Hmo Steve Lieberman Summary

While our understanding has evolved with respect to certain advantages of MCO’s, our understanding of the disadvantages has also grown. This analysis will evaluate the use of MCO’s as a gatekeeper to controlling health care cost and offerings. It will evaluate the advantage MCO’s provide in a rapidly growing market due to the aging of baby boomers. The analysis will evaluate disadvantages that can arise with relying on MCO’s. These disadvantages work against the insurance company forcing a polarizing balance between how much control the MCO should retain over recommendation and provision of services.

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

There has been discussion to have universal healthcare system similar to Medicare as a method to have a centralized monitoring system of cost. There have also been other systems tried beginning with HMOs in the 1970s in an effort to streamline access to necessary healthcare services by employing a gatekeeper to their access at the primary care levels. With patient dissatisfaction, PPOs were tried which circumvent the necessity of referrals (Hacker, 1998). Either of these models had substantial effect on healthcare outcomes while the cost of healthcare continued to skyrocket. The US spends more than any other country on healthcare but outcomes are not better (Blackstone, 2016). In 2010, under President Obama’s leadership, Affordable Care Act was passed and one of the promising features is the formation of accountable care

HMOs are usually the least expensive health plans, offer predictable costs for health care, the least administrative paperwork, and cover preventive care (Barsukiewicz, Raffel, & Raffel, 2010). However, HMOs also restrict direct access to specialists by requiring referrals by a PCP, requiring patients to see a provider in the HMO network, and often not covering more costly procedures or care options, because care is managed to control excessive or unnecessary care. Providers gain if they provide less care (Austin & Wetle, 2012). This incentive could affect patient-provider trust.

ACO, another 3 letter health care organization consisting of integrated groups of providers, comes along promising the elusive goal of reducing health care cost, improving population health, and bolstering custom satisfaction. Sounds like a perpetual remake of a 70s movie called HMO that went through several reiterations over the past decades which gave us PPO, PSO, IDS, and the different flavors of MCOs. ACO’s hype is credited to the Affordable Care Act as it sought to reduce health care costs is by encouraging doctors, hospitals and other health care providers to form networks that coordinate patient care and become eligible for bonuses when they deliver that care more efficiently. Bottom line, providers are promised to make more if they

The Accountable Care Organization (ACO) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients (McCarty, B., 2016). For example, Medicare Shared Savings Program was created by The Center for Medicare & Medicaid Services to monitor and establish that all ACO’s are meeting the quality performance benchmarks and reduce Medicare spending by certain percentages (H., 2017). The growth of ACO’s from 2011 to 2016 is astonishing, in 2011 there was 64 ACO’s and by 2016 they have risen to 838 in the U.S. (H., 2017).

The Affordable Care Act created a new approach to care which is called the Accountable Care Organization. ACO is a system of doctors and hospitals that share a financial and medical responsibilities. If the ACO is successful in meeting quality and cost savings targets, these organizations qualify for financial incentives or shared saving from Medicare programs. The goal of the ACO is to coordinate

The concept of an Affordable accountable cCare oOrganization (ACO) is still evolving. Generally, an ACO is a group of health care providers (including primary care physicians, specialists, and medical facilities) that work in partnership and are collectively accountable for the cost and quality of health care they deliver to a specific population of patients. At the heart of each patient's care is a primary care physician.

ACOs provide high-quality care to their patients and reduce cost by avoiding unnecessary duplication of services and preventing medical errors. ACOs may involve a variety of provider configurations, it can range from integrated delivery systems and primary care medical groups to hospital-based systems and virtual networks of physicians such as independent practice associations (McClellan et al, 2010).

In the past few years the American health care system has changed in many ways. First there was the passage of the Affordable Care Act, which is a law that is giving Americans the opportunity to obtain health care. Under this new law, in 2011, the Department of Health and Human Services decided to create Accountable Care Organizations (ACO) to help doctors, hospitals and other providers better coordinate care (AthenaHealth.com). The first idea of an Accountable Care Organization was brought up in 2006 by Elliot Fisher, MD, and now there are over 400 in the United States (Healthcatalyst.com). An ACO’s primary job is to improve health care delivery, performance, and payment. This is done through physicians and

The viewpoint of their proponents, there is a difference from historical managed care arrangements in ACOs predominantly HMOs since they are centered around providers ahead of insurers and usually are not detained at complete monetary peril for the price of health care. In an ideal world, ACO payment approaches will include improvements in quality of care measurement that take into account the range of service delivery ACOs are designed to provide. If legislated, nationally health reform could most likely include more or less research with ACO incentives. On November 7th , 2009 the United States House of Representatives passed, the Affordable Healthcare for America Act (H.R. 3962) which called for pilot payment incentive that would encourage ACOs in both Medicaid and Medicare, along with other policies on payments alterations and authorized demonstrations and pilots (Huntington, Covington, Center, Covington, and Manchikanti,

Throughout the last half of the 20th century, employers have acted on their own to regulate health costs by requiring employees to join health maintenance organizations (HMOs). More than 100 million Americans are under managed care. However, many patients and doctors complain that HMOs impose too many regulations and sacrifice healthcare quality. HMOs are undergoing a high level of scrutiny due to criticisms that the network is controlling and jeopardizing the healthcare system of the nation.

The creators of the Affordable Care Act inexcusably anticipated that new kinds of health plans, designed in our nation’s capital, would emerge to displace the national for-profit insurers.(Gottlieb, 2015, para. 3) Two inventions were engineered to help guide the Affordable Care Act in favor of the consumers.

Like many, my previous opinion regarding the Affordable Care Act (ACA) was primarily based on political and philosophical differences with the legislation and its supporters/opponents. While I continue to have an ideological difference to many of the principles in the ACA, I do now realize that this legislation does have some theoretical positive aspects regarding a shift towards more managed care and the increasing encouragement of Accountable Care Organizations (ACOs). This shift has the potential to be helpful in terms of cost controls as it makes a substantial shift towards outcomes and away from fee per service care. ACOs also have great potential for helping to reduce overall costs in high risk, high cost patients (Powers & Chaguturu, 2016). This can be extremely beneficial as this high cost group is only a small percentage of our population but makes up the majority of our healthcare spending. It appears that the legislation at a minimum also helped to increased public awareness that we have a cost and quality problem, and I believe this recognition is helpful long term. However, I am still under the belief that the content of the legislation was built primarily for the benefit of the powerful lobbyists throughout the healthcare industry (i.e. insurance companies, AMA, etc.) and very little was included that would encourage the type of long term changes in the way we view healthcare and personal responsibility to be truly effective.

The American health care system has been victim to an escalation in the prices of health care services juxtaposed with inefficiency in delivery of care services. There has even been cases where State spending on the actual health care increased dramatically in the United States and one of the key components of curbing this problem which has been prevalent over the mass media and has been a major discussion among physicians is the advent of Accountable Care Organizations. Accountable Care Organizations (ACOs) is structured with the goal of trying to improve health care delivery and aid in the reduction of the overall cost of services (Weissert & Weissert, 2012). If there is insufficient coordination of high quality care delivery in the health care industry, this will have a negative impact on patient safety and diminish affordable care for patients. Hence, the development of ACOs is envisioned to be the savior of medical practices and can improve the overall fabric of the American society (Bresnick, 2013). ACOs serves as one of the answers for curbing the problem of high costs, low quality care and possible segmented delivery and as much as it serve as the major determinant for improvement in patient satisfaction, there are minor