NURS 8100 Discussion: Unintended Consequences of Health Care Reform

A Sample Answer For the Assignment: NURS 8100 Discussion Unintended Consequences of Health Care Reform

I can also add that ACOs are networks of hospitals, physicians, specialists, and other combinations of providers that voluntarily contract with a payer to share the medical and financial responsibility for coordinating the care of an assigned population. Payers and policymakers designed ACO contracts to counteract the incentive to deliver “sick care” and instead, emphasize prevention and wellness through incentive payments and financial risk arrangements. In other words, ACOs can earn more for delivering care that improves population health, shortens lengths of stay, and ultimately results in care that keeps patients out of the hospital or exam room when appropriate. At the base of the ACO payment structure are incentive payments.

Providers in the ACO receive fee-for-service payments throughout the performance period. At the end of the period, payers adjust the payments based on the ACO’s quality performance on specified metrics. Quality performance also dictates whether an ACO qualifies for shared savings payments under financial risk arrangements. A key component of the ACO payment structure is financial risk. ACOs take value-based reimbursement to a new level by not only tying payments to quality, but also holding providers financially accountable for the care costs of their patient population. Payers and policymakers would like to push many more ACOs into downside risk arrangements, which spread the financial responsibility more evenly across stakeholders(RevCycleIntelligence, 2019).

Reference

RevCycleIntelligence. (2019). Understanding the fundamentals of accountable care organizations. RevCycleIntelligence. Retrieved from https://revcycleintelligence.com/features/understanding-the-fundamentals-of-accountable-care-organizations

The Accountable Care Organization (ACO)s are defined as are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients and reductions in the rate of spending growth for a defined patient population (Wilson et al., 2020).

The goal of this harmonized kind of care is to ensure that patients get the right care at the right time, in addition to minimizing or totally avoiding unnecessary duplication of services as well as the prevention of medical errors. The ACOs are dedicated to quality and efficient care, e.g, Medicare has a shared services program, where healthcare organizations meet quality benchmarks while reducing spending by a certain percentage to qualify for cost savings.

They also have the authority to impose practice, reporting, and compensation standards including penalties and rewards across a group of physicians on behalf of the patient population (Wilson et al., 2020). The providers are responsible for ensuring the objectives of the coordination are met completely and embody alternative payment models capitation (Blackstone, & Fuhr, 2016). 

They are also primarily accountable to patients and third-party payers for high quality, efficient, and competency-based care, equating provider reimbursements to quality metrics and reducing the cost of care while at it (Burke, 2011).

The ACOS organizations have various advantages, they improve the population health of the community that they serve by increasing emphasis on preventive care, providing basic but essential primary care services, and lowering the cost to the patients (Blackstone, & Fuhr, 2016). This is through preventive care, and increasing operational efficiencies which reduce the chances of readmissions, thereby saving on the operational cost which translates to low patient charges. 

The other advantages include fostering quality through the greater clinical integration of care, across healthcare settings, greater financial efficiency, and increased transparency and information about the process, costs, and outcomes of health care (Colla & Fisher, 2017). Other positive results achieved include having the providers meet patient-centeredness criteria, as developed by the Secretary of HHS, with a focus on strategies to engage patients better and actively in their health, measure patient satisfaction, and increase patient accountability (Burke, 2011). 

It also mandates that both the providers and patients are expected to be mutually accountable for following a predetermined treatment plan. It equips the patients with the knowledge to discuss and request the care they feel they need, instead of completely depending on the physician’s advice and orders (Burke, 2011).

One of the unintended consequences of OCAs is that physician integration with hospitals was associated with higher outpatient spending that did not appear to be warranted by the observed differences in disease burden. This has implications for potential harms from increased hospital market power spurred by consolidation with physicians under ACO formation (Lin et al., 2021). My current organization does not participate in ACOs because it has yet to meet the required quality benchmarks for participation and to focus on prevention and managing patients with chronic diseases (Colla & Fisher, 2017).

References

Blackstone, E. A., & Fuhr, J. P., Jr (2016). The Economics of Medicare Accountable Care Organizations. American health & drug benefits, 9(1), 11–19.

Burke T. (2011). Accountable care organizations. Public health reports (Washington, D.C.: 1974), 126(6), 875–878. https://doi.org/10.1177/003335491112600614

Colla, C. H., & Fisher, E. S. (2017). Moving Forward with Accountable Care Organizations: Some Answers, More Questions. JAMA Intern Med. 177(4):527–528. doi:10.1001/jamainternmed.2016.9122

Lin, M.-Y., Hanchate, A. D., Frakt, A. B., Burgess, J. F., Jr, & Carey, K. (2021). Do accountable care organizations differ according to physician-hospital integration? A retrospective observational study. Medicine, 100(12), e25231. https://doi.org/10.1097/MD.0000000000025231

Wilson, M., Guta, A., Waddell, K., Lavis, J., Reid, R., & Evans, C. (2020). The impacts of accountable care organizations on patient experience, health outcomes, and costs: a rapid review. Journal of Health Services Research & Policy, 25(2), 130–138. https://doi.org/10.1177/1355819620913141

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Submission and Grading Information

Accountable Care Organizations.

The discussion this week will focus on accountable care organizations (ACO). The ACO have both benefits and consequences which will be addressed below.  Lastly the discussion will incorporate the relevance of using ACO in a continuing care retirement community (CCRC) and the nursing profession as a whole.

Positive Results

There are different ways that ACO can be defined or explained. One such definition is by Dewey (2020) that describes an ACO as a heath care concept. Different providers or clinicians with diverse specialties are in agreement for care coordination, with payment options that are affordable and not aggravating.  The same concept is validated in the video (Walden, 2011), where ACO can be visualized by looking at health care delivery and financial burden or lack thereof.

One positive result that has been achieved by ACO is control of health care costs. According to Figueroa, Lam,  Phelan, Orav & Jha (2021), ACOs have been an acceptable model for organization of health care delivery not limited to management and care coordination. This has in turn led to saving of resources in terms of time and money.

Unintended Consequences

One of the unintended consequence of an ACO is the decreased flexibility of patients to find providers that are not associated with an ACO. Sometimes clients prefer to have a second or third opinion from different providers not associated with a specific ACO. This is not always an easy task.

Those providers in an ACO do not always use the same electronic health record (EHR). According to Perloff & Sobul (2022), the diverse structures of ACO can lead to multiple EHR use resulting to extreme delays. This could have severe consequences in compliance especially when there is an expectation to report quality measures through EHRs.

Issues Considered for the Organization and the Nursing Profession.

Working in a CCRC is dominated by geriatric patients. ACOs have part of their focus on patients who are receive Medicare benefits especially those that have chronic diseases and elderly and do not necessarily have the Medicare advantage program.

Some of the issues that can be considered in the organization is physician participation in an ACO. Some of the patients have had the same physician for many years and are not willing to switch providers. Unfortunately, these are the providers who are not ready to be part of the ACO.

It is crucial to admit ACOs offer a holistic patient centered approach which is attractive to the geriatric population who opt to receive services in a central place. Family members especially for those patients who have cognitive impairment also appreciate the coordinated care of an ACO.

References

Dewey, J. (2020). Accountable Care Organizations (ACOs). Salem Press Encyclopedia of Health.

Figueroa, J. F., Lam, M. B., Phelan, J., Orav, E. J., & Jha, A. K. (2021). Accountable Care Organizations Are Associated with Savings Among Medicare Beneficiaries with Frailty. Journal of General Internal Medicine, 36(12), 3891–3893. https://doi.org/10.1007/s11606-020-06166-6

Perloff, J., & Sobul, S. (2022). Use of electronic health record systems in accountable care organizations. The American Journal of Managed Care, 28(1), e31–e34. https://doi.org/10.37765/ajmc.2022.88818

Walden University, LLC. (Executive Producer). (2011). Healthcare policy and advocacy: Reforming health care delivery: Accountable care organizations. Baltimore: Author.

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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,