NURS 8100 Unintended Consequences of Health Care Reform
Since the Patient Protection and Affordable Care Act (PPACA) became law, healthcare delivery has shifted from the traditional fee-for-service model to value-based care. The aim is to provide patients with high-quality, well-coordinated care (Patient Protection and Affordable Care Act, 2010). One approach to achieve this transformation is the establishment of accountable care organizations (ACOs). ACOs consist of a group of healthcare providers who jointly assume responsibility for achieving better quality of care and reducing the rate of spending growth (McClellan, McKethan, Lewis, Roski, & Fisher, 2010). They prioritize team-based care and shared accountability for patient outcomes. The Centers for Medicare and Medicaid Services (CMS) are actively promoting the formation of ACOs.
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In these population-based models, CMS aligns a Medicare beneficiary population with an ACO, linking them to specific quality and spending targets, departing from the volume-based fee-for-service approach. Unfortunately, individuals with mental illness, who are among the high-cost Medicare beneficiaries, have not received adequate attention in the implementation of ACOs. While the ACO goals of delivering coordinated, patient-centered chronic and preventive care align with the ideals of many mental health providers, the population-based approach may be unfamiliar in this context.
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ACOs play a pivotal role in achieving the CMS’s triple aim of “better health care, better health, and improved quality” by focusing on care coordination for Medicare patients across different providers and care settings. However, the needs of patients with mental illness have been largely overlooked in ACO implementation, much like previous quality improvement initiatives (Zima & Mangione-Smith, 2011). Mental health conditions, both as primary disorders and when comorbid with general medical conditions, impose substantial financial burdens, driving up the costs associated with general medical disorders (Maust, Oslin & Marcus, 2013). The population of older adults with mental illness is projected to increase from less than eight million in 2010 to 15 million by 2030 due to factors such as the aging of baby boomers, their elevated rates of depression and anxiety, and the onset of late-life psychiatric disorders in the expanding aged population (Maust, Oslin & Marcus, 2013). Despite the growing burden of mental illness and its financial implications, current ACO efforts to improve quality and reduce costs primarily concentrate on chronic general medical conditions. The only exception is depression screening with a documented follow-up plan, but this may have limited impact on actual care quality (Maust, Oslin & Marcus, 2013).
To meet quality and spending targets for high-cost, high-risk patients, ACOs should not only assess the quality of medical care but also the quality of mental health care for patients with mental illness. Additionally, federal agencies should invest in understanding the impact of population-based initiatives on patients with mental illness. It is essential to evaluate the influence of mental health conditions, not just as primary disorders, but also in terms of their impact on the quality of care for comorbid general medical conditions. For instance, if an ACO aims to enhance the quality of diabetes care, it should include quality measures for beneficiaries with comorbid mental illness. While improving mental health care may not be a primary goal of ACOs, evaluating the overall quality of medical care should place a special focus on vulnerable populations, including individuals with mental illness (Maust, Oslin & Marcus, 2013).
References
Maust DT, Oslin DW & Marcus SC. (2013). Mental Health Care in the Accountable Care Organization. https://doi.org/10.1176/appi.ps.201200330
McClellan M, McKethan AN, Lewis JL, Roski J, & Fisher ES. (2010). A national strategy to put accountable care into practice. Health Affair, 29 (5), pp. 982-990
The Patient Protection and Affordable Care Act. (2010). US Centers for Medicare & Medicaid Services https://www.healthcare.gov/where-can-i-read-the-affordable-care-act/.
Zima BT & Mangione-Smith R. (2011). Gaps in quality measures for child mental health care: an opportunity for a collaborative agenda. Journal of the American Academy of Child and Adolescent Psychiatry 50:735–737
Accountable Care Organizations (ACOs)
Accountable Care Organizations (ACOs) are collaborative groups comprising doctors, hospitals, and various healthcare providers who choose to work together voluntarily to provide well-coordinated, high-quality care to the Medicare patients under their care. The primary objective of this collaboration is to ensure that patients, especially those with chronic conditions, receive the right care at the right time. This approach aims to prevent unnecessary duplication of services and reduce the occurrence of medical errors. A key feature of ACOs is their potential to share in the savings achieved when they succeed in both delivering high-quality care and using healthcare funds more efficiently for the Medicare program.
The landscape of healthcare payments is undergoing a significant transformation as payers and providers shift from a focus on volume to a focus on value. Amid various value-based care models, accountable care organizations have emerged as popular and effective strategies. ACOs consist of groups of hospitals, physicians, and other providers who commit to coordinate patient care, ensuring it is delivered at the appropriate time and avoiding unnecessary service utilization and medical errors. ACO participants also assume responsibility for the overall costs of care for their patients. ACOs that successfully reduce the total costs of care for their patient populations can share in the resulting savings with the payer. However, in certain models, they may also be financially liable for reimbursing losses if their costs exceed predetermined spending benchmarks (Moore et al., 2017).
Policymakers and healthcare leaders view ACOs as a crucial solution for addressing the inefficiencies of the fee-for-service system. These programs encourage healthcare providers to collaborate with others along the care continuum. Some providers are formalizing partnerships to gain control over a wide range of services, achieve economies of scale, and access the technology, data, and clinical capabilities of their peers. ACOs have become and are likely to continue playing a significant role in the ongoing transformation of value-based care and payment. When all the components of an ACO work in unison, they can reduce costs and enhance the quality of care, all while earning incentive payments. In contrast, Health Maintenance Organizations (HMOs) typically focus on cost-cutting by setting fixed prices for services, potentially incentivizing providers to limit utilization or compromise on care quality in order to stay within budget constraints (Colla et al., 2018).
References
Colla, H., & Fisher, E. S. (2018). Moving forward with accountable care organizations: some answers, more questions. JAMA internal medicine, 177(4), 527-528. https://doi.org/10.1001/jamainternmed.2016.9122
Moore, K. D., & Coddington, D. C. (2017). Accountable care the journey begins. Healthcare Financial Management, 64(8), 57-63. Retrieved from https://www.proquest.com/trade-journals/accountable-care-journey-begins/docview/746684537/se-2?accountid=14872
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