Adapting to the ACA: Risk-Assumption Across the Spectrum of Integrated Delivery Systems

Abstract

This thesis examines the growing trend of risk-assumption in health care delivery and financing models and their place in the post-Affordable Care Act (ACA) landscape. Riskassumption is theorized to be a powerful incentive for providers to manage care efficiently. Recent risk-assuming models are also careful to include ties to the value and quality of care, safeguarding against the possibility of the underservice of care. However, little empirical work has yet examined the effect of risk-assumption on quality metrics. This thesis will add to the growing body of work concerning risk-assuming delivery models, referred to here as Integrated Delivery and Financing Systems (IDFSs). First, a quantitative analysis on a national dataset of provider quality examines the relationship between provider ownership of an insurance plan (the most extreme form of risk assumption) and provider quality. Then, a descriptive case study analysis looks in-depth at a range of IDFSs, varying in terms of the level of risk assumption and the extent of integration between the provider and payer functions. Through case studies, this thesis addresses the question of how risk-assumption shaped the way providers were able to respond to and take advantage of the new delivery models and incentive programs offered by the ACA Together, these two components contribute to a decades-long debate of whether risk-assumption, particularly via payer-provider integration, is a useful and feasible model that promotes high-quality, low-cost care. By examining risk-assuming providers in the context of the Affordable Care Act, this thesis investigates the potential for IDFSs to spread in the new environment, as well shedding some light on the question of whether IDFSs should become more prolific. Ultimately, level of risk assumption and extent of integration play a defining role in shaping providers’ ability to respond to the ACA. Highly integrated providers that already had experience with risk assumption had little to gain from the ACA, indicating that the ACA has the potential to shape all other providers to the model of IDFSs. But, IDFSs have currently reached a level of quality care beyond which new innovations are needed to continue improving.