Accountable Care:
A Path Toward the Triple Aim?Trissa Torres, MD, MSPHSenior Vice PresidentInstitute for Healthcare Improvement
G8
April 11, 2014
Agenda
ACOs…
Why
What
Progress
Toward Success
International Comparison of Spending on Health, 1980–2010
Average spending on healthper capita ($US PPP)
Total health expenditures aspercent of GDP
Notes: PPP = purchasing power parity; GDP = gross domestic product.Source: Commonwealth Fund, based on OECD Health Data 2012.
Males Females
Rank Country Average Length of Life Rank Country Average Length of
Life
1 Switzerland 79.33 1 Japan 85.98
2 Australia 79.27 2 France 84.43
3 Japan 79.20 3 Switzerland 84.09
4 Sweden 78.92 3 Italy 84.09
5 Italy 78.82 5 Spain 84.03
6 Canada 78.35 6 Australia 83.78
7 Norway 78.25 7 Canada 82.95
8 Netherlands 78.01 7 Sweden 82.95
9 Spain 77.62 9 Austria 82.86
10 United Kingdom 77.43 9 Finland 82.86
11 France 77.41 11 Norway 82.68
12 Austria 77.33 12 Germany 82.44
13 Germany 77.11 13 Netherlands 82.31
14 Denmark 76.13 14 Portugal 82.19
15 Portugal 75.87 15 United Kingdom 81.68
16 Finland 75.86 16 United States 80.78
17 United States 75.64 17 Denmark 80.53
Wealthier, Not Healthier
Source: Institute of Medicine. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Available at: http://www.iom.edu/Reports/2013/US-Health-in-International-Perspective-Shorter-Lives-Poorer-Health.aspx
Social Spending
Source: Bradley EH, Elkins, BR, Herrin J, Elbel B. “Health and social services expenditures: associations with health outcomes.” BMJ Quality & Safety. March, 2011. http://qualitysafety.bmj.com/content/early/2011/03/28/bmjqs.2010.048363.abstract
An all too familiar scenarioIt’s scary when I can’t breathe.
Sometimes I’m just too tired to go to the doctor.
I miss my family.
An all too familiar reactionI know what she needs, but not how to help her.
If only someone could check on her.
I don’t have the time or the resources.
Affordable Care Act (ACA) “Obamacare” Increasing Coverage, Changing Care Models
2010 2011 2012 2013
President Obama signs the Affordable Care Act. (3/23/2010)
Prohibit Denying Coverage of Children Based on Pre-Existing Conditions (9/23/2010)
Provide Free Preventative Care(9/23/2010)
Bring Down Health Care Premiums (1/1/11)
Increase Access to Services at Home and in the Community (10/1/1/11)
Encouraging Integrated Health Systems &Launch of ACO Pioneer Program(1/1/12)
2014
Understanding and Fighting Health Disparities (3/1/12)
Improving Preventative Health Coverage & Launch of SSP ACO model (1/1/13)
Open Enrollment in the Health Insurance Marketplace Begins (10/1/13)
Prohibiting Discrimination Due to Pre-Existing Conditions or Gender (1/1/14)
Establishing the Health Insurance Marketplace (2014)
Source: U.S. Department of Health and Human Services
Accountable Care Organization (ACO)
Definition
An ACO is an organization of health care providers that agrees to be accountable for the overall care and cost of care for assigned beneficiaries
Experience of Care
Per Capita Cost
Health of a Population
Social circumstances
15%
Environmental exposure
5%
Health care10%
Behavioral patterns
40%
Genetic predisposition
30%
Determinants of Health and Their Contribution to Premature Death
Adapted from: McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff(Millwood) 2002;21(2):78-93.
Proportional Contribution to Premature Death
Triple Aim = Managing Populations
Triple Aim
Results
Defined Populations
Community-Wide
Populations
ACOs are a Payment Mechanism
Fee for Service
Pay for Performance
Shared Savings Shared Risk Global
Payment
Accountable Care Organizations (ACOs)
Source: Leavitt Partners Center for Accountable Care Intelligence
Now over 600 ACOs across the country
ACO Growth
Source: Leavitt Partners Center for Accountable Care Intelligence
ACO Growth by Organization16
Source: Leavitt Partners Center for Accountable Care Intelligence
Growth in Covered Lives
Source: Leavitt Partners Center for Accountable Care Intelligence
Serving over 18 million people
Preliminary ResultsGovernment Sponsored ACOs
Pioneer (n=32) SSPs (n=114)0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CMS ACO Financial Results Year 1
Shared Savings Savings Not At Target Did Not Achieve Savings
Source: The Commonwealth Fund and U.S Department of Health and Human Services
CMS ACO Quality Metrics
Patient/caregiver experience7 measures Timely, communication, specialist access, health promotion, shared decision making, perceived health status
Care coordination & patient safety6 measuresReadmissions, ASC Admissions for CHF, EMR, Med Rec, Fall Risk
Preventive health8 measuresInfluenza Immun, Pneumococcal, Wt screening, Tobacco assessment & intervention, Depression Screen, CRC Screen, Mamm Screen, BP assess
At-risk populations12 measuresComposite scores for management of Diabetes, Hypertension, Ischemic Vascular Disease, Heart Failure, Coronary Artery Disease
What might success look like?
EMS implements shared protocol to treat instead of
transport if appropriate
Care manager
checks on her regularly
Her son gets her a tablet and sets up Facetime
Physician’s office staff ask church members to visit
Population Management
Identify high-risk/high-cost patients using a variety of methods
Understand cost drivers within segments
Assess patient resources and capabilities and their socially-determined risk factors
Understand patient goals and preferences
Understand system barriers from patient perspective
Co-create holistic approaches that impact peoples’ health
Identify patient “archetypes” and design care platforms that encompass multi-sector partners
Move care as close to the patient as possible
Involve non-traditional health care workforce
ASSESS AND SEGMENT THE POPULATION
ENGAGE AND ACTIVATE THE POPULATION
CARE FOR THE POPULATION
ESTABLISH a CROSS-COMMUNITY SYSTEM of CARE: Invest (develop payment mechanisms) in social determinants of health
Build coalitions including patients and families to identify and advocate for policies that support the needs of this population Use stories and narrative to build will
Delivery of Services at
Scale
Community, Family and Individual Resources
Managing Services for a Population
FeedbackLoops
Needs Assessment for
SegmentService Design
CoordinationGoals
Integrator
Population Segmentation
Population Outcomes
FeedbackLoops
Activities of a Population Management Learning System
Click icon to add picture
Enabling and Constraining Factors
Leadership
Integrated Data Systems
Improvement Infrastructure (Learning System)
Provider and Stakeholder Engagement
Leveraging Financial Models
New Mental ModelsHow Leaders Think About Challenges and Solutions
Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
High-Impact Leadership BehaviorsWhat Leaders Do to Make a Difference
Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
IHI High-Impact Leadership FrameworkWhere Leaders Focus Efforts
Population Management Assessment
Experience of Care
Per Capita Cost
Health of a Population
Improved provider experienceI am thrilled we are helping Mrs. Jones.
My team has come together.
Her family, church, and community have all come together to help too.
An all too familiar scenario
I’m not afraid.
Dr. Patel’s team helps me.
I don’t feel lonely anymore.
Recommendations to Accelerate the Journey…
“Act for the individual and learn for the population”
Understand what it truly takes to improve care for individuals
Leverage the richness of individual organizational learning
Create learning systems that enable ACOs to share with and learn from one another
Create more opportunities to convene representatives from the provider, payor, and health information technology communities
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