Author Finds High Degree of Variation Among States to Accommodate Accountable Care

From Medicaid providers that are regulated as insurers alongside managed care organizations, as happens in Mississippi, to “enhanced medical homes,” which are found in Colorado, the variety that exists in healthcare delivery across the states has adapted to reflect the shift to accountable care, according to an author writing for the American Journal of Public Health.

In “Legal Mechanism Supporting Accountable Care Principles,” which will be published in the journal’s November edition, Tara Ramanathan, JD, MPH, explores the less-discussed side of transformation in healthcare: how the legal and regulatory frameworks have had to roll with the tide, and how the word “waiver” has become common as states and providers experiment with new delivery models.

Managed care has hardly vanished from the scene; if anything, states are digging in to bringing cost-containment principles to Medicaid programs, with difficult transitions and mixed results. As Ramanthan writes, the concept of the accountable care organization (ACO), which allows entities to participate in the Medicare Shared Savings Program (MSSP) has been integrated with these efforts, with the stated goal of improving coordination of care along with bringing down costs.

Sometimes, however, this has worked better in theory than in practice, especially as programs switch over from fee-for-service models.

Ramanthan looks at several types of accountable care frameworks:

• Private Accountable Care Entities. These groups have left the shift to accountable care for more than a decade, she writes, developing the metrics to measure progress, many of which are now being used by public health departments. Much of the experimentation has been done through contract law, as large multispecialty medical practices brokered relationships with health plans, or physician and insurers jointly purchased intergrated delivery systems.
• Medicare ACOs. Less variability is seen here, as federal standards require uniformity. The Affordable Care Act spells out requirements for forming an ACO and participating in the MSSP. Requirements are strict; ACOs must serve at least 5000 patients and provide a host of reports on professionals, processes, and how the entity meets patient-centered criteria. Different tracks offer different financial incentives, depending on the setting and characteristics of the ACO. Pediatric ACOs may be approved as demonstration projects.
• Medicaid and Accountable Care. Here, variation is greatest, which Ramanthan said likely reflects “individual states’ history and experience with managed care, other existing delivery arrangements within Medicaid, and the challenges inherent in serving low-income and chronically ill populations.” Some states require an emphasis on population health, including behaviorial health and substance abuse treatment, while other states do not mention mental health at all. ACOs are often left on their own to develop standards and metrics for measuring improvement.

As Ramanthan writes, the lag between reaching an agreement on benchmarks and fully putting them to use means it may be a while before the fruits of accountable care are seen in the Medicare and especially the Medicaid populations.

“Once decision makers determine the metrics that will be used to measure population health measures for the accountable care framework, further research may show which accountable care mechanisms, if any, will be useful in improving public health.”