Is the accountable care community the next evolution of the ACO?

The move to accountable care is ultimately about achieving better health outcomes at lower cost while creating a better experience for the patient. This is the Triple Aim. A narrow view of health focuses on health care, which is understandable in the United States, since a wide range of health-related expenditures are funneled through the medical system. The United States has long been the leader among industrialized countries in healthcare spending, while other nations have led in health outcomes, such as lower infant mortality rates, lower mortality amenable to health care and longer life expectancy. While CMS helped promote the accountable care organization with the Pioneer ACO model, followed by the Medicare Shared Savings Model and now the Next Generation ACO, commercial insurers and state Medicaid programs are also turning to the ACO to help them achieve the goals of the Triple Aim. The problem with this approach is that it remains rooted in the healthcare system. A narrow focus on health care ignores the environmental and social determinants of health that have a greater impact on the overall health status of a population. According to Elizabeth Bradley and Lauren Taylor in their 2013 book, The American Health Care Paradox: Why Spending More Is Getting Us Less, while the United States is the world’s top spender in health care, it is not the top spender in total health service expenditures when social services are added to this category. In fact, the United States is 10^th in total health spending if we combine health care and social services. The U.S. lags behind Sweden, France, Netherlands, Belgium, Denmark, Switzerland, Austria, Germany, and Finland. Those countries that provide their citizens with paid maternity leave, publicly subsidized child care and free higher education leading to higher incomes and less poverty, as well as services to seniors such as subsidized housing, transportation and assistance with activities of daily living in their own homes, enjoy some of the best population health outcomes. While the United States is unlikely to universally adopt many of the social programs that would positively contribute to the health of the population, there are ways to provide a continuum of care to the most vulnerable citizens that leads to lower total cost of care and improved health outcomes. This is the role of the accountable care community, which may be the next evolution of the accountable care organization. Renuka Tipirneni and her colleagues provide two examples of what they call Accountable Communities for Health (ACH) in the July/August 2015 issue of the Annals of Family Medicine. Compared to the current ACO model, the accountable care community does the following:

1. Addresses population health from a community, and not just a health care, perspective
2. Engages stakeholders across multiple sectors of public health, social services and health care.
3. Coordinates patient care across all community sectors, not just within the healthcare system.
4. Considers the total investment in health care across all sectors, not just total cost of care in health care.

The two accountable care community case studies cited in Tipirneni’s article – Hennepin Health in Minneapolis, MN, and the Akron BioInnovation Institute’s Accountable Care Community initiative in Akron, OH – have both delivered total cost of care reductions and improved outcomes. However, more rigorous study designs are needed that test a broader array of program options. While just in the beginning stages, accountable care communities should be considered as the next step in achieving true population health improvement. Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.

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