Can US models of care delivery inform how CCGs should work?

The question at the heart of the debate on the government’s reforms of the NHS is will clinical commissioning groups work? It is still not clear how the proposed reorganisation of the NHS will deliver accountable and integrated care. Two key initiatives in the US also aim to transform the delivery of healthcare to meet the changing health needs: Medical Homes and Accountable Care Organisations.

Medical Homes are highly advanced and comprehensive primary care organisations. Care is coordinated, patient centred and team based, with innovations such as telecare  widely used to improve access for patients. Budgets are capitated and providers are accountable to patients for quality.

Population health is at the heart of the vision of Medical Homes, patients are encouraged to be active participants in their care and physicians lead the practice team in coordinating care. Medical Homes are also able to specialise into specific conditions, and indeed have been most successful when targeted at at-risk patient groups.

Accountable Care Organisations take the Medical Home concept a step further and integrates primary and secondary care services. ACOs build on the success of America’s most innovative integrated healthcare providers, such as Kaiser and the Mayo Clinic, and are now being piloted as providers of Medicare services. The ACOs will be led by networks of primary care physicians, and will be accountable to the patient through their choice of GP to deliver all their healthcare services across different providers that are associated with ACO.

Medicare will finance ACOs to provide services to a population, who will share any savings delivered through more coordinated and efficient care. Performance measurement is essential, and ACOs will need to demonstrate that quality and outcomes have improved, rather than volume of clinical services delivered.

There remains a great deal of flexibility on how Accountable Care Organisations are organised, and is expected that different payment systems and risk sharing arrangements will be developed by different pilots. Rather than creating compulsory arrangements and a nationwide restructuring of healthcare, the creation of ACOs will be voluntary and the lessons of pilots will be used to expand their coverage.

While Medical Homes and Accountable Care Organisations are only just emerging, they offer a powerful vision of what clinical commissioning groups could look like. Rather than using centralised leadership through the national commissioning board, American policy makers are using accountability to the patient and reforms to the financing of healthcare to drive integration. As many have noted structural reorganisation alone cannot change the incentives for providers: changing how money flows through the system is also needed for reform to succeed.