Accountable care activity in the states

Research Objective: States are at the forefront of efforts to design and implement innovative payment and delivery mechanisms that encourage accountability for costs and quality in health care delivery. With the support of The Commonwealth Fund, the National Academy for State Health Policy is identifying and tracking state activity to promote accountable care on an interactive map.

Study Design: Information on state initiatives was collected through internet research and literature review. To guide the research, a literature review and semi-structured interviews with experts were conducted to develop a definition of “accountable care activity” that captures essential features of accountable care arrangements without being unduly restrictive.

Principal Findings: As these new initiatives have continued to spread across the country, patterns have emerged in state approaches to fostering accountable care. Some states are explicitly cultivating accountable care organization (ACO) models, in line with federal efforts to use shared savings models in the Medicare program to support these models, while others are fostering the creation of new provider-led organizations not explicitly conceptualized as ACOs.

States are developing attribution models to define patient populations for the purpose of facilitating accountability. Some states, like Illinois and Oregon, plan to rely on active enrollment by beneficiaries. Other states, like Maine and Minnesota, will use claims analysis to attribute beneficiaries to providers participating in the accountable care initiative.

States are implementing payment mechanisms to encourage value. Their initiatives are employing payments aimed at fostering innovation and transitioning away from strict fee-for-service arrangements. Shared savings approaches are popular, layering new incentives for efficiency and quality on top of fee-for-service reimbursement. Shared savings is one payment model used in Illinois's approach, Minnesota's demonstration, and ACO-style models being fostered in Maine, Massachusetts, New York, and New Jersey.

States are developing performance measurement strategies to ensure accountability. Some states, like Maine and New York, will seek to align measurement approaches for their accountable care initiatives with the Medicare Shared Savings Program. Others, including Massachusetts and Minnesota, will rely more heavily on homegrown measurement systems.

Conclusions: Despite the range of approaches states are implementing, these exhibit key features of accountable care: responsibility for a defined population, payments linked to value for care provided to that population, and reliable performance measurement to accurately gauge value. States are developing attribution models to define patient populations for the purpose of facilitating accountability, implementing payment mechanisms to encourage value, developing performance measurement strategies to ensure accountability.