Special Series: What ACA Insurers Can Learn from the NHS


Four lessons from across the pond on how to navigate complex payer systems.

Charles Alessi, MD

8 min read

As a single-payer health system – and a system where 90 percent of providers are public sector (or quasi-public sector) – the United Kingdom’s National Health Service (NHS) bears little resemblance to the free-market Health Insurance Marketplace (Despite critics’ attempts to label the ACA socialized medicine.) However, there are similarities between the ACA and NHS populations; and ACA insurers can learn from NHS successes – and missteps – in managing its complex population. Here, Dr. Charles Alessi, senior advisor to Public Health England, an executive agency of the Department of Health, offers four lessons from across the pond.

1. Complex populations require new medical management strategies

The NHS population is vastly bigger than the ACA, catering to about 54.3 million people, compared with an ACA enrollment of about 13 million. Yet there are similarities between the two. Both the NHS and ACA insurers navigate the complexity of a diverse population with varied needs and utilization. And both are struggling to manage their most-costly consumer segments.

For its part, the NHS spends 70 percent of its total budget caring for people with at least one long-term condition, such as diabetes. Meanwhile, according to Oliver Wyman analysis, the top 1 percent of the typical ACA population drives 20 percent of total costs; and more than half of the typical ACA population exhibits early-stage chronic disease, complex conditions, or late-stage disease.

To rein in the costs associated with an aging population and the epidemic of chronic disease, the NHS has initiated a number of programs relevant to ACA insurers. For example, the NHS is shifting care for chronic care patients from more-costly hospital doctors to community-based general practitioners; it is focusing on prevention and appropriate treatment of disease; and it is prompting chronic disease patients take more control of their own health by emphasizing care plans that incorporate self-management and shared decision-making.  

2. Value-based payment models key to pop health strategies – if deployed in right way

Experience teaches us that unless one aligns the metrics that drive payment with the aspirations and values that govern population health, it is very difficult to get adherence and traction at scale. The UK has a long history of attempting to introduce commissioning for value. However, we also have real experience over a period of many years where very promising pilots and isolated experimental initiatives failed to get spread through the wider body of the health and care systems. 

For example, fundholding was a system of payment for GPs established in 1991 and adopted by more than half of British GPs. It encompassed GPs taking responsibility for the total spend of populations. The idea was it would lead to increased efficiency and higher quality of care. It was abolished in 1991 amid criticism that it created a two-tier system, with more resources available to the patients of GPs participating in the fundholding program.

Fundholding did not succeed because it was a policy that was applied to just part of the system. The hospital system continued to be driven by activity.  The moral for ACA insurers is one needs to align the whole system to value, not only part of it

Currently, the Quality and Outcomes Framework (QOF) is the NHS’s annual reward and incentive program for GPs. It is a voluntary process that rewards practices based on outcomes and the largest pay-for-performance (P4P) quality improvement initiative in primary care in the UK.

The indicators for the QOF change annually. For 2015/2016, the QOF awards GP practices achievement points for managing some of the most common chronic diseases (asthma, diabetes), managing major public health concerns (smoking, obesity), and implementing preventative measures (regular blood pressure checks). For example, practices report the percentage of patients in whom the last blood pressure reading (measured in the preceding 12 months) was 140/80 mmHg or less. If they go over a certain percentage they get paid; if they go under the percentage, they get nothing.

The lesson coming from QOF is insurers are wise to set a target based on outcomes, and make it a basis for payment that drives the system. Meanwhile, leave the providers of care to determine how to achieve it. It will succeed.

3. UK docs’ population health techniques important – and replicable

The NHS also provides some lessons in utilizing population health approaches to manage hard-to-reach and hard-to-treat patients. GPs in England have long used population health techniques to manage their registered patient lists, and the potential to utilize similar approaches with the ACA is real.

It is true that our GPs enjoy the advantage of each patient being assigned a unique NHS identifier. That provides a starting point for population health analysis and makes it easier to identify target populations. Another advantage our GPs have is long-term relationships with patients. In the United States, churn tends to be significant, with patients switching insurers every couple of years. In contrast, the relationship with GPs in the UK is largely tied to domicile and tends to be prolonged. If a person stays in one community for a long period, it is unlikely he or she will change their GP and it is possible that relationship is life-long.

Even though US providers and insurers do not enjoy these same advantages, they can still deploy pop health strategies with success. The key is to align the metrics to the desired outcome (which must be based on value); the anticipated results will then be more likely to follow.

4. Don’t forget the social care

A final lesson from the NHS it that it is unwise to ignore a person’s social needs. It is important to manage the patient as a person and consider non-medical determinants in their care plan. For example, if a person has no place to live, no job, and no permanent community, than their biomedical metrics (such as blood pressure) tend to be less important to them. Ignoring the non-biomedical causes of ill health will not drive the optimal outcomes.

  • Charles Alessi, MD