Accountable Care Organizations and Managed Care Organizations

The policies of healthcare in the United States have changed over time, focusing on the improvement of the quality access and cost of healthcare by applying different forms of finance and organizational forms. Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs) are two structures with defining features that have impacted the delivery of healthcare services: Accountable Care Organizations and Managed Care Organizations.

Learning and appreciating the differences in the models, their evolution, and their implications for patient groups and the facilities they serve will assist in enhancing patient care and reimbursement mechanisms. Further, such models influence the perception and function of the healthcare system as far as cost containment and the quality of patient care are concerned, which makes the system fluid and complex from the professionals’ perspective.

History of MCOs and ACOs

Managed care organizations came to the scene in the early part of the twentieth century in an attempt to reduce the soaring price of healthcare and the wayward provision of services. The landmark that marked MCOs was the Health Maintenance Organization (HMO) Act of 1973, which provided federal funding for the development of HMOs. The key elements of MCO are cost containment by networks, contract costs, and preventive care (CMS, n.d.). For example, there were Preferred Provider Organizations (PPOs) and Exclusive Provider Organizations (EPOs), which have diverse approaches to cost-sharing and healthcare services.

Conversely, Accountable Care Organizations were introduced as part of the Affordable Care Act (ACA) of 2010 to address inefficiencies in fee-for-service reimbursement models. Accountable Care Organizations represent a pro-quadrennial care organization with a focus on quality and fiscal penalties for additional costs. However, ACOs are primarily focused on the practice of value-based care, whereby these providers will have some incentive to bear certain levels of risk and cost savings targets to achieve quality standards (CMS, n.d.).

ACOs refer to organizations of doctors, hospitals, and other healthcare practitioners working in synergy to offer efficient and quality healthcare services. Also, payment was based on a success formula that encouraged providers to achieve desired patient outcomes and curtail wastage costs.

Populations Served by MCOs and ACOs

MCOs primarily serve patients enrolled in private and government-sponsored insurance programs, including Medicaid and Medicare Advantage plans. They control costs by engaging provider networks whereby the beneficiaries are forced to seek services from the providers within the network (Heaton & Tadi, 2023). These organizations include centers that help people find affordable insurance, as well as organizations for people with rare diseases who need preventive and primary care. MCOs can use prior authorization and case management mechanisms to help manage and contain healthcare demand.

ACOs, on the other hand, predominantly cater to Medicare beneficiaries but can also include commercially insured patients. Their primary objective is to enhance care coordination among different providers, ensuring seamless transitions and reducing hospital readmissions. ACOs serve patients who benefit from integrated and value-based care models, particularly those with chronic illnesses requiring consistent management (Namburi & Tadi, 2023).

By utilizing electronic health records (EHRs) and data analytics, ACOs improve communication between providers, leading to better patient health outcomes. Unlike MCOs, ACOs focus on reducing redundant tests and procedures, aiming to enhance the efficiency of care delivery.

Role of Nursing in MCOs and ACOs

As a nursing professional, my role within MCOs and ACOs varies based on the specific model of care delivery. Assisting with general health administrative tasks that exist beneath the umbrella of an MCO, my specific functions entail teaching patients adequate strategies for penetrating health networks, encouraging maintenance, and following through with set healthcare plans provided by PCPs. Nurses also provide treatment coordination by referring patients to in-network specialists and addressing and overseeing chronic illnesses. Moreover, MCOs hire nurses to help with authorization, where they sometimes monitor patients’ need for services in relation to cost-effective means.

In an ACO setting, nursing responsibilities expand to include care coordination across multiple healthcare providers, patient advocacy, and data-driven decision-making to improve outcomes. In a collaborative manner, one of my roles is to address the problem of patient’s readmission to the hospital by helping them to have proper follow-ups and medication management consultations. Moreover, I am involved in quality improvement activities within nursing aimed at achieving quantitative performance targets entailing finances for the organization (CMS, 2024).

ACO nurses are often involved in transitional care programs wherein patients are prepared to be discharged, and nurses follow up on patients’ progress in the next phase of care. In light of current advances in ICT, nurses have an important role in providing care for patients beyond facility-based care delivery models, enhancing telehealth systems, and chronic disease management.

Conclusion

MCOs and ACOs are important agents in the healthcare system because they seek to establish cost efficiencies and improve access and quality of care. Whereas MCOs focus on constraining costs via provider networks and managed care concepts, ACOs focus on value-based coordinated care with an outlook to measurable improvements. Even though healthcare is mainly the responsibility of physicians, nurses have the following functions in both models: to educate patients and coordinate care. Studying these models makes it easier to fight for patients’ rights and work more effectively within the system.

References

CMS. (2024, May 14). Accountable care and accountable care organizations. CMS.gov. https://www.cms.gov/priorities/innovation/key-concepts/accountable-care-and-accountable-care-organizations

CMS. (n.d.). Accountable Care Organizations (ACOs): General information. CMS.gov. https://www.cms.gov/priorities/innovation/innovation-models/aco

Heaton, J., & Tadi, P. (2023, March 6). Managed care organization. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557797/

Namburi, N., & Tadi, P. (2023, January 30). Managed care economics. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556053/

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 Analyze financial models of reimbursement and their effects on patients and health care providers.

Directions

For this assessment, you will distinguish between Managed Care Organizations (MCO) and Accountable Care Organizations (ACO). Your paper will include the following:

• Provide a brief history of both the MCO and ACO.
• Define the populations MCO and ACO are intended to serve.
• Analyze your role in your specialized area of nursing practice when interfacing with an MCO and ACO clients/patients.

The word count for your paper, excluding the title page and references page

Accountable Care Organizations and Managed Care Organizations

2 pages paper (800 words).

3 references

Reference each paragraph using APA 7^th edition

Assessment Requirements

• follow the conventions of Standard English (correct grammar, punctuation, etc.);
• be well-ordered, logical, and unified, as well as original and insightful;
• display superior content, organization, style, and mechanics; and
• use 7th edition APA formatting and citation style.