VHBC is progressively disrupting health markets by creating space for improving quality, reduce costs and paying for performance and outcomes. How the ACO’s are contributing to this new view of the health market place?
VBHC has stimulated quality in the US in terms of finding ways to incentivize and promote quality, and it has implicitly linked this agenda to a reform of the payment system to incentivize desired outcomes. VBHC is part of a larger movement sparked by the National Institute of Medicine reports: “To Err is Human” and “Crossing the Quality Chasm”. The Accountable Care Organizations are building on those objectives and offer a path to improved integrated and coordinated care that allow paying for value.
ACOs create a partnership between payers and providers, making them accountable to each other within the organization. The structure of the ACO and the embedded incentives that lead to cost containment and higher quality of care include easily accessible primary care services for the defined patient population, prioritization of prevention and chronic disease management that emphasizes integrated and coordinated care. Together these initiatives reduce reliance on hospitalizations and emergency care that both improve quality of care for patients and control costs for providers. I have just completed a paper on the subject that provides some insights on the subjective of ACOs.
What are the basic features of the ACO’s model and how this is different from traditional secondary level’s ambulatories and institutions?
The integration of care delivery, financing, information systems, management and marketing set ACOs apart, and so do the incentives of their payment arrangements. Their integration allows joint decision making on how to structure and operate the organization, and it is built on data, efficiency and quality. Importantly, data are used to track clinical care, costs, productivity, patient satisfaction and other indicators of performance. Information technology and data availability at all levels of the ACO are key, as neither quality nor efficiency can be measured without adequate and appropriate data. Data at the point of care is particularly important to support physicians in their disease management and coordination of care functions.
You mentioned that ACO’s in US, emerged from various angles, such as hospitals expanding outpatient services or health insurance engaging with providers. This process could be replied in developing countries such as Brazil? What are the pre-conditions to do this in the SUS or in the health insurance market?
ACOs offer an excellent alternative to fee for service dependent systems, but two elements are critical for an ACO: (1) information systems that produce relevant and regular data for monitoring at all levels of the organization from nurses to physicians to hospital managers to diagnostic providers to clinical managers; and (2) incentives for performance, meaning the providers and managers are accountable for their activities, and receive rewards and/or penalties for meeting or not meeting, respectively, predetermined goals. Without data management, goals and accountabilities are not possible; and, without incentives, change is difficult if not impossible.
Brazil could easily adopt ACOs through various arrangements, for example: as part of a major hospital network; as a new service program built around physician practices; as a major laboratory service company joining with physician practices. Partnerships of players integral to delivering quality care are at the heart of ACOs and can be adapted to the interests of different kinds of investors and actors. Given the strong insurance market in Brazil, partnerships between payers and the above delivery groups could move the cost containment and quality agendas forward. But it implies new ways of doing business.
ACOs are ideal for public private partnerships, adapting the OSS model in São Paulo, for example, where non-profits have full responsibility for service delivery and management. These arrangements are used extensively in the US by Medicaid, the public insurer for the poor that contracts with private companies and non-profits to set up ACOs that serve that population segment. Data and incentives allow government to accompaniar and oversee progress. Cambridge Health Alliance, an ACO in Boston, is an example where the city has contracted with an ACO to deliver care to a defined population, and they have supported the development of IT, managers and indicators. It entails good management on the part of government, but it helps to shift provision to integrated care providers who have the tools and flexibility to be efficient and raise quality.
In Brazil, the SUS created institutions such as the UPAS, with the objective to increase effectiveness of the health delivery by reducing no necessary hospitalizations. Do you think that UPAS could be operated similarly to the ACOs in order to improve the integrated care in the SUS?
UPAS are a good idea, but they lack the incentives, flexibility, data and accountability that allow ACOs to function effectively. First, the simple lack of prontuario electrônicos (EHRs) that allow clinicians to serve patients across time and levels of care undermines the ability to provide integrated care. UPAS physicians and nurses lack the needed data about patients at the point of care. Second, UPAS do not face incentives to avoid the use of higher level care, and are not rewarded for keeping patients healthy and away from unneeded higher levels of care. Third, where patients can self-refer to hospitals, the case in much of Brazil, providers must make it easy for patients to access primary care. Our work in São Paulo with Consocial suggests that accessing UPAS is time consuming and protracted, leading frustrated patients to public hospitals or the private sector.
ACO’s could work as standalone institutions or need to be integrated to health networks to operate efficiently?
ACOs either have an integrated network or access other providers on a contract basis to provide easy access for their patients. For example, an integrated care provider can contract with diagnostic centers, laboratories and hospitals for referral services for their patient population. The primary care providers coordinate care for their patients at all levels, so effectively the primary care providers integrate the services each individual patient needs.
Given that the main incentive to create ACO’s is changing the payment system, which new healthcare payment systems need to be implemented in Brazil and what are the challenges and preconditions to implement them?
Payment arrangements within ACOs can take virtually any form and ACOS lend themselves to a combination of payment arrangements. For example, fee for service can co-exist with capitation and bundled payments depending on the range of services being offered; alternatively, and most commonly, ACOs simply rely on capitation but with payment tied to performance, namely cost containment and quality outcomes. Here again, the information system is key to provide data on key indicators. However, the significant payment innovation in ACOs are “shared savings” where payers, managers and providers share in savings from the lower costs and enhanced quality of care that comes from focusing on primary care and reducing (over) use of hospital and emergency room services. This is a unique payment arrangement that underpins ACO incentives. These are easily adapted in Brazil, the challenge is the partnership that makes it happen and helping providers adapt to change, but these are challenges in the US as well.
Brazil has seen lots of progress in both SUS and ANS information systems. Are the current systems in Brasil enough to implement a VBHC culture in the Brazilian health systems (SUS and saude suplementar).
The situation is mixed. UNIMED BH has such information, as do some of the closed operadores in other major cities in saúde suplementar, but most do not. Those that do, can build on that capacity and the shift to the ACO model is less onerous. SUS information systems are lagging behind. It requires investments but more importantly a platform that allows development of prontuario electrônicos as well as information about the performance of providers and outcomes of care. SUS has neither, and many operadores lack them as well.
[1] ABRAMGE is the Association of Brazilian Managed Care Organizations