Re-orienting the model of care towards accountability for whole regions

Introduction: Ideally, high performing health systems will try to achieve the ‘Triple Aim’ of improving population health, enhancing the individual care experience and doing so in a cost efficient way. In reality, developed countries all over the world face challenges to focus their health care actors on these aims. A major reason for that is the financial and organizational fragmentation of their health care sector. A possible solution is seen in the implementation of an ‘integrator’, who organizes a close collaboration between all actors and is rewarded for the value it generates. 

Policy  context  and  objective: To stipulate the formation of ‘integrators’ in the US the Obama Administration has introduced Accountable Care Organizations (ACOs) in 2010. Similar initiatives are also on the way in other countries, such as the UK, the Netherlands or Germany. One of Europe’s most comprehensive and most referred to ACOs is the German Gesundes Kinzigtal (GK). The objective of this contribution is to highlight the distinctive features and best-practices of this ACO model and elaborate transferability to re-orienting the model of care in other countries.

Targeted population: GK uses a population-based approach. The ACO is accountable for all 33,000 people living in the region that are insured by the two cooperating insurance funds (about half of the population of the whole region. 

Highlights: GK has generated positive impacts on all three Triple Aim dimensions in the region so far. From 2007-2014 total savings of ~$38.2 million (USD 2014) have been achieved; in 2014 ~$7 million (USD 2014, 7.4 percent). The external scientific evaluation also found that most of the quality and patient satisfaction indicators examined show a positive effect. Distinctive success factors of the ACO model are:

long-term shared savings contract for geographically-defined population with upfront investment, to finance the transition and help the new model become self-sustaining,

regional health management company as “integrator” (partly owned by providers),

evidence-based and locally adapted interventions to reduce progression of diseases,

activation of patients, shared decision making and self-management support,

comprehensive electronic health record, and business intelligence system, and

interventions beyond health care, including prevention, public health and the social arena.

Transferability: The ACO model of GK is currently transferred from the rural area of Kinzigtal to a socially deprived area in the city of Hamburg. Also a transmission of the GK model to the Netherlands and the UK has started. Key elements for transferability are the implementation of regional integrators and value- and population-based payment models with upfront investment or advance payments to build a financial foundation for the incremental change necessary for these value-based approaches.

Conclusions: Re-orienting the model of care towards accountability for whole regions has the potential to improve quality, efficiency and patient satisfaction at the same time. The German ACO GK provides crucial lessons how a regional health system may move towards the Triple Aim and gives hints for transferability. As the ACO approach is addressing similar underlying structural challenges in most developed countries, global learning from ACO best-practices and policies should be facilitated.