NURS 8100 Unintended Consequences of Health Care Reform

NURS 8100 Unintended Consequences of Health Care Reform

NURS 8100 Unintended Consequences of Health Care Reform

Since the Patient Protection and Affordable Care Act (PPACA) was signed into law, health care delivery has evolved from traditional fee-for-service-based care to value-based care in an effort to deliver high-quality, coordinated care to patients (Patient Protection and Affordable Care Act, 2010). One approach to achieve this goal has been the creation of accountable care organizations (ACOs), defined as a group of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth (McClellan, McKethan, Lewis, Roski, & Fisher, 2010). Accountable care organizations emphasize team-based care and shared responsibility for patient outcomes. The Centers for Medicare and Medicaid Services (CMS) is promoting the formation of accountable care organizations (ACOs). In these population-based models, CMS aligns a Medicare beneficiary population to an ACO with associated expenditure and quality targets, transitioning away from purely volume-based revenue of fee-for-service Medicare. Patients with mental illness are among high-cost Medicare beneficiaries, but this population has received little attention in ACO implementation. Although the ACO goals of providing chronic and preventive care in a coordinated, patient-centered manner are consistent with what some mental health providers have long advocated, the population-based orientation may be unfamiliar.

Accountable care organizations (ACOs), by focusing on coordinating care for Medicare patients across providers and multiple care settings, are a key element of the “better health care, better health, and improved quality” CMS triple aim. However, as has been the case for other quality improvement initiatives across the lifespan (Zima & Mangione-Smith, 2011), attention to patients with mental illness has been virtually absent in ACO implementation. Mental health conditions are among the most expensive as primary disorders and, when comorbid with general medical disorders, are associated with increased costs for the primary general medical disorder (Maust, Oslin & Marcus, 2013). The cohort of older adults with mental illness is expected to increase from under eight million in 2010 to 15 million in 2030 for several reasons, including the aging of baby boomers, their higher rates of depression and anxiety, and the onset of late-life psychiatric disorders in the expanding aged population (Maust, Oslin & Marcus, 2013). Despite this growing burden of mental illness and its cost implications, current ACO disease-specific quality and cost efforts are focused almost entirely on chronic general medical conditions. The one exception—depression screening with a documented follow-up plan—may have minimal impact on actual care (Maust, Oslin & Marcus, 2013).

In addressing the needs of high-cost, high-risk patients to meet quality and expenditure targets, an ACO should examine the quality of mental health care it provides as well as medical quality for patients with mental illness. In addition, federal agencies should invest to ensure understanding of the impact of population-based initiatives on patients with mental illness. Mental health conditions need to be examined for their impact not only as primary disorders but also for their impact on quality of care for comorbid general medical conditions. High-quality diabetes care, for example, is an explicit goal that has quality measures included for ACO beneficiaries; if the overall quality of diabetes care improves in an ACO, the improvements should include those with comorbid mental illness. Although improving mental health care is not an explicit ACO goal, part of the overall evaluation of medical care should focus on vulnerable populations, such as persons 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

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This is insightful OLA. Value-based care has developed from conventional fee-for-service-based care to high-quality, coordinated care since the PPACA was enacted into law (Kaufman et al., 2019). The creation of accountable care organizations (ACOs) significantly led to the improvement of quality of healthcare service delivered to different patients. There is a lot of excitement around accountable care organizations (ACOs) as a way to improve the quality and value of healthcare (Lewis et al., 2019). But while there are many potential benefits to ACOs, addressing the needs of high-cost, high-risk patients is critical to their success. One challenge for ACOs is that they are often rewarded for keeping patients healthy and out of the hospital (Resnick et al., 2018). But many high-cost, high-risk patients require expensive interventions and care coordination in order to stay healthy. Without focused attention on this population, ACOs may not be able to achieve the cost savings and quality improvements they are hoping for.

Question: what are some of the contribution of accountable care organizations (ACOs) in the management of ethical issues in the healthcare system?

References

Kaufman, B. G., Spivack, B. S., Stearns, S. C., Song, P. H., & O’Brien, E. C. (2019). Impact of accountable care organizations on utilization, care, and outcomes: a systematic review. Medical Care Research and Review, 76(3), 255-290. https://doi.org/10.1177/1077558717745916

Lewis, V. A., Tierney, K. I., Fraze, T., & Murray, G. F. (2019). Care transformation strategies and approaches of accountable care organizations. Medical Care Research and Review, 76(3), 291-314. https://doi.org/10.1177/1077558717737841 Resnick, M. J., Graves, A. J., Buntin, M. B., Richards, M. R., & Penson, D. F. (2018). Surgeon participation in early accountable care organizations. Annals of Surgery, 267(3), 401-407. https://journals.lww.com/annalsofsurgery/Abstract/2018/03000/Surgeon_Participation_in_Early_Accountable_Care.1.aspx

Accountable care organizations(ACOs).

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.  The healthcare payment process is undergoing a dramatic transformation as payers and providers shift from volume to value. While stakeholders are currently piloting many different value-based care models, accountable care organizations are among the most popular and successful strategies to date. Accountable care organizations, or ACOs, are groups of hospitals, physicians, and other providers who agree to coordinate care for patients and deliver the right care at the right time, while avoiding unnecessary utilization of services and medical errors. ACO participants also agree to take on responsibility for the total costs of care for their patients. ACOs that reduce the total costs of care for their patient populations can share in the savings with the payer.  In certain models, they may also be liable to pay back losses if their costs exceed their spending benchmarks (Moore et al., 2017). Policymakers and healthcare leaders believe tying financial incentives to care quality, patient outcomes, and care coordination through ACOs is a key solution for fixing the inefficient fee-for-service system. The programs encourage providers to partner with others across the care continuum. Some providers are formally acquiring to gain control over a wide range of services, achieve economies of scale, and access the technology, data, and clinical capabilities of their peers. In fact, ACOs are and are likely to continue to be a major player in the value-based care and payment transformation. When all the parts work together, providers in an ACO can bring down costs and improve care quality while earning incentive payments. HMOs, on the other hand, seek to cut costs by setting fixed prices for services, which may encourage providers to reduce utilization or skimp on care in an effort to stay under the cap(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

This is insightful, Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other healthcare providers who come together to provide coordinated care to their patients (Colla & Fisher, 2018). The goal of ACOs is to improve the quality of care while also reducing costs. One way that ACOs achieve this goal is by sharing information about their patients (Meyer et al., 2017). This allows the providers in the ACO to work together to come up with a plan for each patient that meets their individual needs. ACOs can also use this information to track how well they are meeting quality and cost goals (Lewis et al., 2019). ACOs are funded in part by Medicare and Medicaid. However, they are also open to patients who have private insurance. ACOs have been shown to improve the quality of care while reducing costs. For example, a study published in Health Affairs found that ACOs were associated with improvements in quality of care and reductions in spending on Medicare patients.

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

Lewis, V. A., Schoenherr, K., Fraze, T., & Cunningham, A. (2019). Clinical coordination in accountable care organizations: A qualitative study. Health care management review, 44(2), 127. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461217/

Meyer, C. P., Krasnova, A., Sammon, J. D., Lipsitz, S. R., Weissman, J. S., Sun, M., & Trinh, Q. D. (2017). Accountable care organizations and the use of cancer screening. Preventive medicine, 101, 15-17. https://doi.org/10.1016/j.ypmed.2017.05.017