Managed Care Organizations and Accountable Care Organizations

Many financial models have been implemented in the United States in search of a model that best suits the needs of patients and providers. These models serve as the backbone of the healthcare payment system, determining how services are priced, reimbursed, and ultimately delivered (Eriksson et al., 2023). The intricacies of these financial frameworks can profoundly influence patient access to care, the quality of services provided, and the financial viability of healthcare institutions. Embedded within these financial models are Managed Care Organization (MCO) and Accountable Care Organization (ACO) programs. These programs exist to balance the quality of healthcare services delivered to patients and the costs associated with those services (Bao & Bardhan, 2024). This discussion focuses on the history of MCOs and ACOs, populations served, and the role of the nurse when interfacing with these programs.

History of MCOs and ACOs

Managed Care Organizations and Accountable Care Organizations represent significant milestones in the evolution of healthcare delivery and reimbursement models. The introduction of MCOs dates back to 1973 when the Health Maintenance Organization (HMO) Act was passed (Brockett et al., 2021). The organization was created in response to the escalating healthcare costs and the desire to control health expenditures. The growth of MCOs saw patients select primary care physicians from a network of providers and obtain referrals for specialty care. In the 1980s, preferred provider Organizations (PPOs) emerged to allow patients to seek care from both in-network and out-of-network providers without requiring referrals. Today, more than 90% of insured Americans are enrolled in plans with some form of managed care.

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Accountable Care Organizations are defined as a group of providers that voluntarily coordinate care to better serve Medicare beneficiaries. ACOs were also formed to reduce healthcare costs and improve the quality of healthcare services. Unlike the MCOs which were developed decades ago, ACOs emerged recently in response to the Affordable Care Act that was passed in 2010 (Centers for Medicare and Medicaid Services, 2024). Through value-based models, ACOs were formed to improve care coordination, enhance quality, and reduce costs. At the beginning of the program, there were 32 ACOs covering over 7.3 million beneficiaries. These numbers have grown over the years to include over 1000 ACOs covering more than 33 million patients.

Identification of Populations Served by MCO and ACO

Managed Care Organizations and Accountable Care Organizations serve a wide range of populations, each with unique healthcare needs and preferences. MCOs serve Medicaid patients in various states including Florida, New York, and California. Patients in the Medicare Advantage Plan are also beneficiaries of MCOs giving them coverage for essential drugs and dental services. Through the affordable care markets, MCOs provide individualized plans to those who are self-employed and employer-sponsered people. ACOs include a group of doctors and hospitals that come together to coordinate care for Medicare patients (Centers for Medicare and Medicaid Services, 2024). The program serves medicare patients through the Medicare Shared Savings Program (MSSP). For example, those aged 65 years and above and individuals with disabilities are served by these ACOs. Through programs like the ACO investment model, the organization serves those in rural and underserved areas already registered with Medicare. The two organizations also serve dual-eligible populations across various states.

 Role of nurse when interfacing with MCO and ACO

Nurses play a crucial role in interfacing with patients within MCOs and ACOs, acting as advocates, educators, coordinators, and care providers. The nurses coordinate with primary care providers to ensure the patient receives the right services that align with their payment plans. Interprofessional teams need to understand the premise of MCOs and ACOs and how they affect healthcare delivery (Brockett et al., 2021). The nurses are at the front to educate patients about their insurance plans and which specialty services they can receive. For example, the nurses identify high-risk patients and refer them for services that can improve their health outcomes. In my role as a Family Nurse Practitioner, quality improvement is one of the key roles when interfacing with MCOs and ACOs. The nurse in this role collects data, identifies areas of improvement, and implements evidence-based interventions to improve value-based care (Bao & Bardhan, 2024). Apart from quality improvement, FNPs can advocate for patients to ensure barriers related to access to essential services are reduced.

Financial model’s Impact on patients and nurses

ACOs and MCOs are financial models that influence important aspects of healthcare like access to services, quality of service delivery, and job satisfaction. Firstly, MCOs and ACOs have improved healthcare access for many patients, especially those in rural areas (Bao & Bardhan, 2024). Through a focus on timely service delivery, these models have improved health outcomes in patients seeking emergency and subsequent care. Because the MCOs and ACOs are tied to reimbursement by the CMS, the models have improved the quality of services. They have promoted aspects like patient-centered care which ensures patients are involved in their care and costs spent reflect the quality of services given (Eriksson et al., 2023). Financial models have promoted job satisfaction among nurses sand other providers. Aspects like interprofessional collaboration have been boosted as physicians and nurses work together to achieve value-based care.

References

Bao, C., & Bardhan, I. R. (2024). Measuring value in healthcare: Lessons from accountable care organizations. Health Affairs Scholar, qxae028. https://doi.org/10.1093/haschl/qxae028

Brockett, P., Golden, L., Yang, C. C., & Young, D. (2021). Medicaid managed care: Efficiency, medical loss ratio, and quality of care. North American Actuarial Journal, 25(1), 1-16. https://doi.org/10.1080/10920277.2019.1678044

Centers for Medicare and Medicaid Services. (2024). Accountable Care Organizations (ACOs): General information.

https://www.cms.gov/priorities/innovation/innovation-models/aco

Eriksson, T., Levin, L. Å., & Nedlund, A. C. (2023). The introduction of a value-based reimbursement programme-Alignment and resistance among healthcare providers. The International Journal of Health Planning and Management, 38(1), 129–148. https://doi.org/10.1002/hpm.3574