News / ACOs need time and persistence to succeed (Convergence 2017)

Mark Britnell (pictured), partner with KPMG, told the opening day of the HFMA Convergence conference in London that misalignment in healthcare across the globe – conflicting incentives, structures and policies – was causing underperformance and waste.

The UK was not alone in seeing accountable care as a solution to these problems in a context of increasing demographic pressures and a difficult financial environment. And Mr Britnell, a former English foundation trust chief executive, said the consultancy's work with health systems across the world demonstrated there are growing examples of these approaches delivering better outcomes and reducing or stabilising costs.

Accountable care attempts to improve value by achieving the triple aim of improving population health and patient experience while reducing per capita costs. It typically involves a move away from payment for individual treatments and services and towards population-based budgets that allow providers flexibility in how to best meet agreed outcomes.

In the US, Mr Britnell, a former English foundation trust chief executive, said that 50% of Medicare payments would be value-based by 2018 with a 75% target for 2020. Reforms in New York State, based around creating a number of accountable care systems, had seen major improvements. The state's scorecard in the most recent survey by the Commonwealth Fund, identified the state's improvement as its biggest ever jump in scores, putting the state into the top quartile group for the first time.

He also highlighted the health system in Israel, which he said was the only one he had found to be 'truly primary care led' – a goal that was widely understood internationally but typically poorly executed. 'Israel sets the standard,' he said. At 7.3%, he said that spend as a proportion of gross domestic product was a fifth less than other developed countries while life expectancy was three years longer. 

Again integrated accountable care organisations – or health maintenance organisations – were at the heart of the success. He picked out three components that had been important – aligned incentives, integrated care and smart use of data and analytics. 'Accountable care is all about being wise before the event not after it,' he said. 'That is the secret to better care, better health and better value.'

But while these examples should give systems confidence that they can replicate this success, he warned that improvements could not be delivered overnight. 'Accountable care takes time, will, skill, time and persistence,' he said, suggesting that while there were some early wins, complete reform could take 20 years.

He added that structures and redesign processes were important. 'But they are nothing without workforce development,' he said, suggesting a 'demoralised and exhausted' workforce was not a good foundation for system reform. Smart IT, data analytics and use of segmentation and stratification were fundamental to progress. And providers had to be given a 'way out before they are given a way in'. This involved giving providers ideally five years but a minimum of three years to reimagine how they provide care.