High Performance Accountable Care: Building on Success and Learning from Experience

1. 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

2. Report by the Commonwealth Fund’sCommission on a High PerformanceHealth 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

3. 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

4. Public Support for Policies toImprove 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%)

5. Moving Toward aHigh 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

6. 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

7. Commission Recommendations and NPRM Provisions

8. Commission Recommendations and NPRM Provisions

9. 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

10. Appendix

11. Access Problems: More Than Two of Three AdultsHave 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).

12. Potential Waste and Inefficiency: More Than Half of AdultsExperience Wasteful and Poorly Organized Care Percent reporting in past two years: Doctors ordered a testthat 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).

13. Poor Coordination of Care Is Common,Especially if Multiple Doctors Are Involved 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).

14. Support for More Accessible, Coordinated,and Well-Informed Care 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).

15. Support for Doctors Working inTeams 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).

16. A Majority of Americans Say the Health Care SystemNeeds Fundamental Change or Complete Rebuilding 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).