DRAFT IN PROGRESS (1/26/2017) - Duke-Margolis · DRAFT IN PROGRESS (1/26/2017) 1 . Practical...

DRAFT IN PROGRESS (1/26/2017)

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Practical Lessons from International Examples of Accountable Care: A Review of Global Examples and Policy Implications for the U.S.

Authors: Mark McClellan, MD, PhD, Krishna Udayakumar, MD, MBA, Andrea Thoumi, MSc, MPP, Jonathan Gonzalez-Smith, MPAff, Kushal Kadakia

Executive Summary Accountable care payment models, in which a group of providers are held jointly accountable for achieving a set of outcomes for a defined population over a period of time and for an agreed cost, are increasingly being pursued to support better care delivery and improve patient and provider satisfaction. By moving away from volume- or provider-based payments and aligning reimbursement with healthcare delivery transformations, accountable care can respond to the needs of patients with chronic disease. However, innovators in the U.S. have reported significant institutional and cultural barriers when transitioning away from fee-for-service and scaling accountable care, and have a limited base of shared evidence and experience to draw from. In this study, we aimed to fill in the knowledge gap of health system transformation by reviewing promising, international models of accountable care. We leveraged our previously-developed framework of accountable care in practice to examine a range of health organizations in four countries (England, Germany, the Netherlands, and Nepal) and identify solutions to payment and delivery challenges comparable to those faced in the U.S. Our three-pronged analysis of accountable care implementation sought to identify the enabling factors and results of innovation at the context, policy, and delivery levels. We found that support for health system transformation arose from the environment, with institutional, political, and regulatory infrastructure providing a foundation for reform. Successful accountable care policies were holistic in nature, with the transition to value-based care underpinned by the pillars of population, performance measures, support for continuous improvement, payment and non-financial incentives, and support for care coordination and transformation. These policies enabled innovators to design and deploy new organizational competencies in governance and culture, financial readiness, health IT infrastructure, patient risk assessment and stratification, patient engagement, quality and process improvement, and care coordination. After identifying these common themes, we performed a meta-analysis of local and national examples of accountable care, and sought to identify translatable learnings based on shared challenges between innovators in the U.S. and abroad. We offer the following, targeted lessons based on these international experiences with accountable care: Organizational Competencies • Governance and Culture – Invest in organizational models that support clinical leadership and

shared values • Financial Readiness – Develop the financial infrastructure for global cost and utilization

monitoring and payment models to align providers across the spectrum of care delivery • Health IT Infrastructure – Design interoperable platforms for providers to communicate and

share data across a range of care settings


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• Patient Risk Assessment and Stratification – Leverage data and digital referrals to proactively identify high-risk, high-needs patients

• Patient Engagement – Provide care that targets the physical, behavioral, cognitive and social components of a person’s health

• Quality and Process Improvement – Develop the necessary operational infrastructure for regular assessment and evaluation

• Care Coordination – Expand delivery capacity through multidisciplinary teams Accountable Care Policy • Population – Stratify a patient population based on clinical condition and social need • Performance Measures – Complement national metrics with locally relevant indicators • Continuous Improvement – Allow third party evaluations of health outcomes and financial

performance • Payment and Non-Financial Incentives – Develop payment models that better support

physicians during the transition to value-based care • Support for Care Coordination and Transformation – Invest in tools and resources to reorganize

the way that care is delivered Environment • Institutional – Increase opportunities for information sharing and collaboration across health

care organizations • Political – Engage providers, payers, and patient groups in the decision-making process • Regulatory – Reassess the scope of practice legislation to expand clinical and non-clinical care


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Introduction As the number of people with multiple chronic diseases in the U.S. grows and more advanced treatments become available, health care demand and resulting expenditures continue to rise. More than half of Americans live with chronic conditions, such as cancer or diabetes, which pose a significant health and financial risk to society, accounting for 88 percent of deaths (2014) and 86 percent of health care spending (2010).1,2 Many of these individuals live with multiple diseases or conditions that could be treated more efficiently and effectively with a range of health and social services moving beyond the hospital or even the physician office as the main care setting.3 Conventional models of providing and paying for care do not adequately meet the needs of high-need, high-cost populations. While delivery innovations and reforms are advancing, health care payments in the U.S. are primarily tied to services provided. Many care transformation activities, such as efforts to create multidisciplinary teams or increase patient engagement, are not eligible for reimbursement under current fee-for-service (FFS) arrangements. FFS payment systems have reinforced fragmentation of and stifled innovation in care delivery because payment is tied to activity instead of outcomes.4 Therefore, payment reform centered on population-based alternative payment models (APMs) is needed to support care delivery transformation and improve patient and provider satisfaction. There is growing consensus among many U.S. stakeholders – patients, payers, providers, and policymakers – about the need to transform the way care is paid for and delivered. Most advocate for efforts to improve overall population health and the patient experience.5 Ongoing national efforts such as the National Academy of Medicine’s Vital Directions Initiative, the Accountable Care Learning Collaborative, and the Health Care Payment Learning & Action Network have mobilized players across the health care system to design and deploy strategies to transform care delivery and payment.6,7 The public (e.g. the Centers for Medicare and Medicaid Services (CMS) Payment Taxonomy Framework) and private (e.g. the Health Care Transformation Task Force) sectors have also committed to transitioning from volume- to value-based payments.8,9 Private payers are aiming for APMs to comprise 75 percent of all reimbursement models by 2020.10 Furthermore, as of 2016, CMS had shifted 30 percent of Medicare reimbursement to APMs.11,12 Meta-analyses of new payment and delivery models, such as Patient-Centered Medical Homes (PCMH) and the Medicare Shared Savings Program (MSSP), indicate that these pilots can achieve moderate improvements in care quality, but struggle to produce significant gains in health outcomes or corresponding reduction in the cost of care.13-15 Many health care organizations have faced challenges in moving to new payment models. Leadership priorities, organizational structures and coordination relationships, information technology systems, as well as care models themselves must all change for organizations to succeed. Healthcare organizations have reported institutional and cultural barriers to the transition away from FFS, and have experienced difficulty in effectively using information technology, integrating care outside of the hospital or clinic, and scaling interventions.16-18 Healthcare providers often have limited knowledge or experience about which patients would benefit from which interventions in a care transformation model, resulting in a lack of confidence about what they need to do to succeed.


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As we have noted previously, many countries are facing similar challenges to meet increasing demand of aging populations and rising population demand for health services.19,20 Countries are shifting away from volume-based care to systems that focus on specific population health outcomes. These approaches to align payments with care delivery reforms that can produce better results are known as accountable care, which we define as “one in which a group of providers are held jointly accountable for achieving a set of outcomes for a prospectively defined population over a period of time and for a joint cost.”19 Accountable care reforms delink the traditional volume- or provider-based payments. In doing so, physician reimbursement is better aligned with the delivery transformations that respond to patient and population needs, with the goal of supporting better outcomes and lower costs. These delivery and payment reforms seek to avoid unnecessary costs, improve the overall cost-effectiveness of the care that providers deliver, and improve patient satisfaction by:

• Promoting prevention through health education and screening; • Using improved diagnostic technologies and predictive models to identify patients with

particular risks before they are diagnosed with a disease and support better patient self-management once they are diagnosed;

• Increasing targeted clinical and social supports to reduce risk factors for patients with chronic diseases;

• Creating multidisciplinary teams to better manage care; and • Coordinating care to improve the transition process, enhance the course of recovery for

hospitalized patients, and prevent readmissions.

Progress toward reform in the U.S. is a subset of a global movement to realign resources to support lower cost and higher-quality care. Given similar challenges in designing and implementing accountable care models around the world, we undertook a review of promising activities occurring outside of the U.S. to explore how these experiences may begin to fill an evidence gap. In this report, we examine a range of health organizations in four countries to identify solutions to payment and delivery challenges comparable to those faced in the U.S. These organizations include: Better Together in England, Gesundes Kinzigtal in Germany, Zorg In Ontwikkeling (Zio) in the Netherlands, and Possible in Nepal. We highlight common obstacles and key enabling factors that have supported the transition to accountable care reforms outside of the U.S. and to show how these lessons could be translated to the U.S. context. Policymakers, providers and payers can use findings from this study to advance accountable care innovations in care in a wide range of settings.


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The Accountable Care Framework Adopting elements of accountable care is likely to be difficult without considering the organizational competencies that health providers already possible or the broader policy environment within which organizations operate. In Figure 1, we show this multi-faceted view of accountable care, including the context level, accountable care policy level and care delivery level. The delivery level includes organizational competencies, or the elements of designing and implementing care reform activities that providers can actively control; the policy level describes the range of accountable care policy components; the context level describes policy reform components in the broader health policy environment that require changes to institutional, political and regulatory frameworks at the local, national or international level.

Figure 1: Accountable Care Implementation Factors

Health care organizations or providers (see delivery level in Figure 1) must have the internal capabilities, such as clinical leadership or the ability to prospectively define populations, to provide value-based care. These organizational competencies, adapted from the U.S.-based Accountable Care Learning Collaborative and National Academy of Medicine, include the following components and can evolve over time:21,22

• Governance and culture: The necessary clinical and non-clinical leadership to create and strengthen an organizational culture focused on taking accountability for a person’s whole care experience, not just delivering services.

• Financial readiness: Ability to accept and bear upside or downside financial risk and understand financial consequences of reforms.


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• Health IT infrastructure: Technological infrastructure and data analytics that facilitate patient-centered care delivery.

• Patient risk assessment and stratification: Resources for patient risk analysis and stratification to target interventions that make the most difference

• Patient engagement: Ability to embed patient perspective in the decision-making process, institutional structure, and clinical interactions.

• Quality and process improvement: Operational infrastructure to provide better care, including support for appropriate performance measures (i.e., health outcomes, patient-reported outcomes, and resource utilization) and feedback mechanisms.

• Care Coordination and Transformation: Ability to integrate care across providers (i.e., clinical and non-clinical staff) to ensure continuity of services.

Previously, we developed five key components of accountable care to describe the many policies or steps that are needed for implementation (Figure 2).23 These range from defining a population to identify patients to include in a disease-specific pilot program or a comprehensive population-based model, to provider payments or other non-financial rewards, such as peer recognition, that can align provider incentives with health outcomes that matter.

Figure 2: Accountable Care Policy Components

The broader health policy environment (see context level in Figure 1) plays a fundamental role in enabling organizational capabilities to develop over time. At all levels—international, national, and local—the health policy environment, including the institutional, political and regulatory frameworks in which health organizations operate, can provide incentives for organizational change and affect the resources available for health care organizations to implement health care innovations. Health policy environment components include:

• Institutional: The existing government institutional structures that determine how resources are distributed and shape communication pathways.

• Political: Political support that unites stakeholder interests by facilitating coordination across government agencies or collaboration between the private and public sector.

• Regulatory: Regulatory infrastructure that supports innovations in care delivery, particularly efforts that support workforce regulations, help align funding streams across medical and non-medical providers, and reduce regulatory barriers to sharing data.

POPULATION PERFORMANCE MEASURES

CONTINUOUS IMPROVEMENT

PAYMENT AND INCENTIVES

CARE COORDINATION

AND TRANSFORMATION

The defined group of patients that are in the model and for which providers are responsible

The set of targeted metrics focused on person-centered outcomes

The way that performance is evaluated through learning and continuous feedback loops

The provider payments or incentives that are aligned with rewards for outcomes that matter to the patients

The low-cost, high-impact or high-value care transformation reforms, which include team-based care and integrated data analytics


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These environmental and organizational factors, when taken together, provide the set of conditions that drive accountable care policy reforms in a particular setting.

International Case Studies of Accountable Care The case studies developed through this project demonstrate that health care organizations outside of the U.S. are applying accountable care principles with some degree of success. Each case study in our series illustrates key elements of the “accountable care policy” level of the framework (Figure 6 in Appendix A), the “delivery” level (Figure 7 in Appendix A), and the health policy context (Figure 8 in Appendix A). We describe each case study in more detail in Appendix A.

• In Nepal, Possible has partnered with the Government of Nepal to deliver primary care services to remote populations through a hub-and-spoke model, using an existing network of community health workers and telehealth services.

• In Germany, Gesundes Kinzigtal has developed a long-term shared savings contract with insurers to provide population-based care for a region with varying care needs, supported by an integrated data platform with timely feedback reports for providers.

• In England, the Better Together Vanguard has focused on increasing stakeholder engagement, aligning payments with performance, stratifying the populations using predictive modeling, and improving data-driven management with electronic integration across providers to reduce hospital admissions and acute care spending.

• In the Netherlands, Zio has integrated primary care, remunerating providers with bundled payments, using a comprehensive set of performance metrics developed locally and nationally, and shifting care from general practitioners (when appropriate) to better manage patients with chronic diseases.

Table 1 describes the key population demographics, the specific delivery or payment innovation, and the national health system context. Table 2 reports key results, including improvements in care delivery process, clinical measures, satisfaction rates, and costs. More in-depth case-specific findings are synthesized in a companion case study series.


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Table 1: Key Demographics, Innovations and Health System Context by Case Study

Organization Model and Demographics Innovations Health System Type Better

Together • Alliance of integrated

primary, acute and social care systems

• Provider-level payments partially tied to performance

• Formed in 2013 • Serves population of

310,000 • Aging and overweight

population with high rates of chronic diseases

• Integrates primary, mental health, acute, ambulatory, after-hour service, and community-health services

• Hospital datasets used to identify at patients at risk of hospitalization

• Capitated payment structure to share risks and rewards

• Universal healthcare • Primary care mostly

delivered through privately-owned practices

• Primary and secondary care fragmented

• Weighted capitation with elements of FFS

Gesundes Kinzigtal

• Health management company that coordinates between multiple types of providers and two insurance funds, covering about 46% of the total population (all ages, no exclusion)

• Organization and provider-level payments partially tied to performance

• Operating for 11 years • Contract automatically

covers 33,000 people in region, of those, 10,000 patients actively voluntarily

• Population is below national income, rural, with high chronic disease burden

• Multidisciplinary care teams include GPs, psychotherapists, hospitals, nursing homes, ambulatory agencies, physiotherapists, and social workers. Also collaborates with non-medical services (e.g., gyms, pharmacies and adult education center).

• Long-term shared savings contract for geographically-defined population

• Pay for performance • Comprehensive EHR

and business intelligence system with predictive modelling

• Interventions including prevention, public and social arena

• National health insurance with private options (mainly amenity features)

• Primary care delivered through private sector

• Shared risk through sickness funds, which negotiate with providers

• Reimbursement system for physicians is combination of capitation and FFS / hospital services via diagnosis related groups (DRGs)

ZIO • Integrated primary care group targeting patients with specific chronic diseases

• Bundled payment to physicians, partially tied to performance

• Piloted in 1997, formalized in 2007

• 24,500 patients enrolled

• Task shifting to specialty nurses

• Bundled payment contract for defined package of care

• Stratification of patients into four modules

• Universally-mandated private insurance, regulated and subsidized by government

• Primary care delivered through private sector

• GPs act as gatekeepers to secondary care

• Providers paid through a combination of capitation and FFS


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Possible • Non-profit, public private partnership providing primary care to rural areas

• 20 percent of organization payment tied to performance. Physician remuneration partially tied to performance

• Operating for 8 years • Serves region of 440,000 • Low-income, rural with

growing chronic disease burden

• Community health workers reach patients through hub-and-spoke model

• Telehealth services • Portion of physician

remuneration tied to performance

• 20 percent performance contract with the government

• Decentralized • Private sector driven • High out-of-pocket

spending • Primarily FFS


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Table 2: Key Results

Organization Process Clinical Satisfaction Costs Better

Together Reduced inappropriate emergency attendance by 4%

$27.67 million in total savings in 2016-2017 $4.35 million gross savings in 2016-2017 122% ROI

Gesundes Kinzigtal

Hospital admissions increased by 22.9% less than comparative group

• Mean age of death 1.4 years higher than in control group

92% patient satisfaction rate

From 2007-2014 total savings of ~$38.2 million (USD 2014). In 2014: €5.5 million ($7 million, USD 2014); (7.4 percent)

ZIO • Task shifting: Decrease in diabetes-related consultations with GPs and endocrinologists decreased while more (routine) consultations with the DNS took place

• Fewer patients hospitalized

15% decrease in proportion of patients with poor glycemic control

89% of patients would recommend the model

• 54% decrease in hospital admission costs with patients assigned to the DNS

• €142 increase in specialist costs per bundle, compared to the control group in Year 1 (attributed to start-up costs)

Possible

• 100% access to surgery

• Equal access to care for patients of all demographic backgrounds

• Provided health services for less than $20 per patient

14% of total patients with a chronic disease have their disease under control in the first quarter of 2017

Findings: Emerging Lessons and Themes Based on the four case studies, we have developed the emerging lessons and themes described below. The accountable care framework levels provide an organizing principle for stakeholders show what stakeholders can glean from the case examples. Figures 3, 4, and 5 summarize translation opportunities for policymakers, payers, and providers in the U.S.


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Organizational Competencies Governance and Culture - Effective clinical leadership is critical to improving care quality and can increase clinician buy-in for reforms.24 Involving patients, physicians, and other stakeholders in the decision-making process also ensures the organization is responding to issues that matter to the community. A key challenge is creating organizational models that support clinical leadership and organizational change. Organizations have implemented the following strategies to improve organizational culture, leadership and governance.

• Invest in organizational models that support clinical leadership and shared values. Better Together, Gesundes Kinzigtal, and Zio have included physicians on their executive boards, ensuring that the physician perspective is incorporated in management decisions. Possible has established common goals and visions around which stakeholders and staff can organize. They have developed a series of Key Performance Indicators aimed at expanding equitable care to remote, poorer communities to reinforce the organization’s values.

• Meaningfully engage stakeholders. Better Together, Gesundes Kinzigtal, and Possible have implemented stakeholder advisory boards that provide stakeholders, including patients, an active role in the organizational leadership. Better Together, Zio, Gesundes Kinzigtal, and Possible have also developed feedback mechanisms—through frequent patient and staff satisfaction surveys and regular team meetings—to assess stakeholders’ perspectives.

• Consider alternative organizational structures that promote collaboration and shared

responsibilities. Both Possible and Gesundes Kinzigtal have implemented management structures that improve coordination among employees while elevating their responsibilities. Possible’s management structure is relatively horizontal, with teams organized by specific areas of expertise to leverage physician’s skillsets. A medical director oversees clinical care, a Community Health Director oversees community care, and an Operations Director oversees supply chain management and financials. Gesundes Kinzigtal’s heterarchical model drives continuous involvement between independent network partners.

Financial Readiness – A common feature among accountable care efforts is the transition from fee-for-service to person-based payments. While alternative payment models are not the only component of accountable care, they can provide supportive mechanisms to reinforce value-based outcomes. However, payment reforms are often incremental, with shifts over time toward increasing accountability and provider risk tied to performance. Organizations need the technical capability to be able to shift to payment models that require greater risk. The following financial competencies help facilitate a transition to value-based payments:

• Develop financial systems that can monitor costs, revenues, and utilization rates. Organizations need to be able to monitor their current performance to forecast their financial position. Gesundes Kinzigtal tracks total expenditures for insured members compared to a standard benchmark. Better Together’s financial infrastructure accounts for


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uncontrolled activity within the alliance through a variable element, which enables a portion of the budget to flow between providers, should a person change clinicians.

• Implement payment mechanisms that integrate providers across settings. Expanding the umbrella of care across providers is effective when organizations meaningfully integrate providers. For instance, Zio has implemented financial levers to integrate disparate providers. Through bundled payments, Zio covers all primary care needs for patients with chronic diseases, assuming clinical accountability for all diabetes patients in their program.

Health Information Technology – An organization’s health information technology infrastructure can impact their ability to coordinate and improve care. However, integrating electronic health records across platforms and incorporating them into the workflow is technically challenging for most organizations. Organizations often lack the initial resources, staff knowledge, or incentives to meaningfully realize the benefits that health information technology can offer. To address these issues, organizations could consider the following actions in the technical arena that support accountable care delivery:

• Design an information technology infrastructure that is interoperable across providers and platforms. To integrate care, it is essential that information systems can exchange data seamlessly. All case studies have developed electronic health record (EHR) systems with varying degrees of interoperability. Better Together’s Medical Interoperability Gateway allows for the secure and safe sharing of GP patient records for all urgent and emergency care providers over a number of care settings, including out-of-hours, secondary care, ambulance and emergency services. Possible and Zio have developed platforms that systematically collect patient feedback. Zio’s disease-specific EHR system (Medix) allows physicians across the care delivery spectrum to access patient data. Gesundes Kinzigtal is currently implementing a project to give patients direct access to their central EHR.

• Gather data from multiple sources. Aggregated data creates a comprehensive profile of each patient. For example, Gesundes Kinzigtal has used basic claims data (age, sex, and residence), data on diagnoses and services in ambulatory care, prescribing data for office-based physicians, hospital data (admission/discharge diagnoses, length of stay, surgeries and procedures, diagnosis-related groups), sick leave data, and data on nursing care/long-term care. Better Together also tapped into national registries to expand their data, using Secondary Uses Service (SUS), England’s central database for patient-level health care.

• Develop tools to communicate remotely and across providers. Organizations often lack

the infrastructure and manpower to provide high-risk patients with the significant and consistent attention that they need. Both Possible and Better Together have used health information technology to expand the scope of care. Possible, which operates in a rural area with an extremely low patient-to-provider ratio, uses telehealth for remote monitoring of patients and an integrated EHR to enable collaboration between physicians in different regions. Better Together has also developed a telehealth system that enables providers and patients to communicate remotely, alerting providers if a patient’s condition starts to deteriorate. Additionally, Gesundes Kinzigtal is piloting online doctor-patient


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communication tools to reduce unnecessary travel and waiting periods and mobile rehabilitation teams to support geriatric patients in their homes.

Risk Assessment – The majority of health expenditures in many models of care can be attributed to a small subset of high-needs patients. Reductions in cost can often be achieved by improving health status for this patient population. Consequently, a key challenge for many organizations is the optimizing the patient risk-assessment process, so that high-risk individuals can be identified earlier on to increase the effectiveness of health interventions. Organizations developed the following strategies to prospectively assess risk:

• Create a platform to assess risk. Better Together’s advanced risk assessment platform illustrates the benefits of leveraging technology to improve care. Through their platform, Better Together is able to process significant quantities of data quickly and reliably. Regional surveillance has also been an enabling factor for Better Together. They employed the peer-reviewed Devon Risk Stratification Tool to find patients in all levels of care with one or more serious chronic diseases.

• Implement a process to stratify patients and capture trends. Targeting reforms around a specified population can optimize care. Zio stratifies individuals based on the severity of their disease using condition-specific parameters, and provisions care based on this stratification process. Gesundes Kinzigtal and Better Together have also implemented innovative approaches to proactively identify at-risk patients. Gesundes Kinzigtal has developed a business intelligence system to analyze costs and enables them to identify high-risk patients using predictive modelling and other data analysis techniques like logistic regression. Better Together identifies patients at risk of hospitalization with a locally-developed technology that ranks patients according to their future risk of admission.

Person Centeredness – In contrast to conventional health delivery systems, accountable care emphasizes outcomes that matter to the patient. In this paradigm shift, the patient is the center of the model. Achieving this shift requires increasing patient engagement and incorporating patient input throughout the decision-making process. Organizations seeking to develop person-centered models can take the following approaches to facilitate meaningful patient engagement:

• Provide care that targets the physical, behavioral, cognitive, and social components of a person’s health. In one approach to whole-centered care, Better Together relies on interdisciplinary teams of primary, mental health, acute, ambulatory and community-health providers to deliver care to high-risk patients. This integrated suite of health and social care provides systematic support for patients as they transition to self-care. Similarly, Gesundes Kinzigtal employs multidisciplinary care teams that include general practitioners, specialists, psychotherapists, hospitals, nursing homes, ambulatory agencies, physiotherapists, and social workers.

• Ensure that the population can access care easily by aligning medical and social services. Case studies show how embedding multidisciplinary team members in the community can enable access to care. For example, Possible has relied on community


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health workers to conduct rural disease surveillance and home-based investigations to help develop personal relationships with patients. Additionally, Gesundes Kinzigtal is piloting online doctor-patient communication tools to reduce unnecessary travel and waiting periods and mobile rehabilitation teams to support geriatric patients in their homes.

• Involve patients in the decision-making process. There are many approaches to integrating

patient input while designing care. For example, Gesundes Kinzigtal has incorporated shared decision-making between patients and providers and self-management initiatives. Patients actively participate in treatment decisions, working together with providers to develop individual treatment plans and goals. Self-care programs include free gym memberships and nutritional programs for patients with high blood sugar levels. Zio provides education on self-management and promotes health education materials during regular patient checkups.

Quality and Process Improvement – Accountable care depends on the ability to improve performance related to quality of care and resource use. However, developing and implementing these measures to reliably impact interventions, patient well-being, clinical outcomes, and organizational efficiencies is challenging. The following examples illustrate what capabilities organizations can take to improve outcomes and performance:

• Create measures that are meaningful and actionable. All case studies have implemented performance measures related to quality of care and resource use. For example, the Gesundes Kinzigtal model includes disease-specific clinical indicators, general health indicators, mortality rate, care costs, individualized care plan, and plan acceptance by both patients and providers. Zio has developed metrics to supplement nationally set indicators for processes, like the percentage of patients receiving annual foot examinations, and outcomes, like the rate of patients with controlled blood cholesterol levels. To realign risk and reward within their system, Better Together has adopted a variety of performance measures centered on end results rather than inputs. These span four domains: population health, quality of life, quality of care, and care effectiveness.

• Develop the necessary operational infrastructure to support quality improvements. A common trend across the case studies was a focus on “actionable data” at the organizational level. Systems such as Possible and Better Together developed integrated EHR platforms from the ground-up that focused on interoperability and rapid update times. These tools have allowed providers to easily sift through health data and lead regular internal performance evaluations to identify strengths and weaknesses of the model. Increased data transparency has elevated provider awareness about their own role and performance within the system, contributing to a culture of accountability. For example, clinicians in Gesundes Kinzigtal can review their personal performance scores online and compare against their peers’ benchmarks.

Care coordination and Transformation – A core value in accountable care is the idea of “person”- rather than “patient”-based care. In practice this translates to acknowledging and addressing the social and behavioral determinants of health are just as important as medical intervention. This approach requires bridging the divide between providers and social sector


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professionals to ensure individuals have continuity in care across a range of services. Case studies have implemented the following factors that enabled them to coordinate care around the individual:

• Expand care by implementing multidisciplinary teams or establishing agreements with pharmacies and other care settings that provide long-term care or social supports. Holistic approaches to care shift the locus of care from institutions to communities. The case studies show a recognition that shifting this paradigm requires integrating health and social services to meet the wide-ranging needs of each individual. Better Together has assembled eight “Integrated Care Teams” that proactively deliver care to high-risk individuals to prevent hospital admissions and support early discharge. The interdisciplinary teams include GPs, community nurses, occupational therapists, physiotherapist, mental health workers, social workers, and healthcare assistants. Co-location in the community allows provider teams to rapidly mobilize social services in addition to traditional clinical measures, preventing hospital admissions and facilitating the transition to self-management. Possible also instituted multi-disciplinary teams co-located in their communities to optimize care delivery. Possible recruited and trained community health workers to conduct case-finding home visits and build relationships with local clinics. Gesundes Kinzigtal has also implemented multidisciplinary care teams and has established agreements with pharmacies, gyms, private companies that provide workplace health promotion, and adult education centers.

• Distribute tasks in a manner that optimizes care. For example, Zio pioneered a new model to disease management in the Netherlands by shifting tasks from medical doctors towards specialized nurses and from the hospital to GPs. Zio assigned support staff a central role and delegated tasks traditionally reserved for GPs, specialists, and other providers. Today, nurses are responsible for patients with low and medium intensity care, while specialists like endocrinologists attend to patients with high intensity needs. GPs are responsible for the care of the patients with low and medium intensity care. This allows for comprehensive and flexible care.

• Implement a clear clinical decision process to manage care across providers. Several

organizations have established protocols to facilitate care across the continuum. In the Zio model, the primary care unit is responsible for coordinating care across multiple provider settings, and engages in regular patient follow-up and case management. Better Together has created a “Care Navigator” to arrange community alternatives to hospital admission or support a discharge from hospital or care home. Similarly, Gesundes Kinzigtal has developed a “doctor of trust”—any physician, specialist, or psychotherapist within the network—who is responsible for health assessment, helping the patient navigate the healthcare system, coordinating care, and managing all follow-up care.


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Figure 3: Organizational Competencies—Translation Opportunities

Competency Challenges for U.S. ACOs Case Study Lessons Translation to U.S. Context

Governance & Culture

UTSW Fears of losing physician autonomy in value-based care models

Germany Physician-led organization structure; providers as administrators and financial stakeholders

Create pathways for physician leadership to foster ownership of and accountability to the overall system

Financial Readiness

Arizona Connected

Loss of provider revenue during the transition away from FFS

Germany Physicians are financial stakeholders and receive an add-on payment based on system profits

Design new models where providers are financial shareholders and clinical leaders to create monetary accountability for system performance

Health IT Infrastructure

Project Echo

Use of health IT to expand care delivery capacity

England Broader access and use of telehealth for patient self-monitoring

Incorporate digital care platforms and social media to expand provider bandwidth

Patient Risk Assessment & Stratification

MedStar Data gaps preventing the identification of high-risk patients

Netherlands Create “patient profiles” based on disease severity to guide stratification

Collaborate with other providers to tailor care to the needs of specific patient populations

Patient Engagement

Health Share

Lack of consistent outlets for patients to communicate concerns and see improvements

Germany Co-development of evaluation metrics with a Patient Advisory Board

Involve patients in decision-making and incorporate their feedback during the transformation process

Quality & Process Improvement

Marshfield Incremental pace of reform can limit organizational momentum for change

Nepal Dedication of personnel for quality improvement; quarterly performance publications

Invest in transparent performance reporting to show and reward improvements while identifying challenge areas for further work

Care Coordination and Transformation

Hennepin Health

Hospital-focused care increases acute care use and ED visits

England Create public health alliances and invest in social services to shift to community care

Integrate health and social services into care to transition into “person” focused care


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Accountable Care Policy Population –Accountable care policies can support providers in selecting which populations will be beneficiaries of accountable care policy reforms, whether it is the entire population in a specific catchment area or a population with a specific disease or condition. The following examples demonstrate what steps case studies took to proactively identify specific populations:

• Identify patients prospectively. Organizations must first proactively identify population groups. A majority of case studies screened databases to develop profiles of patients. For instance, Better Together uses demographic and clinical information from hospital datasets that cover the past two years of patient history, as well as data from GP Practices, out of hours, and ambulance services. Gesundes Kinzigtal identifies patients who are at risk for certain diseases using data from basic claims and ambulatory, prescription, hospital, sick leave, and long-term care.25 Additionally, providers in Gesundes Kinzigtal identify patients during initial checkups.

• Stratify patient groups. After identifying high-risk patients, organizations should group individuals by risk level. For instance, Zio groups patients into four categories based on disease condition. Intensity of care depends on each patient’s level of need. Better Together stratifies patients according to their risk for hospitalization and then provides targeted interventions using either case management, disease management, or supported self-care.

Performance Measures – Organizations should develop reliable performance measures that reflect patient experience, health outcomes, and resources utilization. To calibrate measures to outcomes, case studies took the following actions:

• Include stakeholder input when creating measures. Stakeholders should help design performance measures to ensure measures are meaningful. For instance, Better Together adopted a variety of performance measures centered on end results rather than inputs. They achieved this by involving a range of stakeholders to develop an “outcome framework”—a collection of measures used to monitor and contract for services. A working group developed the outcome framework with representatives from the local authorities, GPs, secondary care clinicians, and HealthWatch (a patient advocacy group). The working group developed indicators within each domain tailored to specific demographic groups.

• Complement national metrics with locally relevant metrics. Metrics set at the national level can be useful for reducing disparities in care across broad regions. However, organizations should develop complementary metrics that meet the needs of their specific populations. For example, in the Netherlands a national framework codifies the treatment goals and evaluation metrics for diabetes care. To capture the patient experience, Zio then developed additional metrics such as the percentage of patients provided with self-management support. Similarly, in addition to incorporating clinical, mortality and cost of care measures, providers in the Gesundes Kinzigtal model are measured based on the success of individual care plans and plan acceptance by the patient and the provider.


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Support of Continuous Improvement – Real-time monitoring and evaluation to create actionable feedback is necessary to adjust workflow patterns and assess pre-determined benchmarks. Organizations undertook the following steps to adapt to changing health demands and needs:

• Implement timely feedback mechanisms. All case studies developed mechanisms that provides a snapshot of the key performance standings. For instance, providers in Gesundes Kinzigtal receive performance reports every quarter, known as “Health Services Cockpit” (HSC), which is similar to a quality dashboard in the U.S. These interactive web-based reports include detailed data about provider performance in comparison to other providers within and outside of the Gesundes Kinzigtal network. The HSC also provides detailed information at the case, patient, or service level for each indicator. The information is provided in newsletters, physician-led quality review meetings known as “quality circles,” clinical visits, and annual meetings with the CEO of Gesundes Kinzigtal. These metrics serve as a non-financial motivation for physicians to improve their medical practice. Better Together synthesizes performance measures from all providers in the network and analyzes trends in clinical performance. Combined, the results are published internally for performance management. Better Together also provides monthly dashboards detailing performance measures at the locality level. This ensures that the model adapts to the changing needs of the population’s needs over time.

• Allow third parties to evaluate performance. In addition to in-house evaluations, organizations should consider using a third party for audits, ensuring the independence of results. For instance, an external quality institution audits Gesundes Kinzigtal annually and Gesundes Kinzigtal implements changes every two to three years based on audit results. Gesundes Kinzigtal also developed an independent scientific review agency in conjunction with a university to oversee proposals by research institutions to evaluate Gesundes Kinzigtal’s program outcomes.

Payment and Non-Financial Incentives – The financial and non-financial supports, whether they are through APMs, public reporting or other efforts to increase provider accountability, can enhance care delivery changes occurring at the organizational level. The case studies are experimenting with different payment models, such as bundled payments or increasing provider risk, and using non-financial incentives, such as provider recognition to reduce gaps in care.

• Mitigate financial risk by holding providers accountable. Gesundes Kinzigtal, Zio, and Possible each established financial incentives for participating providers to adopt processes or technologies that reduce costs in the long term. For example, Gesundes Kinzigtal provides additional reimbursement for services that it considers cost-effective. Gesundes Kinzigtal has also implemented a model whereby physicians share the financial risk in the plan’s savings or losses. Additionally, Zio, Better Together and Possible instituted financial penalties if providers failed to meet contractually agreed upon metrics, ensuring staff are invested in the performance of the system.

• Develop payment models that support physicians in offering value driven care. Traditional fee-for-service models financially prioritize volume of services rather than value-based care. In contrast, performance-based payment models with accountability reorient care around outcomes. For example, in Gesundes Kinzigtal, physicians are


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majority shareholders of the care model. This financial arrangement aligns physicians’ interest with system-wide performance and empowers clinicians to be active in administrative decisions, bridging the gap between payment and delivery. Possible instated a public-private contract with the government provides baseline funding and applies an additional 20 percent reward or penalty to Possible based on population health needs. Physician remuneration is also partially tied to professional performance evaluation and is not volume-based.

Support for Care Coordination and Transformation – Investments in national health information efforts, integration of care teams into payment models and other efforts to reallocate financial support may be needed to achieve measurable care delivery improvements. Implementing effective steps for care transformation is difficult to accomplish without policy changes to support the care coordination activities and team compositions that providers are implementing at the organizational level.

• Invest in tools and resources to reorganize the way care is delivered. In the UK, Better Together has invested in a telehealth service to support patient self-monitoring and person-level analysis of the frequency of a patient’s contact with the system. Zio has also invested in technology that promotes information sharing, protocol standardization and systematic collection of laboratory and clinical data and user feedback.


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Figure 4: Accountable Care Policies—Translation opportunities

Competency Challenges for U.S. ACOs Case Study Lessons Translation to U.S. Context

Population Holy Family Memorial

Optimizing criteria for risk stratification

England Incorporated demographic and clinical data into a highly accurate risk stratification algorithm

Invest in one, universal platform for identifying and tracking patients across the target region

Performance Measures

Health Share

Lack of consistent outlets for community members to communicate concerns and see improvements

Germany Evaluation metrics are internally developed and tied to reimbursement

Offer financial rewards for self-developed system metrics independent of national care and cost targets

Continuous Improvement

Presbyterian Challenge of developing standard measures for patients with diverse needs and conditions

Nepal Regular internal audits used to re-evaluate performance metrics

Ensure measures and processes are adaptable to the changing needs of patients and challenges of the system

Financial and Non-Financial Incentives

Lahey Health

Gap between quality improvement and cost reduction

Netherlands Bundled payments established baseline service coverage and link quality and cost

Align cost and outcomes through flexible payment elements for individual and system performance


Project Echo

Provider burnout and capacity gaps in primary care

Netherlands Re-distributed labor using MDTs to expand the scope and quality of care

Train non-physician providers to fill gaps in primary care


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Health Policy Environment

Institutional – Government institutions can play a vital role in providing the adequate resources for organizations to adopt value-based care. This often requires transforming traditional financial and service delivery mechanisms to better align with innovative care models. For instance, financial support or collaboration between public sector agencies can be tailored to new modes of care delivery. Policymakers should consider the following steps to optimize institutional resources for new care models:

• Support policy efforts for risk-based payment models. As has occurred in the U.S., the majority of case studies have received financial assistance from the public sector to experiment with alternative payment and delivery models. These initiatives, such as the Vanguard program in England and the Statutory Health Insurance Act in Germany, have given health care organizations the financial flexibility to take on risks, especially in the beginning phase of implementation. Health care organizations have used the initial capital as a foundation for broader payment reforms. For Better Together, this has led to the piloting of a capitated budget with an outcomes-based payment element. For Gesundes Kinzigtal, this has manifested as a long-term shared savings contract with new opportunities for provider reimbursement. Both case studies illustrate the importance of designing long-term financial structures to accommodate for the incremental pace of generating savings.

• Increase opportunities for information sharing and collaboration across health organizations. National health policies can facilitate value-based reforms by promoting data exchange across separate actors. For instance, For Better Together, national efforts are currently underway to collect data and link electronic records across primary, acute, and social care settings. Once in place, this expansive database will assist Better Together in monitoring and stratifying patients with comorbidities.

Political – Introducing accountable care models requires buy-in from multiple actors, each with their own interests. Aligning these interests is a prerequisite for successfully implementing and sustaining innovative reforms. The case studies illustrate the following approaches policymakers took to unite stakeholder interests:

• Engage provider, patient groups, and payers in the entire decision-making process. The Better Together model illustrates how to engage diverse stakeholders throughout the planning process. Healthcare leaders in Nottinghamshire region established a blueprint for Better Together in 2013, with input from providers and the local population. The organization administered surveys of the population every six months. Leaders also continuously involved providers while designing the Better Together model. For instance, they established planning boards comprised of hospitals, primary care representatives (GPs, practices managers, and practice nurses) and social care providers to facilitate the planning process. Zio and Gesundes Kinzigtal also emphasized the importance of engaging clinicians and other stakeholders early in the implementation phase. Both organizations cited long-standing collaborations between providers—and models that prioritized collaboration over competition—as critical for achieving buy-in. 26


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Regulatory – Organizations looking to adopt accountable care approaches often face regulatory barriers or unchartered legal territory. Legislation designed to promote safety and clarity for traditional health care organizations may be ill-suited to new health care models. For example, workforce regulations may hamstring an organization’s efforts to expand staff’s scope of practice. Policymakers may consider adopting the following approaches to better align the regulatory infrastructure with value-based care models:

• Reassess scope of practice legislation to expand clinical and non-clinical care. Policymakers can work toward creating policy measures that support task-shifting—the process of distributing tasks to less specialized health workers—to disburden physicians and optimize workflow. The Netherlands, for instance, reformed licensing requirements to improve care coordination in disease management programs. Maastricht University’s (Zio’s predecessor) pioneered a disease management program that shifted tasks from medical doctors towards specialized nurses in outpatient settings. The Netherlands adopted Maastricht’s model as a national standard for disease management programs, authorizing nurse practitioners and physician assistants to autonomously perform specified medical procedures and prescribe certain medicines which were previously restricted to physicians, dentists and midwives.

• Establish legal framework to safeguard new care entities. Policymakers could provide legal clarity as to how organizations are seen from a regulatory perspective. In the case of Zio, the Netherlands formally codified “care groups” as the prime legal entity responsible for negotiating bundled payment contracts. Under this framework, care groups assume clinical and financial accountability for all diabetes patients in their program.27 The Netherlands’ approach illustrates how governments can facilitate accountable care reforms by clarifying the legal status of new care models.


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Figure 5: Health Policy Context—Translation Opportunities

External Factor

Challenges for U.S. ACOs Case Study Lessons Translation to U.S. Context

Institutional Metro Health

Lack of capital to support new pilot programs

Nepal Public-Private Partnership structure to access resources and funds

Repurpose existing public resources where possible to reduce the cost of care for new pilots

Political Hill Physicians

Fragmented decision- making and communication gaps in multi-party care organizations

England Three-part organizational structure that includes the community, policymakers, physicians, and payers

Centralize decision-making process into clear administrative bodies to unify the vision for reform and prevent conflicting actions

Regulatory Marshfield Fiscal and functional limitations for the use of non-physician team members

Netherlands National legislation afforded nurses and physician assistants authority to provide some prescriptions and medical operations

Re-evaluate legal barriers to distribution of clinical labor as a means to optimizing MDTs and expanding care capacity


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How this study was conducted Coordination of National Health Care Experts We convened an advisory group of 20 U.S.-based policymakers, providers, and payers to provide thought leadership and guidance as we refined the accountable care framework, developed the case studies, and created the toolkit describing lessons learned. The project began with a private roundtable that reviewed the investigation’s design, case study model, and international innovators selected for the case study series. We used quarterly calls to track project progress and refine quantitative and qualitative trends from the case studies. We also received input from a complementary advisory board convened for the World Innovation Summit for Health (WISH) Accountable Care Forum to guide the development of the accountable care framework. Design of International Case Studies We systematically analyzed experiences with accountable care in four health care organizations that demonstrated a substantial implementation of delivery and payment reforms with relevance for the improvement of care in the U.S. These organizations included: Better Together in England, Gesundes Kinzigtal in Germany, Zorg In Ontwikkeling (Zio) in the Netherlands, and Possible in Nepal. We designed a case study template to analyze each model’s health policy environment (e.g. national context), accountable care policies (e.g. care coordination), and organizational competencies (e.g. governance and culture). We then contacted the leaders from each health system and collaborated with partners within the organization to (1) apply our previously developed framework of accountable care to each case example and (2) write individual case studies. Case study collaborators provided data presented in the case study reports. The research team supplemented self-reported data with results from published articles (if available). Meta-Analysis of Local and Global Examples We analyzed U.S. examples of value-based care to identify common themes and shared challenges that could ground our international evidence of accountable care in a U.S. context. We conducted a meta-analysis of notable domestic accountable care pilots using 20 case studies from the Accountable Care Learning Collaborative, the American Hospital Association, the Commonwealth Fund, Health Catalyst, and the Integrated Health Association. We reviewed the health policy environment, accountable care policies, and organizational competencies of each U.S.-based example to identify the national challenges associated with the implementation of accountable care. We then used our accountable care framework to stratify illustrative challenges for key U.S. stakeholder groups (providers, payers, and policymakers). Each barrier was then paired with a lesson from one of the four international examples of accountable care to delineate translation opportunities that providers, payers, and policymakers could apply to health reform efforts in the U.S.


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Appendix A Better Together (England) Mid Nottinghamshire Better Together Health and Social Care (referred to as Better Together) is an alliance of regional providers and stakeholders in central England that have integrated primary, acute, and social care systems to reduce fragmentation and inconsistencies across health services to meet the needs of an aging, overweight population with high rates of chronic diseases and unplanned admissions. Better Together is a pilot program that began in 2013 with support from the national government as part of a national initiative to test innovative approaches to care delivery. Key innovations include a capitated payment contract to deliver population-based care, predictive modeling to identify patients who are at elevated risk for hospitalization, and strong stakeholder engagement. Although Better Together is in its first year of implementation, the program has reduced inappropriate visits to emergency departments by five percent, emergency department waiting times, length of hospital stay, and overall number of hospitalizations. In 2016-2017, Better Together also generated £22.275 million ($27.67 million USD, 2016) in total savings, £3.5 million ($4.35 million USD, 2016) in gross savings, and a 122% return on investment. Gesundes Kinzigtal (Germany) Gesundes Kinzigtal Ltd (Gesundes Kinzigtal) is a joint-venture between a physician network and a health management company that operates an integrated care system in rural southwest Germany, serving a lower-income population with a high proportion of non-communicable diseases. Assisted in part by a 2004 law provided financial incentives for integrated care models, Gesundes Kinzigtal developed a 10-year shared savings contract with insurers to coordinate care across contracted providers and manage health services for individuals enrolled in the program. Key innovations of their model include an advanced IT infrastructure that identifies high-risk patients using predictive modelling, timely internal feedback reports, and a focus on patient engagement and self-care. As a result of these innovations, Gesundes Kinzigtal has reduced hospital admissions and has saved 7.4 percent per insuree (in 2013). Zio (The Netherlands) Zorg In Ontwikkeling (Zio) is an integrated care network that provides a continuum of care for patients with non-communicable diseases through bundled payments. Zio negotiates a single bundled payment from insurers to providers that covers a comprehensive range of health services for a disease-specific patient population. Payments are linked to quality measures to create an incentive to improve health outcomes, with 10 percent of provider contracts allocated for performance-based financing. Zio emphasizes primary care and shifts tasks from general practitioners and endocrinologists to nurse specialists. The model also strengthens the role of health insurers as purchasing agents and moves care away from the hospital toward a community-based setting. Zio’s care delivery model for disease management has helped guide national policy reforms for chronic care delivery implemented by the Dutch Ministry of Health. Key results include a decrease in hospital admissions and improved clinical outcomes. Possible (Nepal) Possible is a non-profit healthcare company that partnered with the Government of Nepal to deliver primary care to remote, rural populations that lack access to physicians and have high rates of communicable and non-communicable diseases. Possible aims to reduce barriers to care for low-


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income groups through its disease surveillance programs and by promoting patient self-care and focusing on early detection and prevention of infectious and chronic diseases. Possible created its low-cost, integrated care model by building on pre-existing resources, such as government infrastructure and a community health worker program. Services include hospital care (e.g., outpatient, inpatient, and laboratory), primary care in family practice, and home-based care for follow-up and longitudinal care coordination. As a result of these innovations, Possible has improved access to general and surgical care for patients of all demographic backgrounds, increased follow up rate for chronic diseases, while maintaining affordability (less than $20 per patient on average).


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Figure 6: Key Features of Accountable Care Policy by Case Study

Conceptual Framework

Care Innovation

Bet

ter

Tog

ethe

r (E

ngla

nd)

Ges

unde

s K

inzi

gtal

(G

erm

any)

Po

ssib

le

(Nep

al)

Zio

(N

ethe

rlan

ds)

Population Whole-person X X

Chronic disease-based X X

X Low-income populations

X X

Performance Measures

Cost measures X X X X Measures based on individualized care plans

X

Outcome measures X X X X Patient experience X X X X

Continuous Improvement

Frequent feedback X X X

Transparent feedback X

X

National standardized measure set X

X Payments and Incentives

Bundled payments

X Capitated payments X

Rewards for outcomes X X X X Risk-sharing X

X


Team-based care with non-clinicians X X X X Interoperable electronic health record X X X

Telehealth capabilities X

X


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Figure 7: Key Features of Organizational Competencies by Case Study


Competency

Bet

ter

Tog

ethe

r (E

ngla

nd)

Ges

unde

s K

inzi

gtal

(G

erm

any)

Poss

ible

(N

epal

)

Zio

(N

ethe

rlan

ds)

Governance & Culture

Inclusion of patients in governance structure

X X X

Empowerment of non-physician providers

X X

Financial Readiness

Performance-based contract structures X

X X

Co-evolution of fee-for-service and performance-based payments

X

Health IT Infrastructure

Telehealth innovations to enhance chronic disease monitoring

X

X

Integrated electronic health record for cross-practice data sharing

X X X

Patient Risk Assessment & Stratification

Electronic analysis of health information (e.g. claims data)

X X

Evaluation of care and social context during risk assessment

X

Patient Engagement

Option for place-based care X X X

Focus on patient self-management X

X

Quality & Process Improvement

Dedicated personnel for internal quality improvement

X X

Redistribution of labor using non-physician providers

X

X X

Care Coordination

Integration of health and social services X

X

Use of partnerships to expand care capacity X

X


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Figure 8: Key Features of Health Policy Context by Case Study


External Factor

Bet

ter

Tog

ethe

r (E

ngla

nd)

Ges

unde

s K

inzi

gtal

(G

erm

any)

Po

ssib

le

(Nep

al)

Zio

(N

ethe

rlan

ds)

Institutional Financial support from the government for reform

X X X

Data sharing facilitated by government partnerships

X

X

Political Broad engagement with different stakeholders to address conflicting incentives

X X

Investment in community relations and co-location of providers to secure buy-in from local population

X

X

Regulatory

Removed legal barriers for non-physician providers

X

Re-distribution of risk to support new model development

X X

X


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