The Affordable Care Act : A Catalyst For Payment And Delivery System Reform

CMS defines ACOs as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.” The goal of coordinated care is, “to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary

Managed care was established in order to manage health care cost, utilization, and quality (Kongstvedt, 2015). In managed care, health insurance is provided through HMO, PPO, and other types of managed care. It has the potential to reduced health care spending and improved the quality of care. However, despite of its success in improving the quality of care through preventive health care services, chronic disease management program, and so forth, many physicians are reluctant to be part of the managed care environment. Some of the reasons are the impact of managed care to physician’s income and autonomy. Under managed care, insurers have decreased the fees paid to physicians. There are different ways how managed care organizations control costs. One of this is through selective contracting with health care providers and hospitals to lower costs. In selective contracting, health care providers agreed to accept lower prices in exchanged for guaranteed volume of patients under managed care plan (Culyer, 2014). This paper will discuss more issues and trends in Managed Care Organizations such as the rise of Medicaid Managed Care spending, the new Medicaid Managed care Rule, and the collaboration of Managed Care Organizations and Accountable Care Organizations to reduce health care spending and improve efficiency of care.

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).

​Kaiser Health News recently published an article on a new trend in healthcare. This trend introduces the Accountable Care Organization (ACO). The Centers for Medicare and Medicaid services defines it as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients” (“Accountable Care Organization,” 2015). According to the Affordable Care Act (ACA), the goal of the ACO is to be able to share health cost-savings with providers who are able to save money by eliminating unnecessary procedures and reduce health costs while increasing quality of care. ACOs make health professionals become more accountable in maintaining good-quality, coordinated healthcare for a patient through a value-based system that is evaluated through a number of criteria and benchmarks (Ronai, 2011).

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,

Accountable care organizations are growing. Accountable Care or Coordinated Care is putting consumers at the front at our evolving healthcare industry. Accountable Care Organizations (ACO) strive to improve outcomes and reduce costs with improved patient care coordination (Robinson, J. C., Schaffer, L. D. 2015). Coordinated Care is defined as the Right care, at the right time, with no duplication, and to prevent errors. The Affordable Care Act encourages health care organizations to improve quality of care and reduce spending. In 2013, there were 320 ACO’s and as of 2014 there are now 700. 2/3 of the population now live in an area that services ACO’s. One out of three hospitals have ACO plans (Perficient Inc. 2015).

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

With these goals ACOs have for following features in place to aid in accomplishing them. ACOs are offered as a opt in plan not mandatory for all patients to buy, then the people who choice to buy into the program are encouraged to use the healthcare system and providers in their network to keep quality high and cost low. The providers in the plan have also bought into the theory of keeping the quality of their care high and the costs low. One of the ways this is done is by focusing on primary care or preventative care. If the providers meet the goal of keeping down the cost and quality of care high are meet, then the ACOs offer inactive pay or bonuses. Some of the way providers have found to meet these goals include making treatment teams to provide for all the patients needs with the best care and lowest cost, use of electronic health records and other technology systems to track what other providers in the team are doing with the patients care preventing things like repeating a test that the patient has already done, and getting patients to buy into their own care and become a part of the treatment team. An example of who uses theses types of plans in the government is Medicare, Medicaid and Tricare. (MHA507 Module 2 Home page, 2015). (Edlin, 2013). (DeTora,

The U.S. healthcare system has considerably transitioned from a period of traditional care to managed care to accountable care. The success of the accountable care regime would largely depend on the ability of ACOs to deliver on promises of cost reduction and quality improvement. And if it does, to sustain the feat. Given annual changes and additions to its forms and measures, ACOs are still in formation and at this stage, it may be untimely to tell if they are indeed the unobtanium of healthcare. Its aim of managing the basic elements of care – cost and quality all in one piece definitely comes with challenges which have been discussed. Nevertheless, it would take time for the health system to completely adjust to the period of accountable

The accountable care organization I researched is called the Physician Organization of Michigan ACO (POM ACO). The POM ACO is a joint venture of the U-M Health System and physician groups around the state, with the aim of improving care for 81,000 Michiganders enrolled in traditional Medicare and slowing the growth of health care costs, according to the announcement by the U-M Health System (Daly, 2013). The group was launched on January 1, 2013 under the Medicare Shared Savings Program. 12 physician organizations from around Michigan came together to take part in a Medicare-sponsored program that strives to improve on the quality of care for traditional Medicare recipients, while also containing cost growth. In 2014, POM ACO expanded to include all the University of Michigan faculty physicians and thousands of other providers from the University of Michigan Health System. The POM ACO is now one of the largest accountable care organizations nationwide. More than 5,700 physicians and other providers are now involved in the POM ACO. Therefore, the POM ACO is organized as a physician-hospital organization. Hence, the patient has more flexibility in where and how their care is delivered. The patient can still use any doctor or hospital that accepts Medicare at any time.

There are three core principles to any ACOs. First, provider-led organizations with primary maintenance and a strong base are liable communally and total per capita costs for quality with full continuum for the population of care for patients. Second, excellent improvements will have linked to also have complete costs reduced, and third, progressively and reliable sophisticated measurement performance to improve, support, and provide the savings of confidence are achieved with improvements of care, , McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES (2010).

The first ACO model started January 1, 2012 and consisted of 32 ACOs with 860,000 beneficiaries (CMS, 2016). ACOs are made up of groups of hospital, doctors, and other health care providers who provide coordinated high quality care to their patients. The goal of this coordinated care is to ensure patients receive the appropriate care in a timely manner while avoiding unnecessary services and duplication of services. The expected end result is the delivery of high quality care and reduction of health care cost and the incentive for the health care provider to meet the goal is the share of the savings they will receive. As stated by Dr. Berwick, (Its (ACOs) purpose is to foster change in patient care so as to accelerate progress toward a three-part aim: better care for individuals, better health for populations, and slower growth in costs through improvements in care” (Berwick, 2011). The ACO providers are held responsible for meeting quality improvement measures while reducing their rate of spending.

Accountable Care Organizations can help curb over s spending with the use of accountability factors that have been put in place. Because of the span of an ACO, the population it will oversee, and the size of the group of healthcare providers overseeing the patients needs there will be an elimination of duplicated and unnecessary healthcare service. This will also flow into their quality model of patient care where they have put in place checks and balances to make sure that a patient medical needs are being looked after to the highest standard, if providers do these effectively they will receive financial incentives.

The Accountable Care Organization and Patient Centered Medical Home case studies both did best to implement pilot programs, models and experiments that will essentially coordinate at the same time integrate healthcare goals with the healthcare system aimed at improving patient outcome and lowering costs for quality service. PCMH also did best in making sure patients had constant access to their providers at the same time provide care that was team based by coordinating care with various providers at the same time assure the quality and safety of each patient. As for ACO they did best in their improvement of care and lowering cost by coordinating with physicians and institution that are providing care to Medicare beneficiaries. Their ultimate goal is improving the quality and value of health care services at the same time control costs while improving the delivery of healthcare by measuring quality and satisfaction as defined in Shi and Singh (2015) Donabedian Model which can be achieved by establishing structure, process and outcome (p. 494). In the end ACO and PCMH focused their attention in preserving wellness, disease prevention, and treating illness by assuring that each patient received the best care possible from their health care providers.

Employer-based health insurance has dwindled slowly since the 2014 implementation of the ACA. Health insurance in the United States has significantly transformed since the ACA and it’s been the biggest U. S. healthcare system reconstruction since the 1960s