Accountable Care Organizations Can Change Everything, But Only If We Get the Definition Right

Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over “population health.”

This correspondent says the article is what is muddled and that the readers of JAMA deserve better.

According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing “population health” for an entire geography.

Between the here of “improving chronic care” and the there of “population health,” Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term “population health” in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.

In short, they don’t believe ACOs, as currently configured, are up to the new task. That’s because ACOs would need to collaborate with social service organizations, be responsible for a geographically defined service area and improve long term public health outcomes. According to the authors’ subtitle, the answer to the question “should they try” is “no.”

This correspondent humbly disagrees. That’s because Drs Noble and Casalino, the editors of JAMA and the manuscript’s peer reviewers seem to be ignorant of the the correct definition of population health. It’s right there on the Care Continuum Alliance’s web site, in this longstanding page that describes the “population health model of care.” When I did a simple Google search on “population health definition,” I had little difficulty finding the link.

The CCA helpfully describes population health as:

a delivery model characterized as a physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health.

Was that so hard?

And how is that accomplished? According to the CCA, the ingredients to that make for population health include:

• Population identification strategies and processes;

• Comprehensive needs assessments that assess physical, psychological, economic, and environmental needs;

• Proactive health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles;

• Patient-centric health management goals and education which may include primary prevention, behavior modification programs, and support for concordance between the patient and the primary care provider;

• Self-management interventions aimed at influencing the targeted population to make behavioral changes;

• Routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers;

• Evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall population health

Accordingly, if an CMS-contracted ACO can identify its assigned Medicare population, perform needs assessments, promote awareness of health risks, offer education as well as support, increase self management, use data feedback and evaluate outcomes, it is offering “population health.” By using that playbook, an ACO will be capitalizing on the experience of a community of population health service providers that have been doing precisely this for over a decade.

This vision is far more compact than the overreaching, misinformed and muddled definition of “population health” offered in JAMA. It is also, if ACOs invest in the right resources and partnerships, well within reach.

This correspondent’s answer to the question “Should they try?” is “yes.”

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where this post first appeared.

12 replies »

  1. One of the best ways to provide healthcare solutions is to use Doctors-on-call services which will provide much better coverage for patients. These solutions help physicians in taking care of concerns for far more patients in a shorter amount of time, at a reduced cost 24/7.

  2. This article misses the point.
    ACO’s do not care for a fixed sub-population of patients.
    Multiple ACO’s can care for the same catchment area.
    EMR’s are not configured for population health or inter-ACO communication.

    If there were, then the same could be done for small medical practices making the ACO an unnecessary construct.

    It’s really not about whether ACO’s are viable. It is more about what the ACO concept has evolved from and what it will evolve into.

  3. “a physician-guided health care delivery system designed to develop and engage informed and activated patients”

    So what happens to the patients who choose to remain uninformed and unactivated?

  4. You know what? That’s not a half bad idea…. If we can’t make health care stop growing and crowding other things, then just throw everything else into the “care” rubric. Who needs Big Government when we can privatize it all into Big ACOs…. Right out of Pinky and The Brain…..

  5. So, ACOs need to deal with: “social services, public health, housing, education, poverty and nutrition”

    Why stop there?
    – What about global warming, poverty, justice and peace in the Middle East?
    – Since “war is unhealthy” why don’t we put them in charge of foreign policy and the military?
    – And since people need to get back and forth to their doctors appointments, why not put ACOs in charge of transportation and the FAA?

    Yes, these untested organizations that have not even been proven to be able keep their members healthy need to be put in charge of more things!

    And they ask me why I drink …..

  6. hi Jaan,
    Interesting post. So do you think ACOs will actually try to do this? It’s unclear to me why they wouldn’t gravitate towards focusing their resources on the high-utilizers (and those at high risk of becoming high utilizers). I would love to see them assess all Medicare beneficiaries and offer preventive services, but I’ll be [pleasantly] surprised if they do more than screen for whatever is mandated by quality measures.