About four years ago, Nick Macchione, who oversees San Diego County's public health system, had an idea to expand the accountable care organization concept in a way that would involve a much broader range of stakeholders working together to improve the health of an entire region.
During a meeting that focused largely on the role of healthcare providers in reducing hospital admissions, Macchione says he remembers thinking that the ACO approach alone will do little to fix fragmented healthcare. “I said we can do better than ACOs,” Macchione recalls. “We've got to do an accountable care community.”
That's the philosophy behind the county's Live Well, San Diego! program, a comprehensive strategy that relies on involvement from a variety of players other than healthcare providers—including schools, businesses, law-enforcement agencies and faith-based organizations—to improve the health of the county's population of more than 3 million. The concept—which doesn't have the formal structure of an ACO—is also taking root in other parts of the country where civic leaders are using the “all in” approach to healthcare that looks beyond a community's hospitals and physician practices.
That's happening through San Diego's program, which the county board of supervisors approved in 2010. The total budget for San Diego County is $5 billion, including $2 billion for Macchione's Health and Human Services Agency. Officials didn't provide specific spending figures for Live Well, but say everything in the agency's budget aligns to advance the program's various components.
One initiative is “Healthy Works,” which develops and implements policies that promote better lifestyle choices. Through Healthy Works, more than 6,000 people have signed up for FreshFund, a program for low-income residents on public assistance. Members receive a match of up to $20 a month for every $20 they spend on fresh produce grown by local farmers.
In Oregon, the state launched a health-improvement initiative two years ago that also depends on strong community partnerships. Dr. Bruce Goldberg, director of the Oregon Health Authority, says Gov. John Kitzhaber, also a physician, had the idea for coordinated-care organizations, which later received bipartisan support from the state Legislature. Today, 90% of the state's Medicaid population receives care through 15 coordinated-care organizations, governed locally to meet community needs and also operate on a fixed budget.
“The notion is that it's much more than doctors and hospitals that contribute to our health—it's housing, it's where and how we live,” Goldberg says, adding that the state has received federal approval to use Medicaid dollars flexibly to pay for nontraditional healthcare services. For example, Goldberg says the funds could be used to help residents with housing. Goldberg says he hopes the CCOs will expand and “encompass more of the services that contribute to people's health.”