Accountable Care Organizations and Cultural-Area Variation

One of the more audacious promises of the accountable care organization (ACO) movement is the idea that providers of medical services can play a larger role in improving a population’s health. It stems from a notion that health care financing reforms will move the focus of providers from “the tyranny of the office visit” to activities where success will be judged according to improvement in clinical metrics whether a patient visits the office or not. It’s the right vision from a health promotion advocate’s vantage point because it may serve as a preamble to an era where medical and public health practices and public policies truly intersect. Dartmouth’s Jack Wennberg famously observed predictable provider-centric small-area variation in the use of clinical procedures while the Centers for Disease Control and many other public health observers have long shown that ZIP codes have more to do with health than do medical codes. Can the next generation of health reforms reconcile the tension between these loosely related truths?

Providers have argued that pay for performance for patient outcomes should account for adverse selection, and that payments should be adjusted for risk according to the level of acuity of the patient panel. That is, physicians have said “I’m known for being good at managing disease X, so I attract the sickest patients.” Similarly, the shared savings opportunities for ACOs will be affected by whether an adverse community culture surrounds a practice. In the future, ACOs may boast that “our practices are in geographical locations with some of the least healthy cultures. We’re serving patients where healthy choices have not been easy to come by but we seek out these markets because we’re known for being better at supporting a culture of health in the communities we serve.”

I’ve argued elsewhere that experts who posit that culture change and behavior change are separate challenges seem to have ignored the entire field of social psychology. Still, changing cultures or the public policies that influence a community’s health have not typically been central to the business interests of managed care companies. Nevertheless, some measures that matter to providers, such as Judith Hibbard’s “patient activation measure” (PAM), are as likely to be influenced by cultural supports as by educational interventions. Hence, the first order of business, if we are to address how culture impacts an ACO’s capacity to produce shared savings, will be to determine and test metrics showing how health improvements vary according to new categories such as these four:

1. High patient activation and low culture support
2. High patient activation and high culture support
3. High culture support and low patient activation
4. Low culture support and low patient activation

Culture measures that matter to an ACO

Just as pay-for-performance policy in patient care migrated from paying for improved process metrics to improved outcomes metrics, the same should occur with respect to whether and how an ACO improves the health of a community. Yet Albert Einstein cautioned that “not everything that matters can be measured and not everything that can be measured matters.” Similarly, Risa Lavizzo-Mourey, the president and CEO of the Robert Wood Johnson Foundation (RWJF), has written that improving a culture of health must start with assessing “the bigger picture of what defines health in America, how health will always be linked to health care, but also extends to work, family, and community life; how health equity is connected to opportunity.”

Fulfilling the promise of the ACO movement should start with better understanding of the linkages between culture and health. This will probably require the intentional convergence of measures like PAM with research like Wennberg’s and the epidemiology of the CDC. Furthermore, CMS and pioneering ACOs will need to add their voices to a call to action like that of RWJF. Both public policy and scientific consensus is needed to develop cultural metrics that show whether America’s health system can play a larger role in a community’s culture of health. I predict we will find that shared savings are a function of shared opportunities and that health equity is a keen proxy for equity writ large.

Paul E. Terry, PhD, is executive vice president and chief science officer at StayWell.