Most countries have well-established mechanisms to pay for medical treatments. However, many innovations – telemedicine, use of community health workers and lower-cost versions of treatments – are inadequately reimbursed, if reimbursed at all.
Payment systems are often slow to support new care models, and understandably so: additional payments for innovations create fiscal concerns; innovations may not be cost-effective unless integrated appropriately with other services; and existing institutions may lack experience or clear authority to support new services. Accountable care can help to overcome such barriers.
Accountable care seeks to align health financing and regulatory systems with person centred care reforms and enable changing population health needs and opportunities to be addressed at a lower cost. We define accountable care as a group of providers who are held jointly accountable for achieving a set of outcomes for a defined population over a period of time and for an agreed cost. Evidence suggests that adopting accountable care through incremental policy changes or comprehensive payment reforms can reduce hospital readmissions, emergency department use and overall spending. Accountable care can also increase patient satisfaction, improve chronic disease management and prevent costly complications.
However, to implement accountable care requires new organisational capabilities and professional expectations. Effective implementation is not only technical. It will involve putting into practice new performance measures and financing models, but also steps to support healthcare organisations in managing change.
The report defines accountable care as a group of providers who are held jointly accountable for achieving a set of outcomes for a defined population over a period of time and for an agreed cost. The authors draw on diverse case studies to illustrate how accountable care can be achieved through three different approaches:
- Innovating primary-care-focused reforms to build efficient access to low-cost preventive and primary care services, and better co-ordination with advanced and specialized care.
- Problem-focused care reforms to support broader access to more efficient, high-quality services providing ‘episodes’ of care for specific conditions.
- Comprehensive care reforms to incorporate accountability for the full spectrum of care for a population.
- The case studies, all at varying levels of maturity, share several common features that demonstrate how accountable care goals can be achieved on a practical level.
The evidence suggests that adopting accountable care through incremental policy changes or comprehensive payment reforms can have a substantial impact: reducing hospital readmissions, emergency department use and overall spending. Evidence outlined in the report also suggests that the successful implementation of accountable care requires policymakers to respond to local priorities, create momentum and convey the practical relevance of reform to stakeholders.
Policymakers must also take into account the largest gaps in health and efficiency of care and the capabilities of local healthcare organisations.
An incremental model may be most appropriate for countries tackling long-term and costly conditions, such as diabetes. In other cases, countries may implement a model with full accountability for population health results. In all cases, simply changing payment mechanisms is not enough to achieve the implementation of much needed innovation.
Forum Chair: Mark McClellan, MD, PhD
Dr Mark McClellan
Mark McClellan, MD, PhD, is the Robert J. Margolis Professor of Business, Medicine, and Policy, and Director of the Duke-Margolis Center for Health Policy at Duke University with offices at Duke and in Washington DC.
Dr. McClellan is a doctor and an economist, and his work has addressed a wide range of strategies and policy reforms to improve health care, including payment reforms to promote better outcomes and lower costs, methods for development and use of real-world evidence, and approaches for more effective drug and device innovation. Dr. McClellan is a former administrator of the Centers for Medicare & Medicaid Services (CMS) and former commissioner of the U.S. Food and Drug Administration (FDA), where he developed and implemented major reforms in health policy. He was also a Senior Fellow at the Brookings Institution and a professor of economics and medicine at Stanford University.