What impact do accountable care organisations have on care quality?

Although there are many notable differences between the UK and US health systems, both countries are united in a common purpose: to improve the quality of care and to control its cost. Both systems use similar approaches to achieve this – namely, new care models that bring providers together, offer more co-ordinated and patient-centred care, and incentivise outcomes rather than activity.

The US system is largely reliant on two organisational approaches to meet these challenges – primary care medical homes (PCMHs), which emphasise care co-ordination, and accountable care organisations (ACOs), groups of providers that take collective responsibility for the quality and cost of population health. Both models prioritise the central role of primary care. The Commonwealth Fund and the Kaiser Family Foundation recently published the results of a survey of providers’ views on these models.

Overall, those surveyed held mixed views on, or were unsure about, the impact of new care models on the quality of care. However, they tended to favour PCMHs more than ACOs, possibly because there is a closer relationship between PCMHs and care delivery whereas an ACO involves a contractual relationship with a payer and might be slightly more removed from individual patient interactions. Furthermore, PCMHs have a longer history than ACOs and are more established.

In contrast, the Centers for Medicare and Medicaid Services (CMS) argue that ACOs have improved overall mean quality scores in their first two years of operation. However, financial performance has been much more mixed. Many ACOs have dropped out of the CMS programme – largely because of financial concerns. Those that remain tend to be those with a longer history of collaboration, and a stronger infrastructure to support the partnership. In essence, we can agree with the survey findings – performance of these care models on quality improvement and cost control is mixed.

Those surveyed were generally positive about the impact of information technology on quality of care. IT is extremely important in these new care models, which require prompt co-ordination and transfer of information across providers, and the need to keep a close watch on patient outcomes and other measures of performance for which providers are held to account.

However, results were more negative on the use of quality metrics and incentive payments based on quality. In particular, primary care physicians were negative about the impact of financial penalties for patients admitted or readmitted to hospital unnecessarily, probably because this type of performance management might threaten both their clinical autonomy and their income. Not surprisingly, those who were most positive were those who had received quality-based payments.

Although these survey results present only a partial story of the evolution and performance of integrated organisational models in the US, we can draw out some lessons for the NHS.

  • Impact takes time. We know from previous work on contracting for integrated care that providers need time to learn how to work together and to build the necessary infrastructure and capacity. New structures or contracts will not fast-track these relationships.
  • Information is key. Despite some concerns about the burden of new technology, primary care providers were generally enthusiastic about the benefits of IT. If providers are expected to work more closely together and bear increasing financial and clinical risk, it is essential that they have ready access to the information they need to understand and manage that risk.
  • Loosen the reins. Although incentive payments and penalties are designed to stimulate improvement in performance, they are generally unpopular and the evidence on their impact is uncertain. Alternative payment mechanisms (such as capitation) may present a more appealing option for providers within new care models, empowering them to develop pathways and deliver care using their expertise. Giving professionals more clinical and financial control might have a greater impact on the quality of care than rewarding or penalising performance.

There is a great deal of enthusiasm across the NHS for the types of care models being developed in the US. Policy-makers, commissioners and providers have all expressed aspirations to move towards the apparent nirvana of an accountable care organisation. Although the ambitions of the care models in the US may resonate with our intentions here, we would be wise to learn from the early experiences of those who went before us.

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#544465 Ruth Robertson
Research Fellow
The King's Fund

A really interesting blog, thanks. I agree that capitated budgets may be more motivating to front-runners and early adopteers, for example those setting up Vanguards, who will relish the freedom to be creative within a set budget. But I wonder if different payment/contracting mechanisms might be needed for those further down the innovation curve: the' late majority' or the 'laggards'?

#544470 Ted Adams
Senior Registrar
Liverpool Women's NHSFT

Just back from a year in the US as a Harkness Fellow. The barriers between primary and secondary care are less acute in the US than in the UK and often specialties we would think of in the UK as secondary (e.g. obstetrics or respiratory medicine) are thought of as primary care in the US. The UK divide is just that - divisive. Ok someone may need to commission care, but care should follow patients. Why can't pregnant women get their whooping cough vaccine from secondary care when they come to secondary care for their scans? We need to look more closely at patient journeys and incentivize efficiencies along those journeys. The US doesn't do this either, but their barriers tend to be the effect on the patient of the complexity of their provider and payment systems - something we should be able to avoid in the UK, particularly from the patient's perspective.

#544475 george coxon
various inc independent commissioning advisor and care home owner
various inc CCH Ltd, Cogora, MHNA

I’m a huge supporter of outward looking perspectives when developing and improving health and social care provision - I'm just back from Reykjavik after a skill sharing event with fellow mental health practitioners and have spent time in the US, China, Europe and other Scandinavian countries and am off the Amsterdam in November talking to service leads there about dementia care models. I am however sceptical about how much we 'import' and how we are too often regarding the transferability or portability of different H&SC models as applicable to our service culture and design - lots to learn yes but caution on the magic bullet from afar factor!

Key elements for me are leadership, followership, ownership and partnership and getting over the' what’s in it for me' re funding barriers and focusing a more 'can do' ethos on 'we're in it together'. Sorry to digress but my train of thought on the current challenges about accountability and the quality of care tend to lead me to these points more often than not.

#544560 Paul McGough
Patient Leader
Various Voluntary: spanning regional NHS Eng, CCG, Acute hosp

Thanks - very interesting article with insightful comments below - can anyone share or direct me to - new NHS organisational structures / visuals showing new models of health and social care - spanning Primary and Acute Care (PACs) and Multi Specialty Community Providers (MCPs) Emergency medical Units (EMUs) Minor Injury Units (MIUs) Reablement Units/Centres and Accountable Care Organisations (ACOs) - Foundation Trust chains. My aim is to understand how the different elements of the new systems integrate with each other - the accountable Governance arrangements - to ensure things work properly across acute, community and primary and social care - through to home based care? Patients need to know and understand how things knit together - who's responsible and accountable for making things happen - how models relate and fit together - importantly - where to go for what - how to access the right services at the right time in the right way. Many thanks if you can share your understandings - or point me towards links that explain all this in one place if possible?

#544564 awaters
Digital Communications Assistant
The King's Fund
Hi Paul, Hopefully the information on this page will help: http://www.kingsfund.org.uk/projects/nhs-five-year-forward-view
#544567 Paul McGough
Patient Leader

Many thanks! Paul

#550042 Stephen Gray
GP partner/CCG representative

Very interesting topic.
I agree the primary/secondary care interface in UK is currently a big barrier.
Also capitated budgets send shivers down my spine- demand continues and will inevitably continue to increase on NHS and social care- one cant continue to do more for the same. GPs currently work on a capitated budget (GMS/PMS) and this model is failing.
A third issue which gets very little air time is the fact GPs and partners are governed by partnership law, which many commentators are either ignorant of or fail to address ie if we go bust we are 'jointly and severally liable' for any costs ie redundancy/property debt and therefore are at risk of personal bankruptcy- yes it has and does happen to GPs. We cannot hold a GMS/PMS contract within another business vehicle unlike every other provider in the wider system which would help alleviate this risk (it puts nearly all newly qualified docs off becoming partners in our uncertain politicised NHS. Could Kings fund point me to any experience of how partnerships (and the risks they carry) have been incorporated into ACOs?

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