Studying health care reform abroad: Lessons in chronic disease management

While the countries of the world have diverse approaches to the role of government in health care delivery, as well as contrasting cultural and institutions, they do share many of the same challenges. Most need to improve quality of care and address rising costs. To those ends, the United States  and many countries are implementing payment and regulatory reforms intended to support new care delivery models that achieve better care and improve population health at lower cost.  These so-called accountable care reforms are designed to hold a group of providers responsible for achieving explicit health and cost outcomes for a defined population, over a specific time period.  The execution of accountable care is challenging, but the U.S. and other nations have growing opportunities to learn from each other about successful innovations in care delivery and payment reform.

To build on our prior work on global accountable care, the Center for Health Policy convened a roundtable at the 6th National Accountable Care Organization Summit to discuss accountable care models that address the needs of chronically ill patients, such as those with diabetes or cancer. The care of these complex patients is a good place to start because of the many opportunities worldwide to improve chronic disease care through such steps as better care coordination, more convenient sites of service, remote monitoring, and team-based approaches.  Starting with the harder-to-treat will yield lessons for those with more minor conditions.  As a basis for the discussion, we reviewed some examples of accountable care  experiences from outside the U.S., and gathered a range of perspectives from providers, health plans, and public agencies on the potential relevance of these cases for their own work.  The roundtable focused on identifying promising areas for “reverse learning” — that is, for health care reformers in the U.S. to learn from accountable care reforms implemented abroad.  We found we could learn quite a bit, and we had an excellent exchange of ideas.

Promising Areas for Reverse Learning

While there was a high level of interest in experiences from outside the U.S. with specific aspects of accountable care reforms, three major themes emerged from the roundtable.

Identifying and investing in low-cost technology, such as text messaging or basic mobile use, to track service usage and to support complex patients with multiple non-communicable diseases.  Many such low-cost tools have been developed outside the U.S., including tools for patient engagement and shared decision-making, which could be useful for U.S. health care providers that are being held accountable for lowering costs while also improving care.  For example, CASALUD in Mexico has low-cost electronic tools for both diabetic patients and providers.  Patient portals feed directly into electronic health records (EHR) for shared decision-making and improving care.  Performance measures are shared across providers to promote transparency and competition.  As a result, CASALUD has been able to embed accountability into the Mexican public health care system that covers around 50 million people in an easy and low-cost way.

Incorporating community health workers and caregivers into multidisciplinary team-based care. To provide more comprehensive care at lower overall costs, care teams are being put together that include community health workers, care coordinators, care liaisons, social workers, therapists, and caregivers for complex patients.  Rio Grande Valley ACO in Texas uses a team-based approach to coordinate care across providers through a site-based care coordinator. The program is low tech with a focus on education, regular case management, and clinical adherence to best practices such as using a diabetes checklist.  The patient-focused model has resulted in the proportion of patients with comprehensive control of diabetes rising from 23 percent in 2012 to over 49 percent in 2014.  Outside the U.S., very low-cost models of team-based care have also emerged.  For example, SughaVazhvu in India is a private primary health provider that uses community health workers to screen for diabetes and manage the community they service.  The model is low tech and low cost; patients purchase subscription care packages for chronic disease management, improving access, and health utilization.  While licensing and other regulatory barriers may prevent the exact replication of such models in the U.S. without regulatory reform, these non-U.S. models highlight the kinds of lower-cost staffing arrangements and support tools that could further optimize team-based care.

Scaling up successful models that span the spectrum of care for chronic diseases. The spectrum includes proactive prevention and early detection, coordinated and engaged management for ill patients, as well as end-of-life care. Requirements will differ from patient to patient, so effective models will target patients individually in order to adapt to differences in patient needs and expectations.  For example, patients often have different end-of-life goals, such as prioritizing home-based care. Ribera Salud in Spain is an advanced chronic care management model that offers individualized care plans for those patients with multiple complex conditions.  Ribera Salud has considerable experience under a largely capitated arrangement or a per person payment, which can provide a useful perspective for U.S. health care providers who have only limited experience so far with taking on and managing “downside” financial risk across the spectrum of care. Ribera Salud has achieved significant reductions on hospital admissions and readmissions, leading to cost savings alongside better outcomes.

Practical Learning From Global Experiences

These examples highlight now accountable care reforms for chronic diseases in other countries can help address the challenges of implementing accountable care reforms in the U.S., despite significant differences across health care systems. Many international collaborations, such as Innovations in Healthcare  and the World Innovation Summit for Health, are also taking a closer look at how to learn from innovations in health care and in policy reforms to accelerate improvements in seemingly diverse settings around the world. By using a structure like the accountable care framework that we have developed through such global collaborations, it is possible to use evidence that can bring to bear a much broader set of practical experiences and support progress on achieving better outcomes and lower costs for chronic disease care.

Supported by

the Commonwealth Fund

, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy.  The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff.