It’s good to be back blogging. Having left The King’s Fund nearly a year ago now there has been a period of radio silence while I have been getting reacquainted with the corridors of Richmond House.
In this blog I will sharing insights, stories and personal reflections on some of the developments in research and practice that catch my eye and how these can help address the big strategic issues that face the health and care system. I want to bring fresh thinking into the Department drawing on international experiences as well as insights from other sectors and the frontline of care. So please do send me your views, ideas or any articles of interest.
I thought I’d kick off with a few reflections on the US experience of accountable care organisations (ACOs). I was delighted to host Stephen Shortell recently at the Department of Health – a leading academic from Berkeley who has done extensive research on ACOs. Steve was over in London to promote a paper he and co-authors from The King’s Fund published on learning from accountable care organisations in the United States and the implication of these developments for integrated care initiatives in England.
There is growing interest in accountable care organisations in the NHS. Shortell and co-authors describe the basic concept of an ACO as “a group of providers who agree to take responsibility for providing all care for a given population for a defined period of time under a contractual commitment with a commissioner”. The aim of an ACO is to align incentives for finance and quality so that achieving financial success also means improving quality and improving people’s health. Some of the early ACOs have shown they can deliver both quality improvements and cost savings. So do ACOs offer a model for the NHS?
Organisational models
I was firstly struck by the range of different models outlined by Steve in his seminar. ACOs are not all large fully integrated delivery systems, like Kaiser or Geisinger, that we hear so much about but which have proven difficult to transfer to the NHS.
Here in England, the primary interest has been in applying this model to groups or federations of general practices. Data that Steve presented showed that about half of the shared savings ACOs are physician sponsored. Physician sponsored ACOs typically are led by multi-specialty group practices or groups of family doctors (known as independent practitioner associations).
Just over a third of ACOs are hospital sponsored, but under the financial incentives they face these hospitals have strong networks with local physician practices. A third of all ACOs include a community health centre. Could NHS hospitals take financial risk, like ACOs, and work collaboratively with a network of affiliated general practices to deliver the improvements in cost and quality?
Such a model might be suited to areas where primary care is less developed or where District General Hospitals have merged with community services. The US experience suggests if we were to develop ACOs in England then we should encourage a diversity of models that reflect local circumstances and organisational capabilities.
Taking on risk
Most of the ACOs have taken ‘upside’ risk that means they can share in an agreed proportion of the savings that they generate with a portion being returned to the insurer. Some ACOs have entered into contracts with both ‘upside’ and ‘downside’ risk – in other words they take a hit on any losses they make. The nature of these risk sharing contracts seems critical, not so much to the incentives and behaviours, but to manage the financial risks of insolvency. Some of the early Independent Practioner Associations were not large enough nor did they have the skills to manage the risks they took on with hard capitated budgets. A lesson here perhaps for NHS commissioners to make sure there is a staged implementation or ‘phasing in’ of risk sharing contracts and new payment methods so that risk is transferred at a pace that the providers can manage and respond to.
Care management
Critical to the success of the ACOs was their approach to care management. They used predictive data analytics to identify the high risk/ high cost patients and proactively managed the care of these patients to meet quality measures and reduce costs. Steve emphasised this was not about one or two interventions but a whole package of changes that needed to be implemented together. He also emphasised the importance of supporting patients in taking on on a greater role in managing their own health and care.
He identified a number of critical factors that determined the state of readiness of organisations to become ACOs: care management capabilities and team based care for the chronically ill involving health coaches, nurse practitioners and training in motivational interviewing; an electronic patient record or other integrated information systems that provide feedback and support to clinicians; physicians with the capabilities to lead and staff with the skills to do rapid-cycle quality improvement. Many of the foundations on which ACOs could be built are in place or being put in place in the NHS.
Conclusion
There is an urgent need to improve the care of people with multiple chronic conditions, frail older people and those with both health and care needs. All parts of the health and care system are working together to develop plans for improving services through the Better Care Fund. The new GP contract also provides incentives to provide more proactive care for high risk patients and this week the government launched the Transforming Primary Care programme, the next step towards safe, personalised, proactive out-of-hospital care for all. ACOs offer a potential model for the future for how we could bind together hospitals, general practices and community services to make them jointly accountable for both the costs and quality of care.
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