High Performance Accountable Care: Building on Success and Learning from Experience Stuart Guterman, Stephen C. Schoenbaum, Karen Davis, Cathy Schoen, Anne-Marie J. Audet, Kristof Stremikis, and Mark A. Zezza The Commonwealth Fund

Report by the Commonwealth Fund’s Commission on a High Performance Health System Lays out the rationale for accountable care organizations (ACOs) Describes several promising types of organizational models and payment approaches that could be used to encourage the implementation and spread of accountable care Presents a set of recommendations on what ought to be expected from ACOs and how to enhance their success in moving toward an effective and efficient health system

The Need for Coordinated, Accountable Care Access problems Getting an appointment with a doctor the same or next day Getting advice from your doctor by phone or email during regular working hours Getting care on nights, weekends or holidays Waste and inefficiency Doctors ordered a test that had already been done Time spent on paperwork related to medical bills Health care system poorly organized Poor coordination of care—especially if multiple doctors are involved Getting results of medical tests Sharing of important patient information among providers Availability of test results/medical records at time of scheduled appointment Communication between primary care physician and specialists

Public Support for Policies to Improve Coordination People want more accessible, coordinated, well-informed care One provider responsible for primary care and coordinating care (93%) Place to go for care at night and on weekends (85%) Doctors with easy access to medical records (96%) Information on quality of care for different providers (96%) Information about the costs of care (89%) People think doctors working in teams or groups improves care Doctors and nurses working closely as teams (86%) Doctors practicing with other doctors in groups (65%) Majority (72%) of Americans say the health care system needs fundamental change (46%) or complete rebuilding (26%)

Moving Toward a High Performance Health System Essential strategies: Affordable coverage for all Aligned incentives to promote quality and efficiency Increased accountability Improved coordination of care Effective leadership in the policy and health care communities The creation of ACOs as a new type of provider in the Affordable Care Act recognizes the importance of coordinated, accountable care in achieving the goals of a high performing health system: Better health Better care Lower cost This new initiative is consistent with all five strategies laid out by the Commission

Commission Recommendations Overall goal: to achieve a high performance health system that is organized to attain better health, better care, and lower costs Strong Primary Care Foundation Accountability for Quality of Care, Patient Care Experiences, Population Outcomes, and Total Costs Informed and Engaged Patients Commitment to Serving the Community Criteria for Entry and Continued Participation That Emphasize Accountability and Performance Multi-Payer Alignment to Provide Appropriate and Consistent Incentives Payment That Reinforces and Rewards High Performance Innovative Payment Methods and Organizational Models Balanced Physician Compensation Incentives Timely Monitoring, Data Feedback, and Technical Support for Improvement

Commission Recommendations and NPRM Provisions 1. Strong Primary Care Foundation Functional requirements and performance measurement standards in line with the goals of a medical home 2. Accountability for Quality of Care, Patient Care Experiences, Population Outcomes, and Total Costs Performance measures cover multiple dimensions of care Any shared savings payments are contingent upon meeting performance standards Pay-for-reporting in the first year; subsequent years will taken into account performance levels Minimum scoring threshold: 30th percentile of fee-for-service or Medicare Advantage 3. Informed and Engaged Patients Strong patient-centeredness requirements including (but not limited to): beneficiary representation on the governing board patients notification that their provider is in an ACO specific processes to enable patients and their caretakers with information to be engaged in care choices ACOs must collect patient-reported experience information and incorporate it into personalized care plans 4. Commitment to Serving the Community Each ACO must demonstrate that it evaluates the health needs of its population, incorporating diversity. Community stakeholder involvement to help identify high-risk individuals and develop individualized care plans for targeted populations Encouraged to include the community’s stakeholder representatives on the governing board 5. Criteria for Entry and Continued Participation That Emphasize Accountability and Performance Allows flexibility in the types of tools ACOs can use to meet the functional and performance standards outlined Also substantial flexibility in the types of organizations and configurations of providers that can participate Limitations on the types of providers that can apply independently; however, any type of Medicare provider can participate by partnering with an ACO

Commission Recommendations and NPRM Provisions 6. Multi-Payer Alignment to Provide Appropriate and Consistent Incentives The proposed rule is fairly silent with regard to multi-payer alignment 7. Payment That Reinforces and Rewards High Performance Empirically-based minimum savings thresholds Adjustments for health status, minimal adjustments for geographic variation Some incentives to include small and safety net providers At least a several month lag in shared savings (losses) payments from end of the performance period 8. Innovative Payment Methods and Organizational Models Allows ACOs the option in the first two years to receive a higher share of savings if they agree to take responsibility for a share of excess spending. This two-sided approach will apply to all ACOs in the third year. CMS, through its Innovation Center, will consider alternative payment models 9. Balanced Physician Compensation Incentives Any shared savings payment is dependent on the extent to which quality standards are met. ACOs will be monitored for actions that may inhibit patients from seeking care, particularly outside of the ACO network. 10. Timely Monitoring, Data Feedback, and Technical Support for Improvement Aggregated data reports on the ACO populations at the beginning of the first performance period and then on a quarterly basis, Limited amount of beneficiary identifiable data Data sharing will also include Part D information

Take-Away Messages There is a real need for coordinated, accountable care that is patient-centered, effective, and efficient There is an important relationship between payment methods, the organization of health care delivery, and health system performance The current payment system encourages fragmented, uncoordinated care and does not reward value Changing the way health care is paid for, organized, and delivered is essential to achieve the Triple Aim of better health, better care, and lower costs—and there’s a lot to be gained from achieving these goals The Affordable Care Act, in provisions like the one that creates ACOs, provides a set of policies that can help move the health system toward these goals Success requires bold action, leadership, and collaboration on the part of Medicare, other public programs, and private insurers, as well as hospitals, physicians, and other providers, and patients For ACOs to be successful, they will need a clear idea of what is expected of them, a strong connection between their performance and how and what they are paid, and data and technical support in making the changes necessary to improve the way health care is delivered and reduce cost growth

Appendix

Access Problems: More Than Two of Three Adults Have Difficulty Getting Timely Access to Their Doctor Percent reporting that it is very difficult/difficult: Getting an appointment with a doctor the same or next day when sick, without going to the emergency room Getting advice from your doctor by phone during regular office hours Getting care on nights, weekends, or holidays without going to the emergency room Any of the above Source: K. Stremikis, C. Schoen, and A.-K. Fryer, A Call for Change: The 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System (New York: The Commonwealth Fund, April 2011).

Potential Waste and Inefficiency: More Than Half of Adults Experience Wasteful and Poorly Organized Care Percent reporting in past two years: Doctors ordered a test that had already been done Time spent on paperwork related to medical bills and health insurance a problem Health care system poorly organized Any of the above Source: K. Stremikis, C. Schoen, and A.-K. Fryer, A Call for Change: The 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System (New York: The Commonwealth Fund, April 2011).

Poor Coordination of Care Is Common, Especially if Multiple Doctors Are Involved Number of Doctors Seen Percent reporting in past two years: Any 1 to 2 3 + After medical test, no one called or wrote you about results, or you had to call repeatedly to get results 27 21 36 Doctors failed to provide important information about your medical history or test results to other doctors or nurses you think should have it 23 22 26 Test results or medical records were not available at the time of scheduled appointment 18 14 29 Your primary care physician did not receive a report back from a specialist you saw 15 11 24 Your specialist did not receive basic medical information from your primary care doctor 12 9 Any of the above 47 42 55 Source: K. Stremikis, C. Schoen, and A.-K. Fryer, A Call for Change: The Commonwealth Fund 2011 Survey of Public Views of the U.S. Health System (New York: The Commonwealth Fund, April 2011).

Support for More Accessible, Coordinated, and Well-Informed Care Percent reporting it is very important/important that: Total: Very important or important Very important Important You have one place/doctor responsible for primary care and coordinating care 93 64 29 On nights and weekends, you have a place to go besides ER 85 54 31 All your doctors have easy access to your medical records 96 70 26 You have information about the quality of care provided by different doctors/hospitals 58 38 You have information about the costs of care to you before you actually get care 89 Note: Subgroups may not sum to total due to rounding. Source: K. Stremikis, C. Schoen, and A.-K. Fryer, A Call for Change: The Commonwealth Fund 2011 Survey of Public Views of the U.S. Health System (New York: The Commonwealth Fund, April 2011).

Support for Doctors Working in Teams and Groups to Improve Patient Care Percent reporting it is very important/important for improving patient care 86 65 Note: Subgroups may not sum to total because of rounding. Source: K. Stremikis, C. Schoen, and A.-K. Fryer, A Call for Change: The 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System (New York: The Commonwealth Fund, April 2011). 15

Only minor changes needed Fundamental changes needed A Majority of Americans Say the Health Care System Needs Fundamental Change or Complete Rebuilding Percent reporting Only minor changes needed Fundamental changes needed Rebuild completely Total 22 46 26 Annual income <$35,000 21 42 30 $35,000–$49,999 43 34 $50,000–$74,999 41 27 $75,000 or more 19 57 Insurance status Insured all year 24 49 23 Uninsured during year 16 40 37 U.S. region Northeast 17 31 North–Central 20 25 South 45 West 44 Note: Subgroups may not sum to total due to rounding. Source: K. Stremikis, C. Schoen, and A.-K. Fryer, A Call for Change: The 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System (New York: The Commonwealth Fund, April 2011).