Accountable Care Organizations: opportunities for social workers.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 "value-based purchasing" 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. There is reason to believe that included in this cluster will be safety net providers, a group already at financial risk (Pollack & Armstrong, 2011). As pointed out by Hall (2011) and Kastor (2011), the unintended consequences of ACOs for specific essential types of providers, such as safety net providers or academic medical centers, need further analysis and monitoring as health reform unfolds.
Although the intended health payment and organization reforms to be implemented through ACOs are far-reaching, it is interesting that the proposed regulations conceptualize ACOs as reimbursed using traditional fee-for-service methods, with any resulting savings to be shared with the ACOs (HHS, 2011). This provision continues the historical payment structure of Medicare Parts A and B that uses fee-for-service reimbursement for providers, with limited restrictions about which providers beneficiaries may see (Crosson, 2011). The reliance on fee-for-service payment systems has been in historical conflict with policymaker efforts to create integrated managed care systems using bundled payment. Although capitated managed care models have demonstrated that they can be successful in achieving value-based purchasing of coordinated services for people with complex conditions, widespread support for these integrated strategies has not won out (Bachman, Tobias, Master, Scavron, & Tierney, 2008; Crosson, 2011).
For a number of years, policymakers have attempted to promote innovative approaches to improve the coordination, efficiency, and effectiveness of health and support services provided to Medicare beneficiaries. These activities have included efforts to create managed care arrangements that provide integrated care. Examples of programs that have been tested include the Program of All-Inclusive Care for the Elderly (PACE); the Social/Health Maintenance Organization; and the Medicare + Choice plans (National PACE Association, 2010; Newcomer, Harrington, & Friedlob, 1990; Walsh & Clark, 2002; Weiner, 1996). It is important to remember as the ACO model evolves that none of these plans were successful in enrolling large numbers of beneficiaries. The implementation of value-based purchasing has consistently proven to be easier said than done within a capitated managed care model. Retaining a fee-for-service reimbursement framework within ACOs may address beneficiary concerns related to underprovision of services within a managed care plan. At the same time, however, it is not clear whether ACOs can overcome the incentives to provide more care that are inherent in a fee-for-service reimbursement framework.
WHAT ARE THE OPPORTUNITIES FOR SOCIAL WORKERS?
Social workers have important opportunities to shape the evolution of ACOs, such as the chance to promote consumer inclusion and empowerment as well as the opportunity to analyze and influence the clinical and policy implications of the new delivery model. Social workers are well positioned to think broadly about the potential unintended consequences of ACOs for vulnerable populations, including those that participate in ACOs through Medicare and those that are covered under other payment systems or remain uninsured but will still be affected by the attendant large-scale shift in our health care system that will be prompted by ACOs.
Springgate and Brook (2011) noted that so far patients have not been active participants in conceptualizing ACOs. It is somewhat puzzling that a model of health service delivery that is being developed to promote patient-centered care has begun its evolution with questions about whether including the consumer voice is an essential priority for policymakers. Social workers, with their professional expertise in consumer engagement and focus on client empowerment, can engage with patients who will be enrolled in ACOs and work with them to advocate for their inclusion in the policy debate around ACOs. Social workers who practice in the community have ongoing links to groups that may already be working to promote consumer involvement in the policy development process; these efforts must be supported across the country.
Moreover, social workers can identify and advocate for the needs of vulnerable populations that will be affected by the development of ACOs but may not be enrolled in one through Medicare. Populations that may experience negative consequences include individuals enrolled in Medicaid, those who remain uninsured after health reform, immigrant populations, people with greater than typical health care needs, and those who rely on safety net providers for even basic primary care.
Gorin (2011) has pointed out that the ACA is a "work in progress." As health reform implementation unfolds, the ACA may be vulnerable to calls for repeal, especially in times of economic retrenchment. Social work has been called on to support health reform both because of the gains in coverage that will result for currently uninsured populations and because of the benefits to the profession (Gorin, 2011). ACOs are an essential element of the redesigned health care system under ACA. Regardless of whether health reform or ACOs are fully implemented, as the health care system continues to evolve, social workers can continue to actively promote the well-being of all patients.
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Sara S. Bachman, PhD, is associate professor, School of Social Work, Boston University, 264 Bay State Road, Boston, MA 02215; e-mail: firstname.lastname@example.org.