When the accountable care organization (ACO) model was initially conceptualized, many in the health policy world hoped it could provide a platform for real transformation of US health care.
Among the ACO model’s most promising innovations was its explicit orientation towards achieving “the Triple Aim.” First articulated by Don Berwick and the Institute for Healthcare Improvement (IHI), the Triple Aim is a strategy for optimizing the health care delivery system and achieving the best of all worlds. It outlines three goals: high quality health care, lower costs, and population health. The Center for Medicare and Medicaid Services adopted this goal and still describes a version of the Triple Aim on its webpage titled “Innovation.”
Clearly articulating population health as a goal of the ACO model was supposed to allow for the expansion of the role of health care providers in attaining better heath. Whereas providers had traditionally been paid and considered responsible primarily for clinical care, the inclusion of population health was thought to encourage providers to take a leadership role in prevention activities and other “upstream” efforts to create and sustain health apart from medical care. In light of strong evidence to suggest that social, behavioral and environmental factors are responsible for roughly 60% of health outcomes, the ACO model allowed providers flexibility to potentially redirect the significant resources of the health care sector towards determinants of health such as diet, exercise, education and employment.
But population health has turned into the red-headed step child of the Triple Aim. It has proven difficult to define and even more difficult to operationalize. And somewhere between the initial articulation of the ACO model and the operationalization of that model, population health has all but disappeared.
Among the 33 measures that CMS has required ACOs to report since 2012, only a few can be considered potential metrics of population health. Measures #24-25 focus ACOs on ensuring a high percentage of their assigned communities have low blood pressure and are non-smokers. These measurements may be considered process or interim outcomes more than actual health outcomes. Only Measure #7, generally referred to as “Health Status/Functional Status,” meets the IHI’s standards of how to measure the population health portion of the Triple Aim.
In addition to being given short shrift in how the ACOs are evaluated, population health has been entirely left out of the pay-for-performance scheme. In 2015, ACOs will be able to be paid for improved performance on all but 1 of the CMS measures – #7 Health Status/Functional Status.
Thus, we find ACOs in a similar position to health care organizations of the past insomuch as they are rewarded almost entirely on the quality of clinical care they provide. This is an important role, to be sure, but does not fulfill the promise of the initial ACO model.
In the end, the evolution of the ACO mandate leaves the health policy community with a critical question: If ACOs (as representatives of health care providers) are not going to “do” population health – then who will?
Read more: For a great peer-reviewed paper on population health and the ACO mandate see Hacker and Walker “Achieving Population Health in Accountable Care Organizations (2013).” Elizabeth Bradley and I also discuss this issue in some depth in The American Health Care Paradox.