NURS 8100 Week 2 Discussion: Unintended Consequences of Health Care Reform
A Sample Answer For the Assignment: NURS 8100 Week 2 Discussion Unintended Consequences of Health Care Reform
The selected topic for this discussion is Accountable Care Organizations (ACOs). ACOs refer to networks of healthcare professionals who collaborate to deliver enhanced and more cost-effective treatment interventions to patients (Lewis et al., 2018). ACOs were instituted under the Medicare Shared Savings Program, a segment of the Patient Protection and Affordable Care Act (PPACA) of 2010.
Positive results that could be achieved with ACOs include having cost-effective treatment services. The ACA incentive matrix was created to offset the trend of costs rising unreasonably under the traditional Medicare fee-for-service model. ACOs could reduce healthcare costs since ACO providers are ranked against a sequence of quantitative benchmarks that are modified to account for regional cost variations (Wilson et al., 2020).
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Besides, ACOs can realize substantial savings and maximize their Medicare incentives if they meet their agreements with the CMS. Nonetheless, individuals may face unintended consequences such as perceiving that they are stuck in an unfavorable network (Lewis et al., 2018). ACOs are created to lower this risk by getting rid of the structural barriers of the HMO system. However, some healthcare economists express concerns that consolidation may restrict options available to consumers.
My current organization should consider unintended issues such as facing losses with regard to ACOs. Financial losses may occur because ACOs have savings to share if they fail to reduce the cost of care. Consequently, the organization’s operating budget may be affected because of the costs of investments used to improve care (Wilson et al., 2020). Besides, the organization may pay penalties if it fails to meet quality and cost savings benchmarks.
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Furthermore, the nursing profession should consider the quality of patient care with respect to ACOs. Healthcare providers who participate in an ACO must meet particular quality benchmarks, focusing on prevention and adequately managing patients with chronic diseases (Colla & Fisher, 2017). Thus, nurses who participate in an ACO must consider providing high-quality preventive care and management of chronic illnesses.
References
Colla, C. H., & Fisher, E. S. (2017). Moving forward with accountable care organizations: some answers, more questions. JAMA internal medicine, 177(4), 527-528. https://doi.org/10.1001/jamainternmed.2016.9122
Lewis, V. A., D’Aunno, T., Murray, G. F., Shortell, S. M., & Colla, C. H. (2018). The Hidden Roles That Management Partners Play In Accountable Care Organizations. Health affairs (Project Hope), 37(2), 292–298. https://doi.org/10.1377/hlthaff.2017.1025
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
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, E. S. (2018). Moving forward with accountable care organizations: some answers, more questions. JAMA internal medicine, 177(4), 527-528. https://doi.org/10.1001/jamainternmed.2016.9122
Moore, K. D., & Coddington, D. C. (2017). Accountable care the journey begins. Healthcare Financial Management, 64(8), 57-63. Retrieved from https://www.proquest.com/trade-journals/accountable-care-journey-begins/docview/746684537/se-2?accountid=14872
Accountable Care Organizations
Accountable Care Organizations (ACOs) are a novel approach to patient care that aims to provide more fluid and less segmented care. An ACO is a collaborative effort between physicians, hospitals, and care providers to provide high-quality care to all Medicare patients. According to one of the respondents in Piper’s (2010) interview, ACOs engage providers who are willing to look at health care provision through a different lens and consider how they can influence the broader population. The traditional model has not emphasized well-being at all levels of care, and ACOs enable health care providers to begin to practice differently.
Kaiser Permanente is cited as an excellent example of a well-functioning ACO by Bodenheimer and Grumbach (2020). The Kaiser Foundation strives to give their registered patients with all levels of health care in a fluid and seamless manner. Kaiser’s plan extends from primary care to tertiary care. One advantage is that patients are not need to determine who they should see and what their reputation is. The group eliminates the need to ask questions like, “Who should be selected for a medical procedure?” This is because all of these services and providers are within their network, and patients covered by their plan have rapid access to the treatments they seek. I work in a hospital that is part of the Colorado Kaiser Permanente network. They have a medical office building (MOB) directly next to the hospital, and they see nearly two-thirds of all patients who visit us. Patients are evaluated in the MOB and then directed to the hospital next door for labs, treatments, prescriptions, or even hospitalization. Furthermore, this group has hospitalists on-site 24/7 in my hospital, allowing for quick collaboration with other health care specialists and access to patients. These strategies, which are all part of my hospital’s high-functioning ACOs, provide a big boost to patient satisfaction.
The Colorado Kaiser Permanente group has the disadvantage of being a physician-only group. There are no Certified Registered Nurse Anesthetists, Certified Nurse Midwives, or Nurse Practitioners employed. This results in an increase in the patient’s costs. It also fosters an environment in which registered nurses are told that their ability to practice to the full extent of their licensure is not recognized. Furthermore, hospitals put themselves in financial jeopardy by partnering with ACOs like this without diversifying. Three years ago, the Kaiser Foundation decided to build a free-standing ambulatory surgical care clinic and transport all patients in the Denver Metro area there. As a result, the number of surgical patients seen at my hospital, as well as the institution’s and system’s, decreased significantly.
References:
Bodenheimer, T., & Grumbach, K. (2020). Understanding health policy: A clinical approach. McGraw Hill.
Piper K. (2010). Accountable Care Organizations in the Era of Healthcare Reform… Mark B. McClellan, MD, PhD. American Health & Drug Benefits, 3(4), 242–244.
The PPACA of 2010 fostered new provisions for health care and the structure of health care delivery. The individual mandate to obtain insurance is one provocative provision. While this provision attempts to increase access to health care, it raises questions on how the existing system could sustain the potentially large influx of newly insured individuals.
Another provision calls for new models of health care provider organizations to ensure delivery efficiency and continuity of care. In this week’s media presentation, Dr. Kathleen White discusses the accountable care organization, which comprises a group of providers coordinating care across a variety of institutional settings. Yet becoming an accountable care organization may present a number of challenges.
This week’s Discussion builds on Week 1, continuing the examination of those societal and organizational contexts that influence health care reform. The unintended consequences of reform policy on the health care system are also considered.
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
To prepare:
- Review this week’s media presentation and the other Learning Resources focusing on how reform may lead to improved quality, greater access, and reduced cost of care. Also think about the unintended consequences that may arise as a result.
- Consider the information presented about the individual mandate and accountable care organizations. What are some questions or concerns you might have regarding the individual mandate? What are the pros and cons associated with becoming an accountable care organization?
- With posting instructions in mind, select either the individual mandate or accountable care organizations as the focus of your Discussion this week.
By Day 3
Post a cohesive response that addresses the following:
- In the first line of your posting, identify the topic you have selected—either the individual mandate or accountable care organizations. With regard to this topic, describe one or more positive results that could be achieved, and one or more unintended consequence(s) that organizations or individuals may experience.
- Briefly evaluate issues on the topic that may be a consideration for the organization you work in and the nursing profession.
Read a selection of your colleagues’ postings.
By Day 6
Respond to at least two of your colleagues in one or more of the following ways:
- Ask a probing question, substantiated with additional background information, evidence or research.
- Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
- Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
- Validate an idea with your own experience and additional research.
- Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
- Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Note: Please see the Syllabus and Discussion Rubric for formal Discussion question posting and response evaluation criteria.
Return to this Discussion in a few days to read the responses to your initial posting. Note what you learned and/or any insights you gained as a result of the comments made by your colleagues.
Be sure to support your work with specific citations from this week’s Learning Resources and any additional sources.