Shared Savings Programs: Paradigm Shifts in U.S. Health Care Delivery

A fee-for-service model has dominated the US health care system for generations.  Escalating costs have brought health care expenses to 17% of the GDP without commensurate improvement in public health.  The 2010 Accountable Care Act (ACA) mandated implementation of fundamental changes to the Medicare/Medicaid systems in the United States. Shared savings programs (specifically Accountable Care Organizations (ACO’s)) are a key feature.  Fundamental components of the  ACO model includes the ability to provide care across a continuum of settings, including ambulatory and inpatient settings at a minimum; the capability for planning budgets and resources; and sufficient size to monitor and report on quality measurements,  minimum size 5000 patients. The March  2011 CMS proposal further refining specifics for ACO’s may prove less popular than anticipated.  Legal, and regulatory concerns combined with requirements for significant capital investment, limited upside of 3% of shared savings and fear of the cost of shared risk make the option less attractive for many physicians, practices, and hospitals. Consequently, other options may evolve to greater implementation. Some of the innovative concepts  for more effective health care delivery described in the ACA or tested in CMS pilots include bundled payments, medical homes, and Consumer Operated and Oriented Plans (CO-OPs).   They would share common features of the ACO, including aligning providers toward giving care in the most effective and cost-efficient manner. Patient-centered care will continue to be a priority, stressing communication among all health care providers for a patient. More cohesive care can reduce duplicated services and lower complication rates. Shared risk for excessive cost or poor outcomes financially aligns physicians and hospital systems.   Factors that will likely remain crucial for any successful shared savings program include achieving quality metrics for disease prevention and reduction of complications.  The models include technology, predominantly in the form of electronic medical records, as a way to both achieve and monitor these quality goals. Further, medical research moving toward Comparative Effectiveness Research will support moves toward patient-specific application of evidence-based medicine with the promise of eliminating expensive treatments and technologies which fail to improve outcomes. Transitioning to models of health care delivery disruptive to the established fee-for-service patterns remains a challenge at all levels from policy-makers to individual physicians.