Briefs & Reports

Accountable Care in the Safety Net

Terry Conway, MD
Pat Terrell


Accountable Care has emerged as a critical delivery system redesign companion to expanded coverage within federal health reform. Accountable Care calls for providers to organize to provide a full continuum of care to patients and populations, to commit to improving quality while controlling cost, and to be rewarded as they succeed. However, the principles of Accountable Care are based upon demonstrations and lessons learned primarily in Medicare populations served by highly organized and integrated health systems.

The Safety Net differs in the patient populations it serves, the structures and relationships between its providers, and its funding, which is mainly concentrated in Medicaid and local government reimbursement. Thus, the federal emphasis on the development of Accountable Care will need to be tailored differently for the Safety Net. Further, California’s Safety Net will face the challenges of building collaborative delivery models earlier than the rest of the nation as the renewal of the State’s 1115 Medicaid Waiver is implemented during the next year. These State and national moves toward integrated care offer both opportunity and challenge to the Safety Net and progress toward Accountable Care will be made only after embarking on an honest and thorough examination of necessary changes in relationships and organization, delivery system design, infrastructure, and revenue distribution.

Taking leadership now to create Accountable Care is a strategy that is most likely to secure the ongoing existence of Safety Net providers, assure access for the patients they have historically served, and improve the health status of their communities. It is also a strategy that is likely to gain the support of the federal government as new models are sought to efficiently and effectively deliver care for a population that will soon represent the single largest publically?funded health coverage program.