Improving Care And Lowering Costs: Evidence And Lessons From A Global Analysis Of Accountable Care Reforms

With advances in treatments to extend life and combat disease among aging populations and with the growing number of people with treatable and preventable chronic diseases, health care spending has increased in recent decades and is expected to continue to rise.¹ Policy makers and health leaders worldwide are under pressure to provide access to high-quality care at a cost that is affordable to consumers and taxpayers.² A broad range of innovations in care delivery holds the potential to improve care outcomes while lowering costs. These innovations include the use of multidisciplinary teams; shifts to less costly sites and treatment methods; the use of data analytics and patient engagement to support treatment adherence and behavior change; and the integration of social, community, and medical care to address the root causes of high utilization. However, traditional payment models, regulations, and other policies often fail to provide sustainable support for such innovations. For example, volume- and provider-specific payments, such as fee-for-service payments within fixed budgets, do not pay for or incentivize many of the investments needed to innovate.

Globally, accountable care has attracted increasing attention as a way to address the adverse financial and health consequences of policies that reward the volume, but not the quality, of medical services. We define accountable care as an arrangement in which “a group of providers…are held jointly accountable for achieving a set of outcomes for a defined population over a period of time and for an agreed cost.”³ This can characterize a variety of arrangements besides “accountable care organizations,” including primary care medical homes and arrangements for specialized populations that include accountability for patient results. Accountable care delinks reimbursement from volume-based or provider-specific payments and shifts the focus of regulations and other policies from particular providers and services to patient outcomes and resources use. This shift can enable providers to develop innovations in care such as mobile technologies that identify at-risk people before diagnosis and support patients’ self-management once they have been diagnosed, health screening and promotion to reduce risk factors for people with chronic diseases, and evidence-based care pathways that efficiently link services together based on individual needs.

Many countries are implementing this policy shift toward accountability. Policy makers in England, the Netherlands, and Singapore have embedded new accountable care reforms in their national health strategies, accounting for system-specific characteristics.^4–6 For example, since 2015 the National Health Service in England has supported what it calls “new care models”—fifty organizations that have adopted accountable care principles.⁴

In the United States, accountable care organizations (ACOs) have become a common form for operationalizing accountable care principles. As of March 2017 there were 923 ACOs, ranging from physician- or hospital-led groups and alliances to fully integrated health care systems.⁷ Over half of the ACOs are operating in the Medicare Shared Savings Program, which covers over nine million Medicare beneficiaries—representing an incremental shift from volume-based payment.⁸ In addition to ACOs, the patient-centered medical home and bundled episode payment illustrate the shift from volume-based payment toward accountable care.⁹

Despite increasing pressure to deliver high-value care efficiently and global interest in accountable care reforms, the evidence and lessons generated by accountable care are limited. Recent domestic and international pilot programs offer preliminary evidence of important improvements in quality using the same or fewer health care resources. For example, organizations operating in Spain and Germany have improved measures of population health while reducing local hospital admission rates and use of acute services by increasing investment in primary care and multidisciplinary provider teams.^10,11 In the United States, ACO results to date demonstrate quality improvements with some overall modest reductions in health system costs.^12,13 Encouraging early results, such as reduced admissions to residential care,¹⁴ have advanced national trials of accountable care in England. However, in spite of these quality and outcome improvements, early savings in many accountable care programs have been modest, and many organizations have not succeeded in reducing overall costs.¹⁵

These results suggest that in addition to designing policy reforms effectively, success requires providers to develop new patient-focused competencies. Organizations have cited technical difficulties, such as institutional and cultural barriers to transitioning away from fee-for-service and integrating primary and secondary care, and financial barriers to making the investments needed to scale up new patient-focused care models.^16–18 Payers and providers also lack a clear reform pathway and strong evidence to inform implementation of reforms.

To address these challenges, we describe a comprehensive framework that can be used to integrate available qualitative and quantitative data on accountable care worldwide. Using the framework, we make cross-country comparisons to help guide ongoing reforms in many contexts and support the development of a broader evidence base. We apply the framework to examples in three countries—Germany, Nepal, and the Netherlands—to provide practical insights into how policy makers and health care organizations can design and implement accountable care to support new delivery models. The examples illustrate three alternative and potentially complementary approaches to accountable care reforms: innovative primary care, problem-focused care, and comprehensive population care.

The Accountable Care Framework: Linking Context, Policy, And Delivery

To provide a more structured approach for describing and assessing the global implementation of accountable care, we extended our previous work on a policy framework for accountable care. That framework focused on five key elements of accountable care policies: population health, performance measures, support for continuous improvement, alignment of payment and nonfinancial regulations, and support for care coordination and transformation.^19,20 Recognizing the challenges involved in both designing and implementing accountable care, we sought to incorporate recent work on organizational capabilities and environmental context.

To guide us in this effort, we convened two expert working groups of policy makers, providers, and payers in partnership with the World Innovation Summit for Health (WISH) and the Commonwealth Fund. The WISH advisory board included twelve health policy experts from Australia, Canada, Qatar, Singapore, Spain, the United Kingdom, and the United States. Twenty US policy makers, providers, and payers made up the Commonwealth Fund advisory board. We undertook an international review of promising care and payment innovations to expand the understanding of the policy and organizational factors needed to implement accountable care.

The resulting framework enables analysis of how the impact of accountable care depends on the interaction of specific policies adopted within the broader health policy environment and the competencies of health care organizations. Key competencies are summarized below from the work of the US-based Accountable Care Learning Collaborative and National Academy of Medicine’s Vital Directions for Health and Health Care initiative.^21,22

There are seven key competencies: governance and culture, which requires sufficient leadership to shift an organization’s focus toward achieving better patient outcomes and value, not simply excellence in specific procedures or services; financial readiness, which makes it possible for an organization to bear risk and reallocate financial resources; health information technology, or the infrastructure and analytics needed to support patient-centered care; patient risk assessment and stratification, which make it possible to target interventions; patient engagement, or embedding the patient perspective across organizational processes; quality and process improvement, or activities linked to performance measures and mechanisms that provide feedback on performance to provide better care; and care coordination, or integrated workflows to support continuity of care.

Although organizations often lack the staff, infrastructure, and expertise to support accountable care policies, assessing these competencies can identify successful approaches for developing them.

The broader health policy environment also shapes the impact of reforms. This includes institutional factors (existing structures and communication pathways that determine how resources are allocated), political factors (such as support to unite stakeholder interests across the public and private sectors), and regulatory factors (such as the regulatory apparatus that facilitates accountable care reforms). For example, falling fee-for-service payments can create pressure to shift to accountable care models. Conversely, poor coordination across government agencies and funding streams responsible for different aspects of patient care, or regulations that limit the use of allied health professionals in team-based care, can complicate accountable care implementation.

Together, the use of these factors creates a comprehensive approach for assessing accountable care reforms to gain generalizable insights about the determinants of success, which in turn can facilitate the transition to accountable care in particular settings.

Global Case Studies Of Accountable Care Implementation

To facilitate learning from global experiences with accountable care, we applied our framework to eleven accountable care reforms and developed in-depth case studies for seven programs in diverse settings. We collaborated with local policy makers and implementers in each country to apply the accountable care framework and summarized available evidence of the impact of each reform on patient care, outcomes, and experience and on resource use and costs. We reviewed the evaluation methods, including performance measures used and whether data were collected both before and after implementation and in a comparison population.

Below, we summarize examples of three approaches to accountable care reform: implementing primary care with a comprehensive person-centered focus (Possible, a primary care public-private partnership in Nepal), supporting person-centered care for specialized conditions (Zio, a chronic disease management model in the Netherlands), and integrating all aspects of care for each patient in a population (Gesundes Kinzigtal, a population-based reform in Germany). These models aim to reward care that patients find valuable by using patient-focused payments such as per member per month payment for a broad range of care, with accountability for results and costs. Exhibit 1 summarizes the reforms and evidence of their impact. More comprehensive analyses of these reforms are available elsewhere.^23–25

Accountable Primary Care: Possible In Nepal

Possible is an example of using accountable care in primary care to improve the quality of care and outcomes. Possible is a nonprofit health services organization that operates in rural Nepal, an area with constrained capacity to finance and support the provision of basic health care services. To improve access to and quality of care, the Nepalese government entered into a public-private partnership with Possible in 2008 to pay for primary care on a per capita basis for the general district population. Possible provides health services for less than US$20 per person per year on average and is accountable for improving population measures of quality, access, and outcomes.

Its payment structure enabled Possible to implement a hub-and-spoke model—a network of primary care providers and community health workers (the spokes) connected to a secondary care facility (the hub)—to improve how it provides chronic disease and maternity care. The financing design has supported the deployment of frugal care innovations and disease surveillance for remote populations. Community health workers conduct home visits and identify patients who need additional care. The workers also use cell phones to remotely monitor and track patients’ health status. Within a limited public budget, these collective efforts have facilitated significant improvements in the delivery of clinical care, such as higher rates of access to surgery and completion of antenatal care.

Accountable Problem-Focused Care: Zio In The Netherlands

Zio, which combines primary and specialty care for patients with diabetes, originated in 1996 at Maastricht University to address gaps and inefficiencies in health care for people with chronic diseases. Zio initiated a disease management program that shifted tasks from endocrinologists to specialized nurses, moved care from outpatient settings to general practices, and stratified patients based on care needs. In 2007 the Netherlands introduced bundled payment to support integration of primary and specialty care. As a result, programs such as Zio were able to contract for services across teams of providers, holding them accountable for a defined population. Zio negotiated a single contract between insurers and groups of providers of diabetes care to integrate the various types of care needed by patients with the disease. These efforts included assessing ways to reduce complication risks in particular types of patients and care coordination—which are key components of our framework. Zio’s experience also took advantage of national policy reforms to broaden nurses’ scope of practice, allowing nurse specialists to perform minor procedures.

An evaluation that compared the quality of care for patients in bundled payment programs such as Zio to that for patients in a comparison population found significant improvements in diabetes control and fewer serious complications in the bundled payment programs.²⁶ A pre-post study within Zio found improvements in outcomes and reduced costs, including a 54 percent reduction in inpatient costs for patients receiving care from nurse specialists.²⁷

Accountable Integrated Care: Gesundes Kinzigtal In Germany

Gesundes Kinzigtal, a private health management company, organized an integrated care network in 2005 in southwestern Germany that served approximately 10,000 people. Gesundes Kinzigtal expanded its program after a national health reform allowed provider groups and insurers to contract directly with each other and allowed insurance companies to reallocate 1 percent of provider expenditures to support integrated care services. Before the reform, coverage in this region was universal, but payments and care were fragmented, and data were not interoperable. Under the new model, patients can choose to either enroll in Gesundes Kinzigtal and receive additional services such as individualized treatment plans or remain in the traditional model of care. In either case, patients retain the same providers and insurer.

The new model includes provider performance measures codesigned by physicians and patients, an internal dashboard that allows physicians to see their comparative performance, and a long-term shared savings contract between providers and insurers. Gesundes Kinzigtal keeps surplus revenue, determined by the difference between actual health care costs and a regional benchmark defined as the average risk-adjusted cost of care. This financial arrangement enables Gesundes Kinzigtal to manage care across providers and facilitate patient self-management programs and other initiatives that prevent the progression of chronic diseases.

Nine years after the start of the intervention, the model generated a 7 percent reduction in per enrollee cost compared to costs in the general population.²⁸ Gesundes Kinzigtal also reduced unnecessary hospital admissions and mortality rates for participating patients, relative to a comparison population of non–Gesundes Kinzigtal patients.^11,29

Emerging Lessons For Health Care Providers

These cases demonstrate how accountable care can promote the development and more effective use of care delivery innovations, such as patient self-management or telehealth, to improve outcomes and use resources more efficiently. The cases highlight the development of organizational competencies to implement the innovations, alongside payment and other policy reforms that enable the innovations to succeed and be sustained. Shifts toward accountable care require new interactions between providers and policy makers, as exemplified by Possible’s negotiation of a performance-based public-private partnership with the Government of Nepal. The cases show that sustaining and scaling up accountable care models also require organizational innovation and policy reforms to evolve simultaneously, from improving links between primary and specialty care, as in the Netherlands, to increasing public awareness and support of accountable care reforms through voluntary participation, as in Germany.

Given the multiple dimensions that evolve together, successful accountable care reforms may best be achieved through incremental steps toward clear systemic goals. These global experiences suggest a set of lessons that providers can use to make stepwise progress.

Focus On Systemwide Change

Organizations should invest in models that enable accountability for results through clinical leadership, shared values, and collaboration across providers and people in the community. A range of organizations can develop the capabilities to succeed in accountable care. Regardless of the organization’s form, one common approach is to gain trust and practical insights by involving key stakeholders—including patient and community representatives—in developing interventions and restructuring care. For example, Possible developed a Community Advisory Board and formed relationships with community health workers to strengthen disease surveillance and service delivery efforts. Creating a structure that focuses organizational attention on health outcomes can promote a patient-centered culture of care delivery. Clinical leadership coordination across provider silos, which was facilitated by Gesundes Kinzigtal’s integrated management structure, also helps organizations implement reforms that could otherwise be controversial or infeasible for particular provider groups to undertake. Zio’s strategy of backing up payment reforms (bundling service payments) with horizontal care delivery integration (well-coordinated clinician teams) drove the organization’s success in problem-focused accountable care.

Share Information

Organizations and providers can develop a shared information technology infrastructure with key longitudinal data points to identify and manage high-risk patients. Integrating full electronic health records across platforms and incorporating them into the workflow is technically and financially challenging for most organizations. Organizations often lack the resources, knowledge, or cooperation to implement major reforms in information technology effectively. Moreover, some key data can be captured through sources other than clinical records. Providers can begin with low-cost, incremental solutions to high-priority data needs and then continue improving the availability and use of health data. For example, Possible uses a low-cost online management tool to collect key patient data each week and provides monthly analyses to guide care delivery. Collecting and tracking actionable data for care coordination and improvement can eventually be expanded to bridge gaps in service. Gesundes Kinzigtal progressively developed infrastructure to support electronic records and interoperable platforms to share information such as prescription data across practices. Sustained but limited and well-targeted investment in health information technology can improve the targeting and performance of innovations over time.

Use Multidisciplinary Teams

Organizations can shift care to multidisciplinary teams with appropriately trained staff members who work together to keep care in the community or home. Patient-focused, prevention-oriented approaches to care involve shifting the locus of care from institutions to communities. Improving linkages to community services, such as through the colocation of different types of health service providers, allows provider teams to mobilize social services rapidly for high-risk patients to prevent hospital admissions and facilitate their self-management. Using accountable care payment reforms, providers can incrementally direct resources to train existing nonphysician staff members and recruit new staff members to fill remaining gaps. Zio empowered nurses to prescribe and expanded their responsibility for diagnostic and therapeutic tasks. Possible invested in community health workers to conduct case-finding home visits and build relationships with local clinics. Diversifying the health professional workforce offers opportunities to meet patient needs more efficiently.

Emerging Lessons For Health Care Policy Makers And Payers

Implement Reforms

Policy makers and payers can implement regulatory and financial reforms to create a supportive environment for high-value, patient-centered care. The case studies show that payment methods and other policies play a vital role in enabling organizations to shift and integrate resources to support patient-focused care capabilities, which in turn enable innovations that can improve outcomes and efficiency of care. Policy reforms should minimize administrative burden and avoid imposing performance and accountability expectations beyond the reach of providers in the near term. Shifts that are too large or too rapid will not permit providers to develop the capabilities they need to make these innovations succeed. Recognizing local provider capabilities, policy makers in each of our cases began with limited reforms—such as those to expand the capabilities of primary care and specialized care providers and population-based reforms with voluntary individual participation. Policy makers should also develop a clear vision for significant change over the longer term, such as Gesundes Kinzigtal’s long-term population-based payment contract.

Coordinated payment and delivery reforms to support the transformation of primary and specialty care and care coordination and integration at the patient level can be synergistic in driving health care transformation. Complementary reforms in primary and specialty care can be linked through shared accountability for population health improvement and cost management. For instance, a “care integrator,” such as an accountable primary care group or other organization, can rely on bundled episode payments for particular health problems to motivate specialists and other providers in the care continuum to align their efforts and ensure continuity in the provision of services.

Start-up payments for providers to invest in developing new patient-focused competencies can increase provider confidence and ability to carry out delivery innovations. If public resources are not available, partnerships with private organizations can provide such capital, as all of the case studies highlighted.

Alongside an incremental reform path to support the development of high-value care models, additional reforms can support performance data collection and exchange across providers, the generation of meaningful evidence on how reforms are working and could be improved, and the dissemination of results and lessons learned.

Use Data To Support Person-Centered Care

Payers and policy makers can support provider shifts to person-centered care through the sharing of financial, clinical, and patient health data. The timely availability of reliable data is the foundation that health care organizations need to create actionable feedback to adjust workflow patterns, assess progress toward predetermined benchmarks, forecast financial outcomes, and reduce disease burden in specific populations. Policy makers and payers have access to key types of patient data needed for success, such as information on the use of care outside of a provider’s own health system, but these data (or analyses based on them) may not be available to providers in a timely way. In each of our case studies, policy makers took steps to provide or facilitate the development of useful data on utilization, cost, and outcomes.

Develop Evidence

Policy makers and payers can develop evidence to guide and refine accountable care reforms. Given the challenges of implementing accountable care effectively, policy makers should encourage meaningful and reliable ongoing evaluations of accountable care reforms, both to improve the models and increase confidence in adopting and expanding them effectively. Gesundes Kinzigtal gained physician buy-in by documenting the financial and clinical performance of physician groups and disseminating the information, which enabled rapid learning from early successes. The Gesundes Kinzigtal evaluations included comparisons to trends in a matched population in the region that did not participate in the reform. Zio’s evaluation provided sufficient evidence to enable the Netherlands to scale the model up to the national level. Both case studies highlight the importance of evaluating innovations for continuous improvement and scaling up. By requiring and supporting evaluation protocols linked to timely data, policy makers can enable rapid learning to accelerate progress.

Conclusion

Transforming health care to improve outcomes and use resources efficiently is difficult, and many innovations in care have not yet fulfilled their promise. The rise in global accountable care activity presents new opportunities to develop the evidence necessary to implement, scale, and sustain these needed innovations in health care delivery. By developing and applying a common framework, we have shown that the diverse cases of accountable care innovation highlighted here have many common elements and face common challenges. Our work aims to facilitate sharing experiences and developing systematic evidence on how accountable care implementation can succeed.

Providers, payers, and policy makers can learn from these diverse experiences and gain confidence in implementing models and policies aimed at improving population health outcomes and making care more efficient. A global accountable care learning network to support organizations adopting accountable care principles that builds on existing regional or country-level reform efforts could enhance the evidence and knowledge sharing from these global experiences. Such a network could also strengthen organizational capabilities by providing peer engagement and practical examples of how to implement accountable care and link organizations to others undertaking similar care transformation efforts. The need for better person-centered models of care is urgent, and the opportunities for innovation are greater than ever.

ACKNOWLEDGMENTS

Some of the material in this article was presented at the World Innovation Summit for Health (WISH), an initiative of Qatar Foundation, in Doha, Qatar, November 29 and 30, 2016, and at “Translating International Models of Care for High-Need, High-Cost Populations in the United States,” a Duke–Robert J. Margolis, M.D., Center for Health Policy public event supported by the Commonwealth Fund, in Washington, D.C., January 30, 2017. Mark McClellan received compensation from the following Duke Sponsored Research Funders: MITRE Corporation, Health Foundation (UK), the Commonwealth Fund, the Food and Drug Administration, Laura and John Arnold Foundation, Novartis, Allergan, Amgen, Bluebird Bio, Spark Therapeutics, Editas, Pfizer, Medtronic, Edwards Life Sciences, Boston Scientific, CEOi, Lilly USA, National Pharmaceutical Council, and Duke-NUS. Krishna Udayakumar has received the following research grants through Duke University or grants/membership support for Innovations in Healthcare, a Duke University–affiliated nonprofit for which Udayakumar serves as executive director: Pfizer Foundation, USAID, the Commonwealth Fund, Medtronic, Novartis Foundation, UNFPA, World Innovation Summit for Health/Qatar Foundation, Health Foundation (UK), Gates Foundation, and Cardinal Health. The authors acknowledge Qatar Foundation and Commonwealth Fund for funding the research reported in this article. Imperial College London serves as a research partner for WISH. The authors gratefully thank the members of the WISH Accountable Care Forum and of the advisory group supporting the Commonwealth Fund project titled Adapting Global Applications of Accountable Care to the US for their valuable insights and contributions in developing the accountable care framework.

NOTES

• 1 World Bank. Health expenditure, total (% of GDP) [Internet]. Washington (DC): World Bank; c 2017 [cited 2017 Sep 22]. Available from: https://data.worldbank.org/indicator/SH.XPD.TOTL.ZS Google Scholar
• 2 He W, Goodkind D, Kowal P. An aging world: 2015 [Internet]. Washington (DC): Census Bureau; 2016 Mar [cited 2017 Sep 22]. (International Population Report No. P95/16-1). Available from: https://www.census.gov/content/dam/Census/library/publications/2016/demo/p95-16-1.pdf Google Scholar
• 3 Thoumi A, Udayakumar K, Patel H, Abou Samra AB, McClellan M. Implementing accountable care to achieve better health at a lower cost: report of the WISH Accountable Care Forum 2016 [Internet]. Doha (Qatar): World Innovation Summit for Health; 2016 [cited 2017 Sep 22]. Available from: http://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/Accountable_Care_Report.pdf Google Scholar
• 4 National Health Service. Next steps on the NHS Five Year Forward View [Internet]. London: NHS; 2017 Mar [cited 2017 Sep 22]. Available from: https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf Google Scholar
• 5 Struijs JN, Baan CA. Integrating care through bundled payments—lessons from the Netherlands. N Engl J Med. 2011;364(11):990–1. Crossref, Medline, Google Scholar
• 6 Ministry of Health Singapore. Reorganisation of healthcare system into three integrated clusters to better meet future healthcare needs [Internet]. Singapore: The Ministry; [last updated 2017 Jan 18; cited 2017 Sep 22]. Available from: https://www.moh.gov.sg/content/moh_web/home/pressRoom/pressRoomItemRelease/2017/reorganisation-of-healthcare-system-into-three-integrated-cluste.html Google Scholar
• 7 Muhlestein D, Saunders R, McClellan M. Growth of ACOs and alternative payment models in 2017. Health Affairs Blog [blog on the Internet]. 2017 Jun 28 [cited 2017 Sep 22]. Available from: http://healthaffairs.org/blog/2017/06/28/growth-of-acos-and-alternative-payment-models-in-2017/ Google Scholar
• 8 CMS.gov. Shared Savings Program: about the program [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [last modified 2017 Aug 17; cited 2017 Oct 11]. Available from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about.html Google Scholar
• 9 Alternative Payment Model Framework and Progress Tracking (APM FPT) Work Group. Alternative Payment Model (APM) Framework: final white paper [Internet]. Washington (DC): Health Care Payment Learning and Action Network; 2016 Jan 12 [cited 2017 Sep 22]. Available from: https://hcp-lan.org/workproducts/apm-whitepaper.pdf Google Scholar
• 10 McClellan M, Tarazona Ginés E, Thoumi A, Drobnick E, Maday M, Alfonso García Pet al. Spain: reinventing chronic care management for the elderly [Internet]. Washington (DC): Brookings Institution; 2015 Apr 6 [cited 2017 Sep 22]. Available from: https://www.brookings.edu/research/spain-reinventing-chronic-care-management-for-the-elderly/ Google Scholar
• 11 Hildebrandt H, Schulte T, Stunder B. Triple Aim in Kinzigtal, Germany: improving population health, integrating health care, and reducing costs of care—lessons for the UK? Journal of Integrated Care. 2012;20(4):205–22. Crossref, Google Scholar
• 12 McWilliams JM, Gilstrap LG, Stevenson DG, Chernew ME, Huskamp HA, Grabowski DC. Changes in postacute care in the Medicare Shared Savings Program. JAMA Intern Med. 2017;177(4):518–26. Crossref, Medline, Google Scholar
• 13 McWilliams JM, Hatfield LA, Chernew ME, Landon BE, Schwartz AL. Early performance of Accountable Care Organizations in Medicare. N Engl J Med. 2016;374(24):2357–66. Crossref, Medline, Google Scholar
• 14 NHS Confederation. Notable early successes as vanguards get serious about prevention [Internet]. London: NHS Confederation; 2016 May 31 [cited 2017 Sep 22]. Available from: http://www.nhsconfed.org/news/2016/05/early-successes-as-vanguards-get-serious-about-prevention Google Scholar
• 15 Muhlestein D, Hall C. ACO quality results: good but not great. Health Affairs Blog [blog on the Internet]. 2014 Dec 18 [cited 2017 Sep 22]. Available from: http://healthaffairs.org/blog/2014/12/18/aco-quality-results-good-but-not-great/ Google Scholar
• 16 Cohen A, Klein S, McCarthy D. Hill Physicians Medical Group: a market-driven approach to accountable care for commercially insured patients [Internet]. New York (NY): Commonwealth Fund; 2014 Oct [cited 2017 Sep 22]. Available from: http://www.commonwealthfund.org/~/media/files/publications/case-study/2014/oct/1770_cohen_hill_physicians_aco_case_study.pdf Google Scholar
• 17 Hostetter M, Klein S, McCarthy D. Hennepin Health: a care delivery paradigm for new Medicaid beneficiaries [Internet]. New York (NY): Commonwealth Fund; 2016 Oct 7 [cited 2017 Sep 22]. Available from: http://www.commonwealthfund.org/publications/case-studies/2016/oct/hennepin-health Google Scholar
• 18 Hostetter M, Klein S, McCarthy D, Hayes SL. Guided care: a structured approach to providing comprehensive primary care for complex patients [Internet]. New York (NY): Commonwealth Fund; 2016 Oct 18 [cited 2017 Sep 22]. Available from: http://www.commonwealthfund.org/publications/case-studies/2016/oct/guided-care Google Scholar
• 19 McClellan M, Kent J, Beales S, Macdonnell M, Thoumi A, Shuttleworth Bet al. Accountable care: focusing accountability on the outcomes that matter: report of the Accountable Care Working Group 2013 [Internet]. Doha (Qatar): World Innovation Summit for Health; 2013 [cited 2017 Sep 22]. Available for download from: http://www.wish-qatar.org/research/reports/reports Google Scholar
• 20 McClellan M, Kent J, Beales SJ, Cohen SI, Macdonnell M, Thoumi Aet al. Accountable care around the world: a framework to guide reform strategies. Health Aff (Millwood). 2014;33(9):1507–15. Go to the article, Google Scholar
• 21 McClellan MB, Leavitt MO. Competencies and tools to shift payments from volume to value. JAMA. 2016;316(16):1655–6. Crossref, Medline, Google Scholar
• 22 Dzau VJ, McClellan M, McGinnis JM. Vital Directions for Health and Health Care: an initiative of the National Academy of Medicine. JAMA. 2016;316(7):711–2. Crossref, Medline, Google Scholar
• 23 McClellan M, Udayakumar K, Gonzalez-Smith Jet al. Case study: Possible: Nepal [Internet]. Durham (NC): Duke-Margolis Center for Health Policy; [cited 2017 Sep 22]. Available from: https://healthpolicy.duke.edu/sites/default/files/atoms/files/nepal_25jan2017.pdf Google Scholar
• 24 McClellan M, Udayakumar K, Gonzalez-Smith J, Kadakia K, Thoumi Aet al. Case study: Zio Integrated Care Network: the Netherlands [Internet]. Durham (NC): Duke-Margolis Center for Health Policy; [cited 2017 Sep 22]. Available from: https://healthpolicy.duke.edu/sites/default/files/atoms/files/netherlands_25jan2017.pdf Google Scholar
• 25 McClellan M, Udayakumar K, Gonzalez-Smith Jet al. Case study: Gesundes Kinzigtal: Germany [Internet]. Durham (NC): Duke-Margolis Center for Health Policy; [cited 2017 Sep 22]. Available from: https://healthpolicy.duke.edu/sites/default/files/atoms/files/germany_25jan2017.pdf Google Scholar
• 26 Elissen AM, Duimel-Peeters IG, Spreeuwenberg C, Spreeuwenberg M, Vrijhoef HJ. Toward tailored disease management for type 2 diabetes. Am J Manag Care. 2012;18(10):619–30. Medline, Google Scholar
• 27 Steuten LMG, Vrijhoef HJM, Landewé-Cleuren S, Schaper N, Van Merode GG, Spreeuwenberg C. A disease management programme for patients with diabetes mellitus is associated with improved quality of care within existing budgets. Diabet Med. 2007;24(10):1112–20. Crossref, Medline, Google Scholar
• 28 Gesundes Kinzigtal GmbH. Innovationen für eine gesunde Zukunft: Jahresbericht Gesundes Kinzigtal 2015 [Internet]. Freiburg: Gesundes Kinzigtal GmbH; 2016 [cited 2017 Oct 2]. German. Available from: http://neu.gesundes-kinzigtal.de/wp-content/uploads/2016/06/Jahresbericht-Gesundes-Kinzigtal-2015.pdf Google Scholar
• 29 Pimperl A, Schulte T, Mühlbacher A, Rosenmöller M, Busse R, Groene Oet al. Evaluating the impact of an accountable care organization on population health: the quasi-experimental design of the German Gesundes Kinzigtal. Popul Health Manag. 2017;20(3):239–48. Crossref, Medline, Google Scholar