability mechanisms are sufficient to support those twin ambitions.PurposeThis exploratory study considers how recently developed ACOs have established governance structures and accountability mechanisms, particularly focusing on attempts at collaborative accountability and shared governance arrangements.MethodologyFour case studies of ACOs across the United States were undertaken, with data collected throughout 2012. These involved 34 semistructured interviews with ACO administrative and clinical leaders, observation of nine meetings, and a review of documentary materials from each ACO.FindingsWe identified very few examples of physicians being held to account as a collective and therefore only limited evidence of collaborative accountability impacting on behavior change. However, ACO leaders do have many mechanisms available to stimulate change across physicians. The challenge is to determine governance structure(s) and accountability mechanisms that facilitate the most effective combination of approaches, measures, incentives, and sanctions to achieve the goals of more accountable care.Practice ImplicationsAccountability structures and processes will need to be tailored to local membership composition, historical evolution, and current stage of development. There are also some common lessons to be drawn. Shared goals and incentives should be reflected through performance criteria. It is important to align measures and thresholds across payers to ensure ACOs are not unnecessarily burdened or compromised by reporting on different and potentially disjointed measures. Finally, emphasis needs to be placed on the importance of credible, transparent data. This exploratory study provides early evidence regarding how ACOs are establishing their governance and accountability arrangements and provides a foundation for future research and theory-building in this area.

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