摘要：We examined areas of potential collaboration between accountable care organizations and public health agencies, as well as perceived barriers and facilitators. We interviewed 9 key informants on 4 topics: advantages of public health agency involvement in accountable care organizations; services public health agencies could provide; practical, cultural, and legal barriers to accountable care organization–public health agency involvement; and business models that facilitate accountable care organization–public health agency collaboration. Public health agencies could help accountable care organizations partner with community organizations and reach vulnerable patients, provide population-based services and surveillance data, and promote policies that improve member health. Barriers include accountable care organizations’ need for short-term financial yield, limited public health agency technical and financial capacity, and the absence of a financial model. Accountable care organizations ascribe to the goal of population health improvement, yet there is almost no documentation of their relationship with the organizations most engaged in the health of populations: public health agencies. (We use the term public health agencies to encompass local, regional, and state agencies.) The following analysis begins to fill this gap by describing current and potential roles for public health agencies in accountable care organizations and identifying approaches that appear particularly promising as well as barriers and facilitators to involvement. One of the overarching themes of the Affordable Care Act (ACA) and related initiatives is the pursuit of the “triple aim”: making care more patient centered, improving population health, and bending the medical care cost curve. 1 The ACA provides support for creative approaches to the triple aim, several of which fall under the auspices of the Center for Medicare and Medicaid Innovation. The Center for Medicare and Medicaid Innovation has developed programs supporting accountable care, bundled payment models, primary care transformation, and accelerated uptake of novel approaches to care. Several of the Center for Medicare and Medicaid Innovation’s models may help bridge the gap between public health and health care, but one model—the accountable care organization—holds particular promise. 2–5 Although Center for Medicare and Medicaid Innovation–sponsored accountable care organizations pursue the triple aim in the context of Medicare beneficiaries, other payer and provider groups also see the accountable care organization’s potential. These include Medicaid, primarily driven by Center for Medicare and Medicaid Innovation’s State Innovation Model program, as well as commercial insurance carriers, which sponsor some of the largest accountable care organizations. 6 Whatever form it takes, the accountable care organization model has experienced tremendous growth: although commercial accountable care organizations are difficult to enumerate, it appears that their number doubled between 2012 and 2013, from 221 to 486, and now exceeds 600, more than half serving Medicare beneficiaries. 7–9 Accountable care organizations are present in most health care markets, and more than 55% of Americans live in areas they serve. 10 Under the accountable care organization model, provider groups assume greater responsibility for patient care cost and quality and in return are eligible to share in savings if they meet cost and quality goals. In some instances, they risk losing funding if they fail to meet goals. 11–14 Coordinated care helps meet the triple aim’s quality and satisfaction goals by increasing the likelihood that patients are receiving appropriate care, at the appropriate time, and in the appropriate setting. Coordinated care also helps meet financial goals by reducing duplication and the potential for medical error. The focus on the health of the entire patient population, not just individual patients, allows the accountable care organization to identify preventive group interventions. Public health agencies have expertise in relevant areas such as prevention, the health issues of high-risk populations, population health assessment, and community health improvement, so the accountable care organization model would appear to offer opportunities for synergy. 3,5 Evidence suggests that public policy changes can promote relationships between public health agencies and other health care system members. 15 The accountable care organization’s population is a subset of the community served by 1 or more public health departments, so the health status of accountable care organization populations is related to that of their communities. 5,16 The expertise of the public health agency in prevention and population health policy initiatives can support the accountable care organization in addressing the population health component of the triple aim. However, in any discussion of the public health–accountable care organization relationship, it is important to note that the meaning of population differs substantially between accountable care organizations and public health agencies. 2,3,16–18
