Barriers and Facilitators To Implementation and Sustainment of 17 New Medicaid Accountable Care Organizations in Massachusetts: A Study Protocol

Background: Accountable care organizations (ACOs) utilize value-based payment models, which incentivize quality of care and cost reduction through shared financial risk contracts for payers and providers. The impact of ACOs on cost and quality has been mixed for Medicare and commercial insurers, but the model has yet to be extensively tested in the Medicaid system, which insures a large number of patients in socioeconomically disadvantaged populations. Additionally, despite substantial heterogeneity in ACO models, the majority of ACO studies have examined ACO outcomes without exploring the potential impact of implementation and sustainment on these outcomes. Understanding barriers and facilitators to implementation and sustainment of Medicaid ACOs will help to better understand their impact on patient care, outcomes and costs for a vulnerable population.Methods and Design: The state of Massachusetts (MA) approved 17 new Medicaid ACOs and associated Community Partner (CP) organizations in 2018 as part of a large-scale pragmatic experiment in healthcare reform. The new ACOs will receive $1.8 billion dollars in state and federal funds over five years aimed at supporting implementation and sustainment the new model. This study aims to identify barriers and facilitators to implementation and sustainment of activities supported by these funds using the Consolidated Framework for Implementation Science (CFIR) as a guiding framework through: (1) review of administrative documents classify organizational characteristics of the ACOs and CPs including plans for innovation; (2) key informant interviews (KII) with ACO and CP leaders, governmental administrative leaders, and patients; (3) case studies of ACOs and CPs; and (4) a survey of front-line providers and staff in the ACOs and CPs. Descriptive quantitative statistics will be used to analyze document and survey data and framework analysis will be used to analyze KII and site visit data.Discussion: The new Medicaid ACOs in MA aim to improve care integration, quality of care, and patient experience while reducing costs through innovations in healthcare delivery and payment. Understanding the barriers and facilitators to implementing and sustaining the ACO model will provide critical context for understanding the overall impact of the Medicaid ACO experiment in MA.