“The [U.K.] proposals draw heavily on market-style incentives to drive improvements in outcomes and increase responsiveness to patients and the public. But they also include new arrangements for accountability, fundamental changes to the structure of the NHS, and a shift in the responsibility for paying for health services to groups of capitated physicians. (1)
Sound familiar? Those words describing the current British health care reform effort could serve as a description of U.S. health care reform and the creation of Accountable Care Organizations (ACO). I know I bill myself as an “evidence-based” blogger, and therefore distant from the personal ranting, either angry or self-serving, by other bloggers, but this article in the New England Journal of Medicine spurs me to electronically shout out in triumph, “I told you so!” In my blog (2) and in a paper (3) I wrote in 1967 (when?) I opined that there seemed to be more similarities than differences between the U.K. and U.S. health care systems. This well-researched article in the NEJM agrees with me.
BOTH the U.K. and U.S. reform acts:
Seek to reduce costs by making providers accountable for total per capita health care costs ($32B less for U.K.over 5 yrs. and $100B less for U.S over 5 yrs.)
Seek to strengthen primary care
Remove payment incentives to increase volume of patient visits (Pay for “value” in U.S.; “fixed budget” in U.K.)
Do NOT require providers to “bear risks” for catastrophic illness like insurance companies do now (but that is an option for ACOs in U.S.)
Primary Care Physicians (PCP)
While the U.S. pays lip service to strengthening the PCP, the U.K. proposal really means it. U.K. will give the general practitioners CONTROL of over 70% of the NHS budget! The GPs will form primary care groups called GP Consortia. These Consortia will buy additional care for their registered patients from hospitals and specialists competing for contracts. 170 Consortia have already been formed and another 100 are being planned. A physician-run ACO in the U.S. would be similar, but the ACO would include both primary care and specialty physicians like present day multi-specialty groups. No one knows how many ACOs will be developed, and many of them will be formed by hospital systems.
Commentators on both sides of the Atlantic have voiced concerns that physicians will not be able to deal with these new managerial responsibilities successfully; physicians in neither country like to develop budgets, live by budgets, or even value management/administrative skills.
In the U.K. the National Institute for Health and Clinical Excellence (NICE) will set care quality standards for the Consortia and the contracts they grant or “commission”. The Center for Effective Research (CER) established by the U.S. Affordable Care Act will have the same role of issuing standards of care. The practice of setting national targets for care will be dropped in the U.K. to be replaced with “a system of open reporting of data on performance and clinical outcomes.” This newly available data will allow patients (“the market forces”) to choose high quality care among the “any willing providers” in the absence of national targets and differential prices. As in the U.S. there is little evidence that patients actually use such data when it is available to make decisions about where to seek care.
Two Big Differences
The U.S. ACO incentivizes coordination of care between primary care, hospitals, and specialist physicians. The U.K. Consortia will control the money and issue contracts for hospital and specialist services. This could increase competition and hinder collaboration in the U.K.
U.K. patients will still have to register with one GP though they will have more freedom of choice of GP, i.e. patients will no longer be restricted to registering with the closest GP to their home. ACO patients will be assigned based on “previous patterns of care” though there will be incentives to use “participating providers”.
What are the take home messages?
We are not the only country muddling through a major health care reform while walking the line between regulations and market forces.
Everyone seems to be seeking the goals of higher quality and lower costs through electronic information upgrades.
Given the similarities between the U.S. and U.K. systems, the charge that Dr. Don Berwick, Head of CMS and a pediatrician, “likes the NHS too much” seems a bit ridiculous.
1. NEJM 364:14, April 7,2011, p.1360-66
2. http://www.hubslist.org, Feb. 1, 2011
3.Mathewson, H.O.. “General Thoughts About General Practice: a medical student’s view of the future of general practice in the United Kingdom.” J Med Educ. 1968, Jan;43(1):36-41.