Introduction
During the 19th century, the US healthcare system adopted reimbursement models that underwent a series of changes leading to the development of Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs). Although financial healthcare reimbursement models were first developed in the commercial market, the federal government implemented Parts A and B of Medicare under President John F. Kennedy, which facilitated the expansion of MCOs. Some Medicare providers identified a niche in the misalignment of incentives in MCOs, which operated in uncoordinated silos and limited patient choice of provider, hence developing ACOs. Analysis of MCOs, which are single organizations managing healthcare plans and ACOs, a network of physicians, hospitals, and care providers that give quality care to Medicare patients, indicates differences in their target patient population and nurses’ roles.
Discussion
Managed care in the US started when individual health providers in cities initiated prepaid healthcare plans for workers’ unions and associations. Following the Great Depression in the 1930s and the Stabilization Act of 1942, prepaid contractual agreements increased hence stimulating the growth of the earliest forms of managed care called Health Maintenance Organizations (HMOs) in the 1970s (Handel & Kolstad, 2022). However, the Preferred Provider Organizations (PPOs) were developed that leveraged cost share savings principles and innovative payment systems to quantify care delivered to align incentives while allowing patients freedom of choosing providers. On March 23, 2010, the Affordable Care Act (ACA) was signed into law, encouraging the expansion of shared savings programs such as ACOs (Handel & Kolstad, 2022). Therefore, the variability in costs in MCO plans triggered the development of PPOs hence the ACOs, which embrace cost-sharing measures.
While target populations in MCOs mainly comprise high-income, behavioral, and disabled patients with acute conditions that require specialized treatment and the elderly population, ACOs are limited to major employees and low-income populations. Populations demanding complex and specialized, high-quality care, such as the elderly, high-income population, and the disabled, make agreed-upon requirements for cost, utilization, and quality (Matulis & Lloyd, 2018). The MCOs operate on a monthly payment plan covering specified health cost risks.
In contrast, ACOs encourage providers’ coordination by providing an integrative system that shares costs and lowers expenses by implementing preventative measures. ACO’s target beneficiaries are mainly contracted employees, low-income demographics, and the general population with fewer health risks. Comparatively, MCOs mainly cover patients with disabilities and high-income chronic and behavioral conditions since they require costly specialized care.
When interacting with MCO patients, nurses ensure their patients understand the MCO’s contract terms, scope, and payment rates. Additionally, nurses are experts in identifying cost-cutting measures, individualized patient follow-up, diagnosis, and post-diagnosis treatment roles. On the contrary, nurses have the role of inquiring about patients’ medical history, coordinating with various sources and physicians, and recording the interaction with ACO patients in the integrative system (Pejewski et al., 2019). In efforts to enhance high-quality care, nurses have the role of recording data in their practice and incorporating it in the ACO system used in large-scale healthcare research.
Conclusion
Ultimately, individual providers developed HMOs that led to the development of MCOs in the 1970s. Consequently, ACOs were developed in the late 1990s and early 200s, which entail provider entities covering Medicare costs of Part A and Part B benefits. An analysis of the target population differences between MCOs and ACOs indicates that while MCOs serve mainly patients with disabilities or in need of acute care, ACOs target the general populations who seek insurance for quality healthcare at managed costs. Notably, nurses play a critical role in managing patient care by understanding their responsibilities when interacting with MCO and ACO patients.
References
Handel, B., & Kolstad, J. (2022). The Affordable Care Act after a Decade: Industrial Organization of the Insurance Exchanges. Annual Review of Economics, 14, 287-312. Web.
Pajewski, N. M., Lenoir, K., Wells, B. J., Williamson, J. D., & Callahan, K. E. (2019). Frailty screening using the electronic health record within a Medicare accountable care organization. The Journals of Gerontology: Series A, 74(11), 1771-1777. Web.
Matulis, R. & Lloyd, J. (2018). The history, evolution, and future of Medicaid Accountable Care. Centre for Healthcare Strategies. Web.