Volume 4, Number 4
April, 2013
Accountable Care – One Community’s Approach to
Avoid the Tragedy of the Commons
By Howard Epstein, MD, FHM and Cally Vinz, RN
I
n the recent Blue Cross and Blue Shield of Massachusetts annual report, Andrew Dreyfus, President and CEO, stated
that exceptional and affordable health care is possible in Massachusetts if the health care community continues to work
together in a spirit of shared responsibility.
Via an included video, he adds, “Massachusetts health reform has been incredibly collegial and collaborative…but even here,
we sometimes retreat to our own corners – as insurers, hospitals, physicians, consumer advocates or business interests –
especially when the question is where to cut costs.
We need to bridge these historic divides. The key to success is going to be shared responsibility among all stakeholders in
healthcare.” The news release on the report is available on BusinessWire.com.
Mr. Dreyfus’s comments reflect a notion that health care suffers from a potential tragedy of the commons. In economics, this
term refers to “the depletion of a shared resource by individuals, acting independently and rationally according to each one's
self-interest, despite their understanding that depleting the common resource is contrary to the group's long-term best
interests.” (Here is the Wikipedia page for the term.)
One approach to avoiding this phenomenon is to regulate the use of finite resources via government intervention. However,
Elinor Ostrom received a share of the 2009 Nobel Prize in Economics for demonstrating how local “solutions can emerge from
the bottom up to ensure a sustainable, shared management of resources, as well as one that is efficient from an economical
point of view.” She is featured in this article from the American Enterprise Institute website. The great question before us is
whether health care will be able to develop a ground-up solution before governments are forced to stem the hemorrhaging of
their budgets by health care expenditures through legislation or executive mandates.
Like Massachusetts, Minnesota has a longstanding culture of collaboration when it comes to clinical quality improvement in
health care. This year marks the 20th anniversary of the Institute for Clinical Systems Improvement, one of the first regional
health improvement collaboratives. Over the course of those 20 years, all of the major non-profit health plans, and the majority
of Minnesota provider systems, hospitals, clinics and physicians, have implemented ICSI’s evidence-based health care
guidelines and collaborated on patient-centered initiatives that improve the quality and value of care delivered to patients in the
state.
Until just a few years ago, the mere mention of health care costs or affordability among ICSI stakeholders was taboo. In 2011,
however, the ICSI Board specifically charged the organization to directly target the issues of total cost of care (TCOC) and
affordability. Board members agreed that addressing this third leg of the Triple Aim was essential to improve their
organizations’ performance on quality health outcomes and patient experience in the new era of accountable care.
There was another acknowledgment driving this focus -- unsustainable increases in health care costs were cannibalizing the
state’s discretionary budget for such community social determinants of health as education, job creation, transportation, and
the environment. These social determinants are known to have a greater impact on the health of a community than the health
care delivery system itself. (See Diagram 1 next page) Through the ICSI collaborative, we began to explore how to address
TCOC and affordability while maintaining or improving the quality and experience of care. But where to begin with such a
complex and seemingly overwhelming problem? ICSI invited stakeholders to join a planning committee to outline broad goals
and strategies for an Affordability Advisory Council that would be charged with overseeing the work on affordability and TCOC.
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Accountable Care – One Community’s Approach …continued
Diagram 1. White Paper Developed from
the State Quality Improvement Institute
2008-2010 in Minnesota, Sponsored by
Academy Health and the Commonwealth
Fund. Magnan S, Fisher E, Kindig D, et.
al. Achieving Accountability for Health and
Health Care. Academy Health and the
Commonwealth Fund 2010.
Using the Berwick & Hackbarth model as a working paradigm, we looked at six broad categories of waste in health care as a
model for bringing health care spending down to a sustainable level. (Diagram 2 below)
Diagram 2. Used with permission. Berwick DM, Hackbarth AD.
Eliminating waste in U.S. health care. JAMA 2012;307:1513-16.
We then adapted the original carbon emissions “stabilization wedges” exercise developed at Princeton Environmental Institute
(based on original work by Socolow and Pacala), to the categories of waste in health care in an exercise we called “The Waste
Wedges.” Initially, we conducted a brainstorming session with the planning committee to identify key focus areas within each
individual waste category (See Diagram 3 next page), then facilitated a process to help narrow our focus and identify areas of
maximum opportunity. We repeated this exercise with ICSI’s Patient Advisory Council and with our Affordability Advisory
Council to further build consensus around five initial areas of focus for waste reduction and affordability improvement.
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April, 2013
Accountable Care News
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Accountable Care – One Community’s Approach …continued
Diagram 3. Copyright 2013 Institute for Clinical Systems Improvement
The next step in this process is the formation of work groups to identify concrete, measurable and actionable affordability
improvement initiatives within each area of waste. One of our goals is to build a portfolio of opportunities for prioritization and
implementation based on potential value and impact that are maximized through a collaborative approach rather than activities
by individual organizations.
One example of this approach is the clear consensus achieved around the overuse of non-indicated tests and treatments. This
work group will focus on evaluating the list of recommendations put forth by the Choosing Wisely® Campaign, an initiative of
the American Board of Internal Medicine (ABIM) Foundation, which aims to promote conversations between physicians and
patients by helping patients choose care that is: supported by evidence; not duplicative of other tests or procedures already
received; free from harm; and, truly necessary.
ICSI, in partnership with the Minnesota Health Action Group was recently awarded one of 21 grants from the ABIM Foundation
to work with patients and consumers to raise awareness of the Campaign and its recommendations, and help providers feel
knowledgeable, confident and competent when engaging patients in shared decision-making conversations about the safety
and additional marginal value of commonly overused tests and procedures.
ICSI will take the lead on project work related to physicians and patients, while Minnesota Health Action Group will spearhead
communication efforts with employers and their employees. The Minnesota Medical Association was awarded a separate
grant to disseminate the Campaign through its physician membership.
Adaptive Changes Needed for Success
As we delve into this work, we must also acknowledge the adaptive and cultural changes needed for adoption and acceptance
of accountable care organizations and a value-based health care delivery system. In a recent Wall Street Journal editorial,
Clayton Christensen, et. al., (The Coming Failure of ‘Accountable Care’. WSJ, February 19, 2013, A15) clearly identify the
need for significant changes in both physician and patient behavior. Novel contracting and benefit design is easy compared to
changing human behavior. By utilizing the consumer-designed conversations of the Choosing Wisely® Campaign that are
evidence-based and endorsed by national physician organizations, we hope to change both provider and consumer culture
and help eschew the notion that “more care is better, and more expensive care is better-er.”
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Accountable Care – One Community’s Approach …continued
One may quickly surmise that there is an enormous difference between what will be required to achieve an affordable and
sustainable level of health care spending in our communities and the efforts described above, which exclude waste attributable
to pricing failures and fraud and abuse -- both beyond the scope of our work. However, it is a beginning and a piece of the
larger puzzle.
A greater awareness of TCOC measurement by providers and patients/consumers is still needed and is essential for ACO
success, much in the way that providers learned to utilize available quality data in the previous decade. ICSI has been
actively educating providers on this topic since 2011 through webinars, seminars, our annual Colloquium and other venues.
Through the work of another non-profit collaborative, Minnesota Community Measurement (MNCM), key stakeholders are also
engaged in work to standardize methodology and specifications around TCOC and resource use measurement. These
measures will be used for affordability improvement as well as public reporting to increase patient, consumer and purchaser
transparency that will help drive value-based decision-making in conjunction with quality measurement reporting.
The key message here is that TCOC must always be evaluated in the context of appropriateness of care and the Triple Aim.
Otherwise, both physicians and patients/consumers will likely perceive, and perhaps rightly so, that accountable care, ACOs,
value-based benefit design, value-based networks, tiering and other novel approaches to payment reform are focused on
decreasing costs at the expense of quality and experience of care. This will only lead to an accountable care backlash
echoing the eventual failure of managed care in the late 80’s and early 90’s.
Fortunately, groups like ICSI and MNCM are well positioned to help health care organizations, citizens and communities
achieve the grand vision of Triple Aim outcomes and sustainability so that we do not fall victims to “The Tragedy of the
Commons.”
Howard Epstein, MD, FHM is Chief Health Systems Officer at ICSI. He may be reached at [email protected]. Cally Vinz, RN is Vice
President, Clinical Products and Strategic Initiatives at ICSI. Reach her at [email protected]
Published by Health Policy Publishing, LLC
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209-577-4888
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www.AccountableCareNews.com