Early Lessons From Accountable Care Models In The Private Sector: Partnerships Between Health Plans And Providers

Abstract

New health care delivery and payment models in the private sector are being shaped by active collaboration between health insurance plans and providers. We examine key characteristics of several of these private accountable care models, including their overall efforts to improve the quality, efficiency, and accountability of care; their criteria for selecting providers; the payment methods and performance measures they are using; and the technical assistance they are supplying to participating providers. Our findings show that not all providers are equally ready to enter into these arrangements with health plans and therefore flexibility in design of these arrangements is critical. These findings also hold lessons for the emerging public accountable care models, such as the Medicare Shared Savings Program-underscoring providers' need for comprehensive and timely data and analytic reports; payment tailored to providers' readiness for these contracts; and measurement of quality across multiple years and care settings.

Posing A Framework To Guide Government’s Role In Payment And Delivery System Reform

“…8 For example, health plans vary the level of shared risk that providers bear based on levels of readiness. In general, plans have been judicious in their approach to payment reform, and in several cases, newer payment models still build on existing feefor-service relationships.…”

“…The specific criteria, reported elsewhere, include strong organizational leadership structure, clinical integration, and sufficient patient panel size-in other words, the number of patients that each provider is accountable for-for reliable measurement. 8 It is difficult for a single health plan to collaborate on newer payment and delivery models, such as accountable care organizations, with providers who see only a small fraction of that health plan's patients. In these cases, small patient panel size poses major challenges for the reliable measurement of a provider's quality and costs.…”

“…Details on each approach and their use have been have been discussed elsewhere. 8,12 Studies have found that methods of attribution can affect provider performance rates in a statistically significant way. 13 For example, attribution rules influence how many patients are assigned to a provider, which directly affects the rates.…”

Provider Performance Measures In Private And Public Programs: Achieving Meaningful Alignment With Flexibility To Innovate

“…2,3 Understanding performance measures and their use is vital to ensuring the availability of reliable performance information. 4 Information on measures that are used to assess providers' performance in Medicare is publicly available through the federal rule-making process.…”

The Design And Application Of Shared Savings Programs: Lessons From Early Adopters

“…Contracts featuring shared savings also are growing in importance among both privatesector ACOs and patient-centered medical homes, both of which use financial incentives to promote better and more efficient care. 1 Under capitation, per person, global, fixed payments are made to providers for the patients they serve; these strengthen providers' incentives to reduce unnecessary or expensive care. Unlike capitated arrangements, shared savings arrangements do not necessarily expose providers to downside financial risk or responsibility for losses that might occur when demand for care exceeds expectations for a provider's patient population.…”