Accountable Care Systems: Betting the Farm on “Promise”?

Back in June this year, Simon Stevens announced the first eight Accountable Care Systems (ACS). NHS England are making some big bets on Accountable Care Systems being able to deliver on the ambitions of Sustainability and Transformation Partnerships (STPs).

Timely then that I remind myself of a conference I attended in San Diego last year where one of the speakers was Dr Linda Dunbar, Vice President, Population Health at The Johns Hopkins Community Partnership (J-CHiP). J-CHiP is an Accountable Care Organisation (ACO) offering a model of community based accountable care in Baltimore.

As far as this ACO in the US is concerned, there is no ‘silver bullet’, just a lot of hard work and a lot of focus on shifting the culture.

I clearly remember Dr Dunbar being very careful in her use of language. It was telling, I thought, that she referred to ACOs as holding “promise” for improving the effectiveness and efficiency of care delivery.

Most interesting were the results she shared of Medicare Shared Savings ACO Performance. A feature of the Medicare Shared Savings programme is that if participating ACOs meet quality benchmarks and keep spending below (capitated) budget, they receive half the savings that result. The remainder goes to Centres for Medicare and Medicaid Services (CMS).

Reporting from the programme’s first year of operation in 2013, results were mixed. In 2013 there were 220 shared savings ACOs in the US and the results are as follows:

  • Only 52 (24%) were able to meet quality of care benchmarks and keep spending below budget targets.
  • 60 ACOs (27%) kept spending under target but did not fulfil their requirements to measure the quality of care delivered or did not reduce spending enough to meet the criteria to share in savings.
  • 102 (46%) did not achieve savings at the target, but met quality targets.
  • 6 (3%) achieved savings but did not report quality measures.

I appreciate that the UK model of accountable care is likely to be very different to that in the US. There is no single model for an ACO in the UK and it is likely that the local context will play an important part in defining form. Indeed when we consider the accountable care experience worldwide it is often said that, “once you have seen one accountable care system, you’ve seen one accountable care system.” That said, I believe the JCHIP experience is worthy of note.

The other three big takeaways from Dr Dunbar’s presentation were:

  • The need to use data to understand how to best invest shared resources to produce the best health outcomes.
  • The need for transparency in the application of that data.
  • The importance of the collection and use of data on social and environmental factors as they are related to risk identification and health outcomes.

Dr Dunbar spoke eloquently about the need for new uses of shared data sources that included social determinants of health.

Important learnings then from some very dedicated individuals who are already fighting at the frontline of accountable care.

And if you thought there was a challenge here in the UK securing the necessary data then, believe me, our travails here are as nothing compared to the US. We are blessed by comparison.

It’s just that sometimes it doesn’t feel that way.

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