Accountable care: A global view

Accountable care has long been viewed as an American phenomenon, yet accountable care principles are now being applied around the globe. On September 8th, at the National Press Club, Health Affairs will host a briefing to discuss global health policy, including a recent publication demonstrating how accountable care reforms can reinforce ongoing payment and delivery changes in a diverse group of health systems. In a 2013 report, we developed a common definition and conceptual framework for accountable care based on the experiences of 10 countries. In the Health Affairs article, we illustrate global accountable care through two main examples: Ribera Salud, a public-private partnership in Valencia, Spain, and two elderly-focused programs in Singapore.

Global Challenge

Around the world, federal and regional governments are facing a common reality: medical advances and improved access to health care, coupled with higher costs to treat the chronically ill, have resulted in increasing private and public expenditures on health. The problem is that this spending increase has not necessarily resulted in comparable improvements in quality or population health.

In response, many policy makers are incorporating the goals of better quality care, better population outcomes, and lower costs into health care reform efforts. Notably, many nations, such as Singapore, the United Kingdom, and Spain, are experimenting with accountable care reforms to better align health care payments with delivery reform goals.

For the last 15 years, Ribera Salud has provided health care to residents in Valencia, Spain, with accountable care type features increasingly embedded in its financing and care structure. The local government pays a capitated fixed amount and Ribera Salud supports financial incentives to all staff members to encourage achieving established health outcomes. Recent evidence shows that outcomes of patients attributed to Ribera Salud have outpaced those of patients who see other providers and capitation costs are lower than other providers in the region. Overall, Ribera Salud patients also benefit from shorter wait times and lower readmission rates than other comparable providers in the region.

In Singapore accountable care principles are built into two programs for the elderly population: the Singapore Programme for Integrated Care for the Elderly (SPICE) that provides community care to elude the use of hospitals and the Holistic Care for Medically Advanced Patients (HOME) that provides palliative care at home. Singapore has reduced thirty-day hospital readmission rates by 40 percent, emergency room visits by 50 percent, and realized patients’ preference to die at home by 70 percent. The savings amounted to more than US$11 million.

Action Steps for Policy Makers: What Next?

Through our work, we found that many countries with a diverse set of health systems are pursuing accountable care strategies. We believe that there is a benefit to sharing experiences around accountable care to accelerate financial alignment to promote sustainability and effectiveness of other health care reforms around the world. We have distilled four recommendations that policy makers can begin or continue to implement to advance accountable care in their own health system.

Take a broader perspective than illness. Instead of solely focusing on illness and activity-based services, the health care system should focus on wellness and outcomes, placing a greater emphasis on preventative or public health services that primary care physicians can provide at the community level. This also requires a shift away from a disease based paradigm to a holistic health paradigm that values social and behavioral care. To accomplish this objective, policy makers can: realign funding streams, establish outcomes relevant for all stakeholders, foster data transparency and interoperability, create team-based care, increase competitiveness and refine treatment protocols.   

Start to pay for outcomes. The shift away from an activity-based payment model to a person-centered approach involves rewarding outcomes rather than the volume of services. This movement does not have to be abrupt; it can be accomplished in incremental steps. An initial step could be a modest risk transfer to providers, with a subsequent change to risk sharing and partial or full capitation. Policy makers could also begin by establishing episode-based models for measuring quality, outcomes and resource use for specific diseases.

Create a favorable environment for collaboration. Policy makers should create a conducive environment – whether it is technological or regulatory – to exchange data and collaborate across providers. In addition to legislative changes that can ease provider collaboration and data sharing, a key factor for collaboration is strong leadership. Policy makers can support payments that promote outcome-based payments and identify a balance between competition and collaboration.

Encourage adoption of interoperable data systems. To foster multi-provider collaboration, policy makers need to integrate health information systems and aim to ensure interoperability across electronic health records. This is necessary for real-time data sharing. Policy makers can begin small by focusing on specific patient registries that track preventable complications. Ultimately, policy makers need to ensure that there is a balance between keeping personal health records private and enabling an environment for data sharing and collaboration.