Question

The Affordable Care Act (ACA) currently includes provisions for Accountable Care Organizations (ACO) and Patient Centered Medical Homes. What are these entities and how may they be related to managed care?​

Answer 1

Accountable Care Organizations:

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 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 duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. Medicare offers several ACO programs:

• Medicare Shared Savings Program—a program that helps a Medicare fee-for-service program providers become an ACO.
• Advance Payment ACO Model—a supplementary incentive program for selected participants in the Shared Savings Program.
• Pioneer ACO Model—a program designed for early adopters of coordinated care.

The Patient Centered Medical Homes(PCMH):

The Patient Centered Medical Homes(PCMH) is being tested by several public and private sector health insurance and provider organizations to coordinate care for patients with chronic illnesses. Medical homes provide care management services, make referrals to specialists, provide support services, and use electronic health records and health information technology to monitor and coordinate services/programs on behalf of the consumer. The medical home is a model that aims to transform the organization and delivery of primary care. The PCMH model focuses on personalized care, teamwork, and coordination of care to ensure that patient needs are met effectively and efficiently. The Patient Protection and Affordable Care Act (ACA) provides opportunities for the PCMH model by supporting nationwide medical home demonstration projects administered by the Center for Medicare and Medicaid Innovation (CMMI).

Section 2703 of the Affordable Care Act indicates that eligibility for Medicaid health homes requires beneficiaries to have: At least two chronic conditions (e.g., mental health condition, substance use disorder, asthma, diabetes, heart disease, a body mass index (BMI) greater than 25); One chronic condition and the risk of a second; One serious and persistent mental health condition.
Health homes must provide all six of the following services, as appropriate based on beneficiaries’ changing needs: Comprehensive care management; care coordination; health promotion; comprehensive transitional care; individual and family support; Referral to community and support services.

The health homes statute further indicates that states should document the “use of health information technology to link services.” These six service components, together with the health IT linkage component, require that states have the capacity to manage a continuum of specialty and primary care health services and, at least, coordinate long-term care services and other supports.

How Patient Centered Medical Homes and Accountable Care Organizations (ACO) is related to managed care.

• The effective coordination of a patient’s health care services is a key component of highquality and efficient care. Two relatively new models in health policy—the patient-centered medical home (PCMH) and Accountable Care Organizations (ACOs)—provide an opportunity to increase the extent and effectiveness of care coordination in the United States. PCMHs are similar to ACOs in that they consolidate multiple levels of care. However, in medical homes the primary care provider (MD, DO, NP, PA) leads the care delivery team in a single practice, as opposed to an ACO, which consists of many coordinated practices.
• Care coordination is a core activity of PCMH. The PCMH team is responsible for assuring communication with patients and their families and across the primary care team. The PCMH is responsible for partnering with professionals and teams in other settings that participate in a given patient’s care including at times of care transitions. The PCMH should also be involved in connecting with community resources and aligning resources, although these functions may be led by or supported by other providers external to the PCMH.
• Building on the care coordination efforts of PCMHs, ACOs can ensure and incentivize communications among teams of providers operating in varied settings. Additionally, ACOs can facilitate transitions and align resources to meet the clinical care and care coordination needs of populations. This work includes and extends beyond creating hospital discharge care coordination programs to creating a ―medical neighborhood‖ where providers share information with one another. Recognizing that, at times, primary responsibility for care coordination for specific patients, including assessing needs and developing a care plan, may be assigned to non-primary care specialty teams (for example, when patients are receiving a complex set of services for a particular disease, such as cancer or severe mental illness), ACOs can ensure that these transitions of accountability happen and that specialty teams are ready, willing, and able to provide these services. ACOs can also develop and support systems for care coordination for patients who reside in non-ambulatory care settings. Health information technology (Health IT) systems also are critical for the successful transfer of information. These systems, when used appropriately, can play a critical role in establishing and monitoring accountability. For example, an ACO could use Health IT to monitor the timeliness and completeness of information flows between primary care providers and specialists, and use the tracking information to incentivize high levels of responsiveness and collaboration.
• A concept that bridges the PCMH and ACO perspectives on care coordination is ―integrated care. Integrated health care starts with good primary care and refers to the delivery of comprehensive health care services that are well coordinated with good communication among providers; includes informed and involved patients; and leads to highquality, cost-effective care. At the center of integrated health care delivery is a high-performing primary care provider who can serve as a medical home for patients.