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Journal Article


Improving Care and Lowering Costs: Evidence and Lessons from a Global Analysis of Accountable Care Reforms

Rural Nepal health service organization connects to secondary care facility


Around the world, health care providers and policymakers are struggling with the same problem: improving patient care while simultaneously lowering costs. Many countries are experimenting with accountable care models to accomplish both aims, but there has been little research done on the best ways to implement these reforms. Commonwealth Fund–supported researchers analyzed accountable care reforms in a diverse group of countries to extract lessons for providers, payers, and policymakers.

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The Issue

Accountable care has attracted attention as a model for counteracting traditional fee-for-service payment, which can encourage health care providers to deliver services that patients do not need and may even cause harm. Although accountable care can take various forms, in most models provider payments are tied to the achievement of certain outcomes — for example, reducing the rate of medical complications for diabetes patients. Primary care physicians, specialists, and other providers thus have an incentive to coordinate their services and rethink how care can be delivered more efficiently. Many countries are shifting toward these models, but reforms have been hampered by a lack of evidence on best practices. To address this gap, researchers applied a framework for assessing accountable care implementation to three promising reforms taking shape in Germany, Nepal, and the Netherlands.

Three Approaches to Accountable Care Reform

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[T]he evidence and lessons generated by accountable care are limited. Recent domestic and international pilot programs offer preliminary evidence of important improvements in quality using the same or fewer health care resources.
  • In rural Nepal, a nonprofit health services organization called Possible improves primary care through a network of providers and community health workers connected to a secondary care facility.
  • In the Netherlands, Zio combines primary and specialty care for diabetes patients by using team-based disease management, training nurses to complete tasks once performed by physicians, and bundling payment for episodes of care.
  • In Germany, Gesundes Kinzigtal, a private health management company, organizes integrated care for approximately 10,000 people. Physician and patients jointly design provider performance measures, and providers and insurers enter into a shared-savings contract.

Lessons for Health Care Providers

  • Focus on systemwide change. When health care organizations implement accountable care reforms, they should solicit advice from a variety of stakeholders, including physicians, patients, and community advocates. In Nepal, for instance, Possible established a community advisory board and formed relationships with community health workers.
  • Share information. Health care organizations and providers need a common information technology infrastructure for identifying and managing high-risk patients. Organizations should begin with low-cost, incremental solutions and then build their platforms over time.
  • Use multidisciplinary teams. Shifting care from hospitals and other institutions to local clinics and other community-based settings can help lower costs. Health care organizations should also improve links to community services and train nonphysician staff members. The Zio model expands nurses’ roles by empowering them to prescribe medications and increasing their responsibility for certain diagnostic and therapeutic tasks.

Lessons for Policymakers

  • Implement payment reform. Financial incentives should be designed to encourage providers to shift to a patient-centered focus and ultimately enable innovations that improve outcomes and efficiency. Policymakers should begin with limited reforms that don’t add to the administrative burden.
  • Use data to support person-centered care. Health care organizations need reliable financial, clinical, and patient health data to adjust workflow, meet benchmarks, and forecast financial outcomes. In each of the three countries, policymakers took steps to provide or facilitate the development of useful data.
  • Develop evidence to guide reforms. Evidence of effectiveness will increase confidence among those asked to adopt and expand new models of health care delivery and payment. High-quality evaluations will help gain physician buy-in and promote rapid learning.

About the Study

The authors convened two expert working groups of policymakers, providers, and payers to develop a framework to allow for valid cross-country comparisons and guide ongoing accountable care reforms. For this study, they applied the framework to examples in Germany, Nepal, and the Netherlands.

The Bottom Line

Providers, payers, and policymakers seeking to improve population health while lowering the costs of care can learn valuable lessons by studying other countries’ experiences with implementing accountable care reforms.

Publication Details



Mary Mahon, Former Vice President, Public Information, The Commonwealth Fund

[email protected]


M. McClellan, K. Udayakumar, A. Thoumi et al., “Improving Care and Lowering Costs: Evidence and Lessons from a Global Analysis of Accountable Care Reforms,” Health Affairs, Nov. 2017 36(11)1920–27.