Accountable care organisations can teach the NHS about integration

Accountable care organisations are being touted as an innovation that may slow the rate of increase in costs and improve quality of care in the US. They take many forms, but in essence are groups of providers that deliver care to a defined population. These providers are held accountable for achieving quality outcomes within a given budget.

‘The experience of ACOs underlines the importance of information sharing about patients and investment in IT’

There are currently around 600 ACOs in the US serving an estimated 20 million people. Emerging evidence on their performance is mixed, both in relation to cost savings and quality improvements. Promising initiatives such as those seen under the alternative quality contract in Massachusetts co-exist with examples of ACOs not delivering benefits and in some cases deciding to drop out of Medicare’s pioneer programme.

Fads and fashions in health reform should be approached with scepticism and these organisations are no exception. Having made this point, their experience offers a number of lessons for the NHS as the integrated care pioneers start work and providers and commissioners explore the potential of ACO-like innovations. These lessons encompass what needs to be done to realise the potential of ACOs and the environment in which they evolve.

The NHS can do better

The first lesson is the need to focus on the small proportion of people who account for a high proportion of use and cost. This is best done through further developments in risk stratification and predictive modelling, learning from past experience of what has and has not worked in the NHS.

Second, there is a role for case management and care coordination to support people most at risk. Our research shows that GPs need to be involved in care coordination but often are not engaged effectively. Changes to the GP contract to ensure patients aged 75 and over have an accountable clinician are a move in the right direction.

Third, the experience of ACOs underlines the importance of information sharing about patients and investment in information technology. The most developed integrated systems, such as Kaiser Permanente and Group Health, have system-wide electronic medical records that give all clinicians who provide care to a given patient access to information about that patient. These systems show that information technology is a powerful facilitator of integrated care.

Fourth, there is huge potential in engaging patients and supporting them to play a bigger part in managing their health and wellbeing. One way of doing this is through collaborative care planning involving patients and health care professionals. Another is to offer training to build skills and confidence among patients in supported self-management. ACOs have not given high priority to patient engagement and the NHS has the opportunity to do much better.

Neglected networks

None of these lessons are new and it is therefore essential that more is done to create the environment in which they can be acted on effectively. This means developing payment systems that are aligned behind the purpose of integrated care. Capitated budgets hold particular promise in avoiding the perverse incentives of payment by results and rewarding providers for keeping patients healthy.

‘The NHS needs to move quickly beyond high level commitment to integrated care into detailed planning’

It also means developing networks and alliances between providers with the leadership and capabilities needed to work effectively. This presents a challenge to the NHS given the historical emphasis on developing strong organisations and the relative neglect of network models. Where provider networks have been established their track record has been mixed, underlining the need to ensure they have the requisite capabilities and governance to succeed.

Commissioners could play a significant part in stimulating the emergence of networks and alliances by using their leverage to accelerate progress. This includes making use of alliance contracting, commissioning outcomes based integrated care and related innovations. Careful selection of the outcomes to be delivered by provider networks has the potential to incentivise integrated care, as was the case with the alternative quality contract.

Move quickly

Another insight from the US is the value of creating mechanisms and systems for learning what works as innovations in provision and funding are implemented. This is being supported through the Centre for Medicare and Medicaid Innovation, which is focused on rapid cycle evaluation of ACOs. The centre has a role in working with the ACO pioneers in continuous quality improvement, recognising that not all innovations are worthwhile and being willing to move on when pioneers fail.

The final point is that ACOs, as successors to earlier initiatives on managed care and integrated delivery systems, need to give serious attention to the implementation and execution of new models of care. What needs to be done is well understood; how to do it remains a major challenge. The NHS needs to move quickly beyond high level commitment to integrated care into detailed planning if its ambitions to develop ACO-like systems are to be realised.

Chris Ham is chief executive and Nicola Walsh is assistant director, leadership, at the King’s Fund. This article is based on a new paper Accountable Care Organisations in the United States and England by Steve Shortell and others, published by The King’s Fund.