For the many health organizations trying out or diving into accountable care, there are some important ideas from abroad to consider during the next stages of design and evaluation.
After examining two large-scale and so-far-successful accountable care programs in Spain and Singapore, Brookings Institution fellow Mark McClellan and colleagues found four key themes that U.S. organizations -- and the federal government -- might heed.
Highlight population health and wellness instead of just treating illness, "pay for outcomes instead of activities," create and environment for collaboration, and promote interoperable data systems such as patient registries, McClellan suggest in the latest edition of Health Affairs.
Capitation in eastern Spain
Now known for a 25 percent unemployment rate and a housing crash that rivalled the U.S., Spain also lays claim to fairly successful public-private population health management scheme that's been running since 1999 in Valencia, an autonomous state of 5 million.
Under the Alzira model, the health services company Ribera Salud manages delivery and reimbursement of publicly-funded comprehensive care for one million residents on the public program, while the regional government -- the payer -- sets the goals.
The government sets the same minimum targets for key outcomes like vaccination rates, waiting times, patient satisfaction and safety levels for all providers, with metrics available to all hospitals, physicians and clinicians.
Although the data is not available to the public, McClellan writes, "clinicians report there is a 'word-of-mouth culture' among patients who discuss outcomes and quality of care, and that culture provides a further incentive for clinicians to excel."
Ribera Salud has incentives to offer patients in its catchment area a good array of choices under its network, because the patients retain the option to seek care outside of their district -- and the company is required to pay "pay 100 percent of the costs, which are usually higher than its own," the researchers note.
While other providers outside the program are paid on a fee-for-service basis, the regional government pays Ribera Salud an annual capitation payment, per resident per year, for providing comprehensive healthcare services for all of the region's residents, who receive care with no out-of-pocket expenses. The company gets to keep 7.5 percent of revenues, with additional profits going back to the regional government.
According to McClellan, the model seems to be successful and sustainable. Per capita spending is 25 percent lower than elsewhere in the Valencia region, waiting times are shorter and readmission rates are lower.
Sustainability in Singapore
Spain as a whole spends about $2,800 per capita on healthcare, and has an average life expectancy of 81, the 18th longest lifespan. Dollar for dollar and year for year, that's better than the outcomes in the U.S: $8,895 spent per capita and a life expectancy of 79, the 43rd longest.
One of country's most revered for its per capita spending a life-expectancy rankings is the sovereign city-state of Singapore -- the fourth longest lifespan, of 84 years, and per capita spending of $2,400 -- and American healthcare organizations can learn a good deal from it, according to McClellan and colleagues.
In 2008, as a new, larger generation was aging, the government created Singapore Ministry of Health to reform long-term care delivery for the country's 5.3 million residents, especially seniors.
"One of the agency's early priorities was to refine the segmentation of elderly patients," using managed care programs to focus on wellness, patient preferences and care coordination.
For several patient groups or populations -- initially the frail elderly and patients near the end of life -- the agency defined specific outcome measurements, evaluation metrics, and care delivery pathways, including a community program using both local care centers and home care for frail elderly and hospice patients.
Aged Care Transition teams help ensure the coordinated delivery of care after a hospital discharge, using national electronic health records linked to patient registries to manage referrals and setting changes. The government agency evaluates the outcomes biannually and funding models include capitated monthly payments that allow providers to pool and shift resources.
Elderly populations under the management of these transition teams saw thirty-day hospital readmissions reduced by 40 percent and emergency department visits reduced by half, according to the study.
The Aged Care Transition program has also saved about 17,000 hospital days, worth more than $11 million, and the government is now expanding the program to include mental health and social care for the elderly.