Traditionally, healthcare systems have dominated as supply-driven enterprises; the supply–or fee-for-service payment structure–has often resulted in fragmented care delivery. The recent shift in the US and across the world towards “accountable care”–a method of aligning healthcare payments with patient-focused goals––necessitates a demand-driven system; in such a system, reimbursement is based on a defined and measurable set of target outcomes for patients. The transition from a supply-driven model to a demand-driven model remains challenging, and global policy makers learn in real time from their successes and failures. By design, accountable care hopes to unite healthcare providers to support this change by improving the quality, coordination, and efficiency of the care. Countries around the world recognize the benefits inherent in this healthcare delivery model–to achieve the objectives of the “Triple Aim”: improve care, improve health, and reduce costs.

McClellan and colleagues published a strategy for understanding, refining, and measuring the impact of accountable care in September 2014.1 Their method assesses if a system can achieve the Triple Aim. The authors conducted a literature review and interview-based study to first define “accountable care system and then identify features common to these care systems. The authors identified five components that together form a framework for assessing reform:

  • Population–Who are the individuals for which providers are jointly accountable?
  • Outcomes–What are the target outcomes that matter most to this population?
  • Metrics and learning–How are these outcomes measured? What can be learned from these metrics?
  • Payments and incentives–What is the value associated with those outcomes? How is this value distributed?
  • Coordinated delivery–How does the system deliver or improve coordinated care?

A productive accountable care system does not develop overnight; it is an incremental journey. Each functional component evolves from a basic level (eg, population level 1 means the system takes a patient-based view) to an advanced level (eg, population level 5 means that intersections between different morbidity groups are carefully planned and accounted for). Successful adoption of an accountable care model requires an iterative approach: setting goals, making multiple adjustments, and incorporating lessons learned.

The authors believe in four key immediate actions for policy makers to take:

  • Take a broader perspective than illness
  • Start to pay for outcomes
  • Create a favorable environment for collaboration
  • Encourage adoption of interoperable data systems

The first action is a fundamental need for an accountable care model to work. Policy makers need to shift thinking from a disease focus to improving individual wellness or overall population health. The second action signals to providers that priorities are indeed changing. The last two actions are linked as collaboration and data integration are needed in order for an accountable care model to mature and to provide coordinated care delivery.

Does accountable care work? While some mature systems thrive, many accountable care reforms remain in their infancy making a complete assessment difficult; however, the early evidence looks promising. Models that met the authors’ definition demonstrate enhanced quality of care and patient experience and reduced unnecessary treatments and admission/readmission rates. Several systems have demonstrated successful and sustained cost reductions. Overall, cost savings during the early years of reform programs tend to be modest, most likely due to the high initial investment needed. Reform programs may achieve short-term savings by concentrating on high-risk patients–who account for the majority of short-term costs.

As more healthcare systems shift towards accountable care, the framework proposed by McClellan et al provides an important assessment tool of accountable care systems to determine if they are meeting the Triple Aim of healthcare: increase quality, lower costs, and improve outcomes.

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By: Jennifer Chang, PhD, and Mario Nacinovich, MSc


  1. McClellan M, Kent J, Beales SJ, Cohen SI, Macdonnell M, Thoumi A, Abdulmalik M, Darzi A. Accountable care around the world: a framework to guide reform strategies. Health Aff (Millwood). 2014;33(9):1507-15.