Accountable Care Organizations: Opportunities for Social Workers

Abstract

A key element of the Patient Protection and Affordable Care Act (known as the Affordable Care Act or the ACA) (P.L. 111-148) is the provision relating to the creation of accountable care organizations (ACOs) (U.S. Department of Health and Human Services [HHS], 2011). ACOs represent a new model for health service delivery and are intended to help promote quality improvement and under the ACA and health reform (HHS, 2011). ACOs will be developed within the framework of a shared savings program that promotes accountability for a patient population, coordination of health services and supplies under Medicare Parts A and B, development of patient-centered health homes, and investment in redesigned care processes. Health care providers and suppliers participating in ACOs can continue to receive fee-for-service payments under traditional Medicare Parts A and B. ACOs will share in the savings that result from the value-based purchasing that should result from associated system redesigns. The proposed federal rule related to ACOs was outlined in the Federal Resister in April 2011, with public comments due in June 2011 (HHS, 2011). In the Federal Resister rules, it was proposed that each ACO will enroll at least 5,000 beneficiaries. ACOs would also meet certain other criteria. For example, it is expected that ACOs will be developed around a group practice or network of providers; ACOs will have in place leadership and management structures, including clinical and administrative systems; ACOs must be willing to submit data on cost and quality; and ACOs must meet patient-centeredness criteria specified by the secretary of HHS, among other requirements. ACOs are scheduled to be implemented by January 1, 2012 (HHS, 2011). HOW WILL ACOS AFFECT HEALTH CARE? Policymakers have begun to critically analyze how the proposed ACO rules will affect current health care practice and systems. Strengths of the new model include its emphasis on primary care, the opportunity to reduce fragmentation in health service delivery, and the flexibility in provider organizations that are allowed to develop the ACO model (Kastor, 2011; Lieberman & Bertko, 2011). If ACOs can deliver on the promise of providing efficient, patient-centered care, the new delivery organization may indeed accomplish value-based purchasing and shared savings. However, significant concerns about the proposed model have also been raised. Because ACOs are a new concept, policymakers do not have experience with this specific type of organization. As it is implemented, there may be unintended consequences of bundling services and supplies in an ACO (Lieberman & Bertko, 2011; Richman & Schulman, 2011). From a regulatory perspective, because many different types of provider groups can become ACOs, it will be challenging to write regulations that anticipate and account for different ACO model variations and how the ACO may be operationalized under each of these scenarios while at the same time promoting the goals of the model and health reform more generally (Lieberman & Bertko, 2011; Richman & Schulman, 2011). ACOs may become so large that they have extraordinary market power, an outcome that may be difficult to manage through regulation (Richman & Schulman, 2011). An additional potential impact of ACOs on the health care market is the evolution of a few large ACOs that concentrate particular subsets of patients into a limited group of health care organizations (Pollack & Armstrong, 2011). There is potential for adverse selection among ACOs if organizations with more market power attract and retain patients who require less care coordination. Patients with more complex needs, including those suffering from the impact of health disparities or those with long-term chronic conditions, will be less attractive in the context of the profitability motive of ACOs. Further complicating this scenario is the risk that because ACOs are a demonstration project under health reform, some providers may not participate if they think they will not be successful. …