E LLIOTT S. F ISHER, MD, MPH J AMES W. S QUIRES P ROFESSOR OF M EDICINE G EISEL S CHOOL OF M EDICINE AT D ARTMOUTH D IRECTOR T HE D ARTMOUTH I NSTITUTE.

ELLIOTT S. FISHER, MD, MPH

JAMES W. SQUIRES PROFESSOR OF MEDICINEGEISEL SCHOOL OF MEDICINE AT DARTMOUTH

DIRECTORTHE DARTMOUTH INSTITUTE FOR HEALTH POLICY AND CLINICAL PRACTICE

THE JOURNEY TO ACCOUNTABLE CARE

Variations in Practice and Spending: Implications for Reform

An additional 1 in 5 patients

survive

Delivering safereliable, and effective care

Cost decreases by $20,000 per patientAvoiding unnecessary care (hospital stays, visits, tests)

Source: The Dartmouth Atlas

Flawed conceptual model: Healthis produced by face-to-face visits with physicians. Care is fragmented.

New model: It’s the system. Establish organizations capable of redesigning practice and eliminating waste.

Wrong incentives reinforce model, reward fragmentation, induce overuse of unnecessary care.

Rethink our incentives: Realign incentives – both financial and professional – with aims.

Confusion about aims: Is it about money or something more?

Clarify aims: Better health, better care, lower costs – for patients and communities.

Absent or poor data leaves practice unexamined and unable to improve; choices uninformed by evidence.

Better information that engages physicians, supports improvement; informs consumers and patients.

Variations in Practice and Spending: Implications for Reform

Underlying Problem Key Principles

The Current Opportunity: Health Care Reform

Affordable Care Act Investments in public health Health information technology Expanded coverage New payment models

“No Outcome, No Income”

David NashDean, Jefferson School of Population Health

The Current Opportunity: ACOs

Core Ideas Population-based virtual budgets Real or virtual organizations Performance measurement Patient choice Accommodate diversity

Fisher ES, Staiger DO, Bynum JP, Gottlieb DJ. Creating accountable care organizations Health affairs 2007;26:w44-57.Fisher ES, McClellan MB, Bertko J, et al. Fostering accountable health care: moving forward in medicare. Health affairs 2009;28:w219-31.McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health affairs 2010;29:982-90.

What Will We Do? An Unfolding Story

ACOs: 2009 (21)

What Will We Do? An Unfolding Story

ACOs: 2013 (328)

Note: The sum of ACOs reflects the total number of unique, publicly identifiable, confirmed private-payer ACOs as of 08/2012 and public-payer ACOs as of 01/2013.

Might it work? The evidence so far…

Overall Duals

All PGP $114 $532 (1%) (5%)

Marshfield $642 $987 (9%) (11%)

Might it work? Encouraging population-based models of care

Primary care system

Patients with diabetes(and their caregivers)

Endocrinologists

Evidence review, updated monthlyCare pathways well-specifiedTechnology to support “right” careCare delivered by “right” provider

Might it work? For specialists

Project EchoSanjeev Arora, MD

Professor of Medicine,University of New Mexico

ELLIOTT S. FISHER, MD, MPH

JAMES W. SQUIRES PROFESSOR OF MEDICINEGEISEL SCHOOL OF MEDICINE AT DARTMOUTH

DIRECTORTHE DARTMOUTH INSTITUTE FOR HEALTH POLICY AND CLINICAL PRACTICE

THE JOURNEY TO ACCOUNTABLE CARE