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’s Commission on a High Performance Health 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 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 to Improve 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 a High 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
1. Strong Primary Care Foundation
Functional requirements and performance measurement standards in line with the goals of a medical home
2. Accountability for Quality of Care, Patient Care Experiences, Population Outcomes, and Total Costs
Performance measures cover multiple dimensions of care
Any shared savings payments are contingent upon meeting performance standards
Pay-for-reporting in the first year; subsequent years will taken into account performance levels
Minimum scoring threshold: 30th percentile of fee-for-service or Medicare Advantage
3. Informed and Engaged Patients
Strong patient-centeredness requirements including (but not limited to):
beneficiary representation on the governing board
patients notification that their provider is in an ACO
specific processes to enable patients and their caretakers with information to be engaged in care choices
ACOs must collect patient-reported experience information and incorporate it into personalized care plans
4. Commitment to Serving the Community
Each ACO must demonstrate that it evaluates the health needs of its population, incorporating diversity.
Community stakeholder involvement to help identify high-risk individuals and develop individualized care plans for targeted populations
Encouraged to include the community’s stakeholder representatives on the governing board
5. Criteria for Entry and Continued Participation That Emphasize Accountability and Performance
Allows flexibility in the types of tools ACOs can use to meet the functional and performance standards outlined
Also substantial flexibility in the types of organizations and configurations of providers that can participate
Limitations on the types of providers that can apply independently; however, any type of Medicare provider can participate by partnering with an ACO

8. Commission Recommendations and NPRM Provisions
6. Multi-Payer Alignment to Provide Appropriate and Consistent Incentives
The proposed rule is fairly silent with regard to multi-payer alignment
7. Payment That Reinforces and Rewards High Performance
Empirically-based minimum savings thresholds
Adjustments for health status, minimal adjustments for geographic variation
Some incentives to include small and safety net providers
At least a several month lag in shared savings (losses) payments from end of the performance period
8. Innovative Payment Methods and Organizational Models
Allows ACOs the option in the first two years to receive a higher share of savings if they agree to take responsibility for a share of excess spending.
This two-sided approach will apply to all ACOs in the third year.
CMS, through its Innovation Center, will consider alternative payment models
9. Balanced Physician Compensation Incentives
Any shared savings payment is dependent on the extent to which quality standards are met.
ACOs will be monitored for actions that may inhibit patients from seeking care, particularly outside of the ACO network.
10. Timely Monitoring, Data Feedback, and Technical Support for Improvement
Aggregated data reports on the ACO populations at the beginning of the first performance period and then on a quarterly basis,
Limited amount of beneficiary identifiable data
Data sharing will also include Part D information

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 Adults Have 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 Adults Experience Wasteful and Poorly Organized Care
Percent reporting in past two years:
Doctors ordered a test that 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
Number of Doctors Seen
Percent reporting in past two years:
Any
1 to 2
3 +
After medical test, no one called or wrote you about results, or you had to call repeatedly to get results 27 21 36
Doctors failed to provide important information about your medical history or test results to other doctors or nurses you think should have it 23 22 26
Test results or medical records were not available at the time of scheduled appointment 18 14 29
Your primary care physician did not receive a report back from a specialist you saw 15 11 24
Your specialist did not receive basic medical information from your primary care doctor 12 9
Any of the above 47 42 55
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
Percent reporting it is very important/important that:
Total: Very important or important
Very important
Important
You have one place/doctor responsible for primary care and coordinating care 93 64 29
On nights and weekends, you have a place to go besides ER 85 54 31
All your doctors have easy access to your medical records 96 70 26
You have information about the quality of care provided by different doctors/hospitals 58 38
You have information about the costs of care to you before you actually get care 89
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 in Teams 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). 15

16. Only minor changes needed Fundamental changes needed
A Majority of Americans Say the Health Care System Needs Fundamental Change or Complete Rebuilding
Percent reporting
Only minor changes needed
Fundamental changes needed
Rebuild completely
Total 22 46 26
Annual income
<$35,000 21 42 30
$35,000–$49,999 43 34
$50,000–$74,999 41 27
$75,000 or more 19 57
Insurance status
Insured all year 24 49 23
Uninsured during year 16 40 37
U.S. region
Northeast 17 31
North–Central 20 25
South 45
West 44
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).