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Abstract
A historically fragmented U.S. health care system, where care has been delivered by
multiple providers with little or no coordination, has led to increasing issues with
access, cost, and quality. The Affordable Care Act included provisions to use Medicare,
the U.S. near universal public coverage program for older adults, to broadly implement
Accountable Care Organization (ACO) models with a triple aim of improving the experience
of care, the health of populations, and reducing per capita costs. Private payers
in the U.S. are also embracing ACO models. Various European countries are experimenting
with similar reforms, particularly those in which coordinated (or integrated) care
from a network of providers is reimbursed with bundled payments and/or shared savings.
The challenges for these reforms remain formidable and include: (1) overcoming incentives
for ACOs to engage in rationing and denial of care and taking on too much financial
risk, (2) collecting meaningful data that capture quality and enable rewarding quality
improvement and not just volume reduction, (3) creating incentives for ACOs that do
not accept much risk to engage in prevention and health promotion, and (4) creating
effective governance and IT structures that are patient-centered and integrate care.