Ahead of the Curve

L ong before “accountable care” became a familiar term in the health care delivery lexicon, I invited a primary care provider (PCP) from Camden, New Jersey, to speak at our monthly Population Health Forum about a nascent attempt to build a citywide health care utilization database. This bright, dedicated, and very determined young man postulated that, if he could persuade all 3 of the city's hospitals to pool their patient data in a relatively inexpensive, uncomplicated computer program, it would be possible to identify, target, and ultimately manage the delivery of appropriate health care services to the city's highest utilizers. Armed with demographic and clinical information about this subpopulation, the city's PCPs and hospitals might work collaboratively to reduce emergency room use and readmissions for chronic conditions, thereby bending the cost curve.

I thought, “What an elegant concept!” The year was 2008; the presentation was titled Building a Comprehensive Database for Use in City-Wide Health Management System ¹ ; and the presenter, of course, was Jeffrey Brenner, MD. Even at this early stage, Dr. Brenner's vision resonated with the health policy, public health, health care quality, and health economics outcomes research faculty and staff in the audience.

With the enactment of health care reform and the official birth of the Accountable Care Organization (ACO) model in 2010, the State of New Jersey was ahead of the crowd largely because of the groundbreaking work of Dr. Brenner and his Camden team in bringing together physicians and hospitals around the shared goal of improving health care for the population of a region. One of the biggest challenges in forming an ACO is forging mutually beneficial partnerships among a wide range of providers. In certain ways, the ACO model is the antithesis of most hospital business models in that it focuses on collaborating with physicians to keep patients healthy and out of the hospital (ie, less use of emergency room services, inpatient admissions, tests, procedures), which results in decreased revenue. However, ACOs are well suited for Medicaid patients whose care often costs hospitals and health systems more than they receive in reimbursement.

Currently, “safety net ACOs” are being formed under Medicaid Waivers in a number of states in an effort to assure access to integrated care, thereby improving the health care status of vulnerable communities. With 2 more regions – the Trenton area and Newark – in the process of learning from and adapting the Camden model in forming demonstration Medicaid ACOs, New Jersey is at the forefront of this important population health initiative.

Some of my health policy colleagues—especially those in favor of striking down most, if not all, of the Affordable Care Act—would argue that, given the complexity of the existing health care system, ACOs not only are destined to fail but also are likely to exacerbate the very problems they set out to fix. The argument goes that by concentrating increased power in fewer organizations, ACOs will become “too large to fail,” thereby undermining competition and entrepreneurship. I couldn't disagree more with this prediction. Especially when viewed in the context of the articles in this supplement, I foresee a much more positive outcome.