Introduction
In a perfect world, healthcare providers always select the most economical treatment for their patients. However, provider-payment conversations aside, healthcare decisions are only sometimes straightforward. The correct selection for each patient should be reached through an open and frank discussion with their physician, covering their options, medical history, and cost-benefit trade-offs. For example, if a patient comes into a doctor’s office with hazy symptoms, the doctor may suggest anything from “wait and see” to “conduct every test we can think of.” The objective of a successful provider reimbursement structure would be to not impede a physician and patient from making the “correct” healthcare decision in a given circumstance. This paper will distinguish between Managed Care Organizations (MCO) and Accountable Care Organizations (ACO).
History
The origin of managed care in the United States can be traced in the late 19th century. It was when a small group of doctors started offering pre-paid medical treatment to members of fraternal orders, unions, and other associations of workers in several American cities. The doctor charged a nominal annual fee to each participant association member in exchange for unlimited access to the medical services the doctor offered. Midway through the 1980s, managed care became increasingly popular among businesses to contain the skyrocketing expense of offering workers health coverage (Newbrander & Eichler, 2018). Enrollments in managed care skyrocketed in the 1990s. Today, managed care provides coverage for most Americans with private insurance and a sizeable portion of those enrolled in the government-sponsored Medicare and Medicaid programs.
ACOs are healthcare organizations created to shift care delivery and payment away from the conventional, volume-driven, fee-for-service paradigm toward an integrated strategy that rewards prevention, wellness, quality, and cost control. ACOs are groups of physicians, hospitals, and other healthcare professionals who work together to offer patient populations coordinated, high-quality care. The Patient Protection and Affordable Care Act of 2010 included the ACO idea, and the first Medicare Shared Savings Program (MSSP) ACOs were allowed in 2012 (Kaufman et al., 2019).
The accountable care organization has developed further and is now a key component of Centers for Medicare & Medicaid Services (CMS) initiatives to improve quality and reduce costs throughout the Medicare and Medicaid programs. ACOs’ main goals include ensuring patients receive the appropriate care at the appropriate time, eliminating medical errors, and avoiding duplication of services.
Populations Served
Health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point of service (POS) organizations are the most prevalent incarnations of managed care organizations. In HMOs, a patient selects an in-network primary care physician who makes specialist referrals. Insurance is normally the least expensive choice and only covers providers in its network (Newbrander & Eichler, 2018). PPO patients can select from a list of in-network providers for primary and specialty care. Patients can also see physicians, not in their network, but they will be charged more than those who are. In addition, patients frequently do not need a referral to access specialty providers who are in-network, and prices typically increase due to more freedom.
An ACO would benefit patients and payers like Medicare in a perfect world. A successful ACO can reduce the fee-for-service (FFS) payment model’s transaction costs, which historically favor volume over value. Some ACOs even abandon FFS in favor of alternatives like capitation, which makes fixed payments to physicians for each patient whether or not they receive medical services (Matulis & Lloyd, 2018). An ACO can function for patients as a highly integrated network of healthcare professionals with a shared understanding of each patient. Patients receive coordinated care that should result in better outcomes at a cheaper cost rather than switching between disjointed doctors and hospitals.
Role of Nurse
Keeping healthcare expenses low for patients and insurance companies is one of the key duties of a managed care nurse. To accomplish this, these nursing experts strongly emphasize ensuring that patients do not undergo pointless operations and motivating patients to seek out preventive medical care. The healthcare expense might soar through the roof due to unnecessary medical treatments. Nurses specializing in managed care work closely with physicians and patients to prevent unnecessary, costly medical treatments (Newbrander & Eichler, 2018). Examining patient medical records and conducting doctor interviews may be required.
According to ACO standards, the organization must provide patient-centered care, in which patients actively participate with their clinicians in healthcare decisions. The best people to communicate information about diagnoses, medications, and post-discharge care guidelines are nurses. These are abilities that nurses directly involved in patient care already possess. As a result, they regularly clarify to patients and their family’s instructions or diagnoses that were not clear when given by other healthcare professionals (Huang et al., 2021). ACOs will probably use nurses to explain and interpret care options and treatment regimens to families.
Conclusion
In conclusion, the basic concept of ACO was to create a group of doctors or a local healthcare organization accountable for the cost and quality of treatment provided to a specific population. ACOs have been used to coordinate patient care and reduce or remove redundant testing and needless treatments. The goal of managed care organizations, which are integrated into the healthcare system, is to lower healthcare expenses. Managed care companies have influenced healthcare provision in the United States since the 1970s through initiatives for preventative medicine, financial provisioning, and treatment recommendations.
References
Huang, N., Raji, M., Lin, Y. L., Chou, L. N., & Kuo, Y. F. (2021). Nurse practitioner involvement in Medicare accountable care organizations: association with quality of care. American Journal of Medical Quality. Web.
Kaufman, B. G., Spivack, B. S., Stearns, S. C., Song, P. H., & O’Brien, E. C. (2019). A systematic review of the impact of accountable care organizations on utilization, care, and outcomes. Medical Care. Web.
Matulis, R., & Lloyd, J. (2018). The history, evolution, and future of Medicaid accountable care organizations. Center for Health Care Strategies website. Web.
Newbrander, W., & Eichler, R. (2018). Managed care in the United States: its history, forms, and future. Recent Health Policy Innovations in Social Security. Routledge.