Accountable Care Organisations:

What are they and should we

be worried by them?Dr Simon Duffy from the

Centre for Welfare Reform, Sheffield

They’re reforming the NHS (again)

• NHS England has recently outlined ambitions for Sustainability and Transformation Partnerships (STPs) to evolve into ‘accountable care systems’ (ACSs) (after ‘several years’)

• Accountable Care Organisations (ACOs) build on previous efforts [Health & Social Care Integration, New Models of Care?] to integrate services in the NHS and draws on experience from health systems in the USA and other countries.

• The language of accountable care comes from the USA, where ACOs [also called Health Maintenance Organisations (HMO)] are the latest manifestation of well-known integrated systems, such as Kaiser Permanente, which have a much longer pedigree [in fact its as old as the NHS]. They come in a variety of forms from integrated systems to looser alliances and networks.

Original text from The King’s Fund [parenthetical comments - me]

• First, they involve a provider or, more usually, an alliance of providers that collaborate to meet the needs of a defined population. Second, these providers take responsibility for a budget allocated by a commissioner or alliance of commissioners to deliver a range of services to that population. And third, ACOs work under a contract that specifies the outcomes and other objectives they are required to achieve within the given budget, often extending over a number of years. [i.e. They collapse the concept of the internal market and the purchaser and provider split which has operated for the past 25 years in the NHS.]

• The most ambitious plans for ACOs in England extend well beyond health and social care services to encompass public health and other services. In Greater Manchester, for example, the aim is to use all public resources to improve health care while also tackling the wider determinants of health. This work, and that of other Sustainability & Transformation Partnerships (STPs), points to the emergence of what we have called population health systems, which seek to integrate care and to improve the broader health and wellbeing of the local population. [i.e. They might align with the emerging and confused world of devolution with its uncertain boundaries, powers and systems.]

Original text from The King’s Fund [parenthetical comments - me]

This may sound new, but this kind of idea has been kicking around for decades, often with reference to the US organisation Kaiser Permanente…

• NOT Keyser Söze, but a non-profit corporation with 10 million members in 6 states, i.e. about 3% of US population often called a Health Maintenance Organisation (HMO).

• It is effectively a ‘privatised’ version of what the NHS already is - a systemic effort to improve health of a whole population - working with a fixed level of funding.

• The internal systems have evolved over a very long time.

• The HMO (which includes health providers) can reward its component members from the savings it makes.

https://www.kingsfund.org.uk/publications/population-health-systems/kaiser-permanente-united-states

“Kaiser Permanente’s structure and its longstanding efforts to integrate services are well known and described in detail

elsewhere. Key organisational features include its role as both insurer and provider of care (within and outside of hospitals),

and the use of capitated budgets for members’ care across regions. Among other things, integration of care at Kaiser

Permanente is supported by population risk stratification, an emphasis on prevention and self-management, disease management and the use of care pathways for common conditions, case management for patients with complex

needs, extensive use of technology and population data, and a model of multi-specialty medical practice where unplanned

hospital admissions are seen as a ‘system failure’.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC64512/

“The widely held beliefs that the NHS is efficient and that poor performance in certain areas is largely

explained by underinvestment are not supported by this analysis. Kaiser achieved better performance at roughly

the same cost as the NHS because of integration throughout the system, efficient management of

hospital use, the benefits of competition, and greater investment in information technology.”

the obvious question is

If HMOs are so great why is US health care so poor?

BUT…

Melissa Hellmann, Time Magazine, 2014

“The U.S. health care system has been subject to heated debate over the past decade, but one thing that has remained consistent is the level of performance, which has been ranked as the worst among industrialised nations for the fifth time, according to the 2014 Commonwealth Fund survey 2014. The U.K. ranked best with Switzerland following a close second.”

Judge a tree by its fruit, but perhaps don’t

cherry-pick the best fruit

Most HMOs are not as good as Keiser and many are associated with severe rationing or promoting institutional solutions

Changing organisational structure does NOT necessarily mean you’ll

get the outcomes you want. Especially when the people, culture

and leadership are all the same.

If we pay attention to the details of what the best HMOs

do then what do we learn?

https://www.kingsfund.org.uk/audio-video/stephen-rosenthal-developing-accountable-care-organisation

HMOs try to pay attention to upstream causes of ill health…

Stephen Rosenthal, Senior Vice President, Population Health Management, Montefiore Health Systems

“So we looked at the social determinants of health and we found that in all instances they raised the cost of

care. And so focusing on them gives us an opportunity to lower the cost of care.”

…but they do this without the legal and moral authority of the NHS.

HMOs try to organise levels of care in order to prevent crisis and extra costs…

Stephen Rosenthal, Senior Vice President, Population Health Management, Montefiore Health Systems

“But we don’t have the benefit of a National Health programme, but because we’re disproportionally government programmes, it’s almost as though our community of providers and system is disproportionately a government programme or a single payer”

…but so does the NHS and with more control, coherence and legal clout.

HMOs try to provide some governance structure to drive change…

Stephen Rosenthal, Senior Vice President, Population Health Management, Montefiore Health Systems

“So our governance structure, I will just talk a moment about that, begins with the Monterfiore IPA structure. And that governance is in equal balance between the providers in the community, the employed providers, as well as the institutions, and that’s the entity that

bears the financial risk in all of our models.  And as you can see we have over 4,000 providers that are in that community touching some 400,000 plus individuals.  And then the ability to manage those relationships between the payers, the governments, the providers, and the patient relationships, the community activities, we created the care management

organisation or company, which is what I run, that essentially in many ways operates similar to an insurance company, has all of the infrastructure around that, but it’s goal is to really

manage the relationship of the patient and the various providers that are in those communities that these patients live in.  And develop the kinds of programmes that will

actually ultimately improve their overall care.”

…but this the NHS is already meant to be accountable both centrally and locally.

Is there anything an HMO does that the NHS can’t do?

• It does help stop doctors from doing private work on the side

• Over a long-term it’s possible that better HMOs might win out over worse (but that’s a very optimistic hope).

• They may be better at encouraging helpful competition between different kinds of providers, but US healthcare remains very defensive and over-medication and medicalisation are rife.

• You may provide better personal incentives for the leaders, doctors and ‘owners’ to promote strategic cost management and innovation (if you’re extremely lucky).

• But remember that HMOs also have incentives to lobby and corrupt the powerful in order to gain advantages that have nothing to do with the public good.

“Accountable Care Organisations” seem like another example of a Government promoting a

critical weakness as if it were a virtue?

(cf. introduction of Personal Independence Payments as way to justify cuts in Disability Living Allowance - you name the programme by the very

thing you’re destroying.)

Best HMOs NHS

US health system is crazy drunk, but the best HMOs act like a

sober designated driver

UK health system is sober but we give control to political

leaders who are drunk on power

The main problem in the NHS is a failure of self-discipline at the leadership level… they

can’t stop reforming it until it’s broke.

Health authorities (involving local authorities) used to be responsible for improving the health of their local population and they funded providers, hospitals etc. from within a fixed funding base

• ‘Reforms’ from 1992 onwards distinguished the role of ‘purchaser’ from ‘provider’ in the hope that purchasers could take a less self-interested perspective and drive positive change. [This is clearly seen to have failed.]

• Since the 1960s there has been constant talk of health and social care integration and attending to the social determinants of health. [No good model has yet emerged.]

• Tony Blair’s government introduced centralised tariffs to pay for additional services and reduce waiting times. [That system is now collapsing as the money runs out.]

To some extent we are just back where we began:

• But we have abandoned the assumption that one particular nationally defined structure will solve the problem of how to create the best outcomes within the available budget.

• It is good that providers are now seen as part of the solution.

• But we are likely to further weaken democratic accountability and the principles of good leadership.

• It seems like a fudge in the light of austerity and our ongoing constitutional crisis.

• Some places may see some better long-term thinking, experimentation and the social change that is at the heart of positive change.

• But short-term pressures and crisis will probably lead to a period of fire-fighting where cuts and changes are hidden by the smoke of organisational change - promising much, delivering little.

• In the worst case scenario ACOs are simply packages of services that could be privatised on the back of trade deal with Trump’s America.

Are we really just ducking more fundamental questions?

• Inequality is primarily created by Government policy, especially tax-benefit policy

• Local engagement and community development relies on giving power and control to local democratic bodies (local government anyone?)

• The quality of environment, pollution and housing is a function of national policy and local leadership

• Mental health is shaped by prejudice, inequality, exclusion and a range of social factors

• Weaknesses in NHS performance may be connected to perversity of allowing private practice as a side-business

From Duffy (2017) Heading Upstream

From Duffy (2017) Heading Upstream

Positive change begins by attending to citizens, families & communities

Who is accountable for what?

What actual changes lie behind the structural?

What constitutional changes should we be seeking?

3 Big Questions

if anyone’s interested in more meaningful changes in healthcare check out these

www.cforwr.org

@citizen_network@CforWR @simonjduffy

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