Opinion
VIEWPOINT
Elliott S. Fisher, MD, MPH The Dartmouth Institute for Health Policy and Clinical Practice, Center for Health, Lebanon, New Hampshire. Janet Corrigan, PhD The Dartmouth Institute for Health Policy and Clinical Practice, Center for Health, Lebanon, New Hampshire.
Editorial page 2099
Accountable Health Communities Getting There From Here Almost 40 years after Hiatt1 called on physicians to become stewards of the scarce resources devoted to health care, physicians have taken on key leadership roles at multiple levels. The Choosing Wisely Campaign is a physician-led initiative that focuses on individual physician decision making as an opportunity to improve care and lower costs by avoiding unnecessary and often harmful treatments.2 Physicians are also taking on prominent leadership roles in new health care delivery and payment models, most notably accountable care organizations (ACOs), that encourage and reward achievement of better outcomes while managing the total costs of care.3 There is an important opportunity for physicians to bring their clinical knowledge, professional values, and wisdom to a third level of activity: the initiatives unfolding in communities and regions across the country that are aimed at investing health resources more wisely. In this Viewpoint, we discuss approaches to overcoming 2 major challenges (ie, effective local governance and sustainable finance) facing efforts to establish what some have referred to as accountable health communities.4
Effective Local Governance: Frameworks for Community Action
Corresponding Author: Elliott S. Fisher, MD, MPH, The Dartmouth Institute for Health Policy and Clinical Practice, Center for Health, 35 Centerra Pkwy, Lebanon, NH 03766 (elliot.s.fisher @dartmouth.edu).
Many have acknowledged the lack of coordination among health care, public health, and social services. Even though all are influenced by state and federal policy, the actual organization and delivery of these services is fundamentally local, varying substantially from place to place. Addressing the increasing burden of preventable health conditions will require engagement from many stakeholders and sectors to address the specific social, behavioral, economic, environmental, and clinical determinants of health in a given community. Similarly, the performance of health systems is also powerfully influenced by local market dynamics, including local practice patterns; the capacity of the health care system (eg, physician and hospital bed supply, the number of proton accelerators); the degree of market power held by hospitals, medical groups, plans, and purchasers; and efforts of regional purchasers to promote transparency and value-based purchasing. Achieving progress will require local governance committed to addressing the full range of determinants of health system performance and effective approaches to coordinating local action across sectors and stakeholders to influence those determinants. In developing a local governance framework, the work of Ostrom5 is particularly helpful. Ostrom re-
viewed approaches to managing complex social problems, including cross-jurisdictional challenges such as metropolitan policing or problems with commons, such as regional fisheries. She found that polycentric governance structures that acknowledge the multiple levels (eg, national, state, and local) at which action is needed while engaging all of the stakeholders (public and private) who need to work together outperformed simpler governance approaches. Her work also points to the importance of governments granting some degree of local autonomy to regional stakeholder groups and to the need for such groups to build trust, develop effective means of supporting collaboration, manage conflicts, and build long-term commitments to stewardship of community resources, which in this case are the physical, human, and financial resources that influence health. A second framework offers particular promise once the goals of a local stewardship initiative are established. Building on the insights of Ostrom and others, Kania and Kramer6 developed the Collective Impact model to help communities more effectively coordinate local activities to achieve sustained and substantial effects on specific social challenges. They include not only the need for effective governance (a multistakeholder backbone organization to coordinate action), but also the actions that are required for effectiveness, which include a common and focused agenda, shared measurement to support and align achievement of the shared goals, and continuous communication. The model has been applied in education (Cincinnati, Ohio) and in community health improvement (Keene, New Hampshire).
Sustainable Finance There is also increasing recognition that the current allocation of resources tilts disproportionately toward health care,7 that much of that spending is wasted, and that redirecting even a portion of health care savings to support proven interventions addressing the upstream determinants of health could achieve substantial returns.8 Consensus is emerging that this will require a transition from fee-for-service payment to financing approaches that hold physicians, hospitals, and others accountable for performance on both cost and quality, whether for defined clinical episodes or for the overall costs of care for the patients served by a primary care practice or ACO. However, savings accrue either to the physicians or hospitals that are receiving payment under the new models or to the payers. It is far from clear how or if the reallocation to support needed investments in public health or social services will occur.
jama.com
JAMA November 26, 2014 Volume 312, Number 20
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Western Oregon University User on 05/24/2015
2093
Opinion Viewpoint
A number of mechanisms are being deployed in communities across the country intended to provide increased resources to support more balanced investments (Box). Potential sources of core support for multistakeholder groups willing to serve as a backbone organization include membership dues, employer contributions, and foundation support. Community benefit funds from nonprofit hospitals also represent a potential source of initial funding for these initiatives. In line with Collective Impact principles,6 some states and local initiatives are focusing on aligning existing resources by requiring or establishing partnerships between health care and community organizations. However, the scope and scale of health problems in most communities are so great that aligning current efforts with readily available resources will be insufficient, especially if health care spending continues to increase, shifting yet more resources from the social sectors critical to population health. Public and private payers could consider (1) accelerating the transition to global payment models such as ACOs, and requiring that a portion of ACO savings are allocated to community-based population health activities; or as is occurring to some extent in Oregon and Colorado,9 (2) moving to geographically focused, population-based global budgeting with accountability for improving care and lowering costs, and the flexibility needed to fund the set of health care and social services required to achieve the best outcome. In addition, wellness trusts, investment in social service programs, and community development funds (Box) all offer opportunities for local initiatives to secure additional funds. Physician leaders must commit to reallocation of resources, regardless of the approach, if indeed prevention is to succeed. Hiatt1 based his argument for physician stewardship on the need to overcome what Garret Hardin articulated as “the tragedy of the commons,” in which it is in the short-term individual interest of each shepherd to put more sheep on the pasture, until the resource collapses. Unfettered growth in health care spending and the increasing burden of chronic illness threaten communities to a much greater degree today than in 1975. Because of the local nature of both health and health care, effective collective action at the community level is likely to be critical to slowing spending growth, improving care, and improving population health.
ARTICLE INFORMATION Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Funding/Support: Drs Fisher and Corrigan reported receiving support from the Robert Wood Johnson Foundation and the Fannie E. Rippel Foundation ReThink Health Initiative, which stimulated some of the ideas in this Viewpoint.
Box. Approaches to Financing Regional Population Health Initiatives Membership Fees or Contributions
Organizations commit to a basic level of support to establish backbone organization capable of managing initiatives (eg, Cincinnati Health Council). Community Benefit Funds
Charitable contributions required of tax-exempt hospitals are allocated directly (or loaned) to support collaborative efforts focused on social, behavioral, and economic determinants of health (eg, Atlanta Regional Collaborative for Health Improvement). Regional Global Payment or Shared Savings
Governmental or private payers establish population-based global budgets or allocate a portion of accountable care organization (ACO) shared savings to community-based programs that enable non–health care investments intended to improve population health (eg, Hennepin Health). Linkages Between Health Care and Public Health or Community Partners
States require health care entities (eg, ACOs, patient-centered medical homes) to partner with community-based programs (eg, social services, behavioral health, community health workers, and housing support) (eg, Vermont Community Health Teams). Health and Wellness Trusts
States and other stakeholders tap various sources of funding (eg, local taxes, conversion of hospitals or health plans to for-profit status) to establish regional or statewide charitable trusts committed to support community-based, population health programs (eg, Los Angeles Wellness Trust). Social Investing
Investors agree to support community-based prevention or social service programs (eg, asthma management) in return for explicit commitments that a share of the health care savings achieved (eg, from reduced emergency department use) are returned to the investors (eg, Fresno Asthma Project). Community Development Financing
Financial institutions satisfy federal requirements to provide capital to underserved geographical areas by funding projects that address social determinants of health and wellness (eg, Mercy Housing).
2. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802.
7. Bradley EH, Elkins BR, Herrin J, Elbel B. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf. 2011;20(10):826-831.
3. Colla CH, Lewis VA, Shortell SM, Fisher ES. First national survey of ACOs finds that physicians are playing strong leadership and ownership roles. Health Aff (Millwood). 2014;33(6):964-971.
8. McCullough JC, Zimmerman FJ, Fielding JE, Teutsch SM. A health dividend for America: the opportunity cost of excess medical expenditures. Am J Prev Med. 2012;43(6):650-654.
4. Magnan S, Fisher E, Kindig D, et al. Achieving accountability for health and health care. Minn Med. 2012;95(11):37-39.
9. Corrigan J, Fisher E. Accountable Health Care Communities: Insights From State Health Reform Initiatives. Lebanon, NH: The Dartmouth Institute for Health Policy and Clinical Practice; November 2014.
Role of the Funder/Sponsor: The sponsors had no role in the preparation, review, or approval of the manuscript.
5. Ostrom E. Beyond markets and states: polycentric governance of complex economic systems. Am Econ Rev. 2010;100:641-672.
REFERENCES
6. Kania JV, Kramer MR. Collective impact. Stanford Soc Innovation Rev. 2011;winter:36-41.
1. Hiatt HH. Protecting the medical commons: who is responsible? N Engl J Med. 1975;293(5):235-241.
2094
JAMA November 26, 2014 Volume 312, Number 20
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Western Oregon University User on 05/24/2015
jama.com
VIEWPOINT
Elliott S. Fisher, MD, MPH The Dartmouth Institute for Health Policy and Clinical Practice, Center for Health, Lebanon, New Hampshire. Janet Corrigan, PhD The Dartmouth Institute for Health Policy and Clinical Practice, Center for Health, Lebanon, New Hampshire.
Editorial page 2099
Accountable Health Communities Getting There From Here Almost 40 years after Hiatt1 called on physicians to become stewards of the scarce resources devoted to health care, physicians have taken on key leadership roles at multiple levels. The Choosing Wisely Campaign is a physician-led initiative that focuses on individual physician decision making as an opportunity to improve care and lower costs by avoiding unnecessary and often harmful treatments.2 Physicians are also taking on prominent leadership roles in new health care delivery and payment models, most notably accountable care organizations (ACOs), that encourage and reward achievement of better outcomes while managing the total costs of care.3 There is an important opportunity for physicians to bring their clinical knowledge, professional values, and wisdom to a third level of activity: the initiatives unfolding in communities and regions across the country that are aimed at investing health resources more wisely. In this Viewpoint, we discuss approaches to overcoming 2 major challenges (ie, effective local governance and sustainable finance) facing efforts to establish what some have referred to as accountable health communities.4
Effective Local Governance: Frameworks for Community Action
Corresponding Author: Elliott S. Fisher, MD, MPH, The Dartmouth Institute for Health Policy and Clinical Practice, Center for Health, 35 Centerra Pkwy, Lebanon, NH 03766 (elliot.s.fisher @dartmouth.edu).
Many have acknowledged the lack of coordination among health care, public health, and social services. Even though all are influenced by state and federal policy, the actual organization and delivery of these services is fundamentally local, varying substantially from place to place. Addressing the increasing burden of preventable health conditions will require engagement from many stakeholders and sectors to address the specific social, behavioral, economic, environmental, and clinical determinants of health in a given community. Similarly, the performance of health systems is also powerfully influenced by local market dynamics, including local practice patterns; the capacity of the health care system (eg, physician and hospital bed supply, the number of proton accelerators); the degree of market power held by hospitals, medical groups, plans, and purchasers; and efforts of regional purchasers to promote transparency and value-based purchasing. Achieving progress will require local governance committed to addressing the full range of determinants of health system performance and effective approaches to coordinating local action across sectors and stakeholders to influence those determinants. In developing a local governance framework, the work of Ostrom5 is particularly helpful. Ostrom re-
viewed approaches to managing complex social problems, including cross-jurisdictional challenges such as metropolitan policing or problems with commons, such as regional fisheries. She found that polycentric governance structures that acknowledge the multiple levels (eg, national, state, and local) at which action is needed while engaging all of the stakeholders (public and private) who need to work together outperformed simpler governance approaches. Her work also points to the importance of governments granting some degree of local autonomy to regional stakeholder groups and to the need for such groups to build trust, develop effective means of supporting collaboration, manage conflicts, and build long-term commitments to stewardship of community resources, which in this case are the physical, human, and financial resources that influence health. A second framework offers particular promise once the goals of a local stewardship initiative are established. Building on the insights of Ostrom and others, Kania and Kramer6 developed the Collective Impact model to help communities more effectively coordinate local activities to achieve sustained and substantial effects on specific social challenges. They include not only the need for effective governance (a multistakeholder backbone organization to coordinate action), but also the actions that are required for effectiveness, which include a common and focused agenda, shared measurement to support and align achievement of the shared goals, and continuous communication. The model has been applied in education (Cincinnati, Ohio) and in community health improvement (Keene, New Hampshire).
Sustainable Finance There is also increasing recognition that the current allocation of resources tilts disproportionately toward health care,7 that much of that spending is wasted, and that redirecting even a portion of health care savings to support proven interventions addressing the upstream determinants of health could achieve substantial returns.8 Consensus is emerging that this will require a transition from fee-for-service payment to financing approaches that hold physicians, hospitals, and others accountable for performance on both cost and quality, whether for defined clinical episodes or for the overall costs of care for the patients served by a primary care practice or ACO. However, savings accrue either to the physicians or hospitals that are receiving payment under the new models or to the payers. It is far from clear how or if the reallocation to support needed investments in public health or social services will occur.
jama.com
JAMA November 26, 2014 Volume 312, Number 20
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Western Oregon University User on 05/24/2015
2093
Opinion Viewpoint
A number of mechanisms are being deployed in communities across the country intended to provide increased resources to support more balanced investments (Box). Potential sources of core support for multistakeholder groups willing to serve as a backbone organization include membership dues, employer contributions, and foundation support. Community benefit funds from nonprofit hospitals also represent a potential source of initial funding for these initiatives. In line with Collective Impact principles,6 some states and local initiatives are focusing on aligning existing resources by requiring or establishing partnerships between health care and community organizations. However, the scope and scale of health problems in most communities are so great that aligning current efforts with readily available resources will be insufficient, especially if health care spending continues to increase, shifting yet more resources from the social sectors critical to population health. Public and private payers could consider (1) accelerating the transition to global payment models such as ACOs, and requiring that a portion of ACO savings are allocated to community-based population health activities; or as is occurring to some extent in Oregon and Colorado,9 (2) moving to geographically focused, population-based global budgeting with accountability for improving care and lowering costs, and the flexibility needed to fund the set of health care and social services required to achieve the best outcome. In addition, wellness trusts, investment in social service programs, and community development funds (Box) all offer opportunities for local initiatives to secure additional funds. Physician leaders must commit to reallocation of resources, regardless of the approach, if indeed prevention is to succeed. Hiatt1 based his argument for physician stewardship on the need to overcome what Garret Hardin articulated as “the tragedy of the commons,” in which it is in the short-term individual interest of each shepherd to put more sheep on the pasture, until the resource collapses. Unfettered growth in health care spending and the increasing burden of chronic illness threaten communities to a much greater degree today than in 1975. Because of the local nature of both health and health care, effective collective action at the community level is likely to be critical to slowing spending growth, improving care, and improving population health.
ARTICLE INFORMATION Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Funding/Support: Drs Fisher and Corrigan reported receiving support from the Robert Wood Johnson Foundation and the Fannie E. Rippel Foundation ReThink Health Initiative, which stimulated some of the ideas in this Viewpoint.
Box. Approaches to Financing Regional Population Health Initiatives Membership Fees or Contributions
Organizations commit to a basic level of support to establish backbone organization capable of managing initiatives (eg, Cincinnati Health Council). Community Benefit Funds
Charitable contributions required of tax-exempt hospitals are allocated directly (or loaned) to support collaborative efforts focused on social, behavioral, and economic determinants of health (eg, Atlanta Regional Collaborative for Health Improvement). Regional Global Payment or Shared Savings
Governmental or private payers establish population-based global budgets or allocate a portion of accountable care organization (ACO) shared savings to community-based programs that enable non–health care investments intended to improve population health (eg, Hennepin Health). Linkages Between Health Care and Public Health or Community Partners
States require health care entities (eg, ACOs, patient-centered medical homes) to partner with community-based programs (eg, social services, behavioral health, community health workers, and housing support) (eg, Vermont Community Health Teams). Health and Wellness Trusts
States and other stakeholders tap various sources of funding (eg, local taxes, conversion of hospitals or health plans to for-profit status) to establish regional or statewide charitable trusts committed to support community-based, population health programs (eg, Los Angeles Wellness Trust). Social Investing
Investors agree to support community-based prevention or social service programs (eg, asthma management) in return for explicit commitments that a share of the health care savings achieved (eg, from reduced emergency department use) are returned to the investors (eg, Fresno Asthma Project). Community Development Financing
Financial institutions satisfy federal requirements to provide capital to underserved geographical areas by funding projects that address social determinants of health and wellness (eg, Mercy Housing).
2. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802.
7. Bradley EH, Elkins BR, Herrin J, Elbel B. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf. 2011;20(10):826-831.
3. Colla CH, Lewis VA, Shortell SM, Fisher ES. First national survey of ACOs finds that physicians are playing strong leadership and ownership roles. Health Aff (Millwood). 2014;33(6):964-971.
8. McCullough JC, Zimmerman FJ, Fielding JE, Teutsch SM. A health dividend for America: the opportunity cost of excess medical expenditures. Am J Prev Med. 2012;43(6):650-654.
4. Magnan S, Fisher E, Kindig D, et al. Achieving accountability for health and health care. Minn Med. 2012;95(11):37-39.
9. Corrigan J, Fisher E. Accountable Health Care Communities: Insights From State Health Reform Initiatives. Lebanon, NH: The Dartmouth Institute for Health Policy and Clinical Practice; November 2014.
Role of the Funder/Sponsor: The sponsors had no role in the preparation, review, or approval of the manuscript.
5. Ostrom E. Beyond markets and states: polycentric governance of complex economic systems. Am Econ Rev. 2010;100:641-672.
REFERENCES
6. Kania JV, Kramer MR. Collective impact. Stanford Soc Innovation Rev. 2011;winter:36-41.
1. Hiatt HH. Protecting the medical commons: who is responsible? N Engl J Med. 1975;293(5):235-241.
2094
JAMA November 26, 2014 Volume 312, Number 20
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Western Oregon University User on 05/24/2015
jama.com
