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.