Accountable care, which holds providers accountable for results rather than specific services, is gaining traction as means of supporting innovations. But according to a new study in Health Affairs, providers in the U.S. could stand to look at some overseas models for tips on how to get the most out of ACOs.
In examining some of these foreign models, the authors pinpointed some common innovations that have borne fruit: the use of multidisciplinary teams; shifts to less costly sites and treatment models; the use of data analytics and patient engagement to support treatment adherence and behavior change; and the integration of social, community and medical care to address the root causes of high utilization.
In the U.S., ACOs have become a common form of operationalizing the basic principles of accountable care. As of March there were 923 of them, ranging from physician- or hospital-led groups and alliances to fully integrated healthcare systems. More than half are operating in the Medicare Shared Savings Program, which covers more than 9 million Medicare beneficiaries.
Yet despite some quality and outcome improvements, the savings in many ACO programs have been modest. Many haven't reduced overall costs at all.
According to Health Affairs, Germany, Nepal and the Netherlands offer up some lessons.
In Nepal, for example, there's a nonprofit health services organization called Possible, which operates primarily in rural settings that can't finance and support basic health services. To improve quality and access, the Nepalese government partnered with Possible in 2008 to pay for primary care on a per capita basis for the general district population. Possible provides health services for an average of less than US$20 per person, annually, as is accountable for improving population measures of quality, access and outcomes.
In the Netherland there's Zio, which combines primary and specialty care for patients with diabetes. Zio initiated a disease management program that shifted tasks from endocrinologists to specialized nurses, moved care from outpatient settings to general practices, and stratified patients based on care needs. In 2007 the Netherlands introduced bundled payment to support integration of primary and specialty care. As a result, programs such as Zio were able to contract for services across teams of providers, holding them accountable for a defined population. Zio negotiated a single contract between insurers and groups of providers of diabetes care to integrate the various types of care needed by patients with the disease. These efforts included assessing ways to reduce complication risks in particular types of patients and care coordination.
Gesundes Kinzigtal, meanwhile, is a private health management company operating in Germany. Its model includes provider performance measures codesigned by physicians and patients, an internal dashboard that allows physicians to see their comparative performance, and a long-term shared savings contract between providers and insurers. Gesundes Kinzigtal keeps surplus revenue, determined by the difference between actual healthcare costs and a regional benchmark defined as the average risk-adjusted cost of care. This financial arrangement enables Gesundes Kinzigtal to manage care across providers and facilitate patient self management programs and other initiatives that prevent the progression of chronic diseases. Nine years after the start of the intervention, the model generated a 7 percent reduction in per enrollee cost compared to costs in the general population.
Those examples, according to the study, exemplify seven competencies that are key to ACO reform in the U.S.: governance and culture, which requires sufficient leadership to shift an organization's focus toward achieving better patient outcomes and value; financial readiness, which makes it possible for an organization to bear risk and reallocate financial resources; health information technology, or the infrastructure and analytics needed to support patient-centered care; patient risk assessment and stratification, which make it possible to target interventions; patient engagement, or embedding the patient perspective across organizational processes; quality and process improvement, or activities linked to performance measures and mechanisms that provide feedback on performance to provide better care; and care coordination, or integrated workflows to support continuity of care.
Providers, payers and policymakers can learn from those examples, the authors said, and implement models and policies that bolster population health outcomes and the efficiency of care.