who can help me?

POLICY & POLITICS

[email protected] AJN ▼ February 2012 ▼ Vol. 112, No. 2 23

Despite continued efforts by congressional Republicans to repeal—or undermine funding for aspects of—the Patient Protection and Affordable Care Act (ACA), policymakers are forg­ ing ahead to improve the quality of health care and contain its costs through reform of how health care is both paid for and delivered. While the emphasis of the ACA is to expand access to health insurance coverage for 35 million uninsured Americans, the new law also encourages the adoption of innova­ tive models of care and payment, such as account­ able care organizations (ACOs).

The ACA describes an ACO as an arrangement between providers and suppliers of health care ser­ vices that “promotes accountability for a patient pop­ ulation and coordinates items and services under Medicare parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient care delivery.”1 While the ACA directs the development of ACOs for Medicare beneficiaries, ACOs are also being launched in many areas of the country as a way to deliver care to Amer­ icans of all ages who have private health insurance.

Because nurses are on the front lines of patient care, they are key stakeholders in any redesign of the pay­ ment and delivery systems and should be knowledge­ able about and involved in the development of ACOs. Nurses are likely to have key roles in ACOs as leaders, managers, clinicians, and care coordinators.

The current U.S. health care system is fragmented and duplicative. Because no sole entity—providers, payers, or employers—takes full responsibility for managing patient care, the costs are high and quality is uneven.2 While there is no rigidly defined ACO model of care, an ACO generally consists of an in­ terrelated system of providers that may comprise hospitals, home care and long­term care agencies, physician group practices, and other health care en­ tities, such as medical homes, whose focus is primary care. The ACO assumes responsibility for managing the care of the patient and the delivery of services across the continuum of care, with a strong empha­ sis on primary care and prevention. Performance

measurement is critical as well. The goal of the ACO is to provide high­quality, cost­effective health care, with providers rewarded for delivering excellent care. ACO types include3

• a “virtual” ACO, which may consist of different types of providers, such as physician practices and hospitals that may get extra payments for deliver­ ing quality, cost­effective care.

• an “integrated” ACO, which may encompass in­ surance and delivery roles, as in the ACOs run by the Geisinger Health System in Pennsylvania and Kaiser Permanente in California.

• a Medicare ACO, which may enable members to receive care outside the ACO, provide for shared savings among providers if costs are reduced, award bonus payments for high­quality care, and even protect providers from financial risk if Med­ icare budget goals are exceeded. In addition, since private insurers often adopt Medicare innovations, a successful Medicare ACO could become a model for the formation of ACOs by private health in­ surers.

NURSES AND THE CMS RULE FOR ACOs While the ACA described Medicare ACOs as focus­ ing on primary care and capable of providing a wide range of services to Medicare beneficiaries, it did not spell out the ACO structure in detail. It did, however, direct the Centers for Medicare and Medicaid Services (CMS) to establish rules governing Medicare ACOs.

An opportunity for nurses? In December 2010, as part of the rule­making process, the American Nurses Association (ANA) formally submitted com­ ments to the CMS supporting reform of the Medi­ care payment and delivery systems through the ACO model of care.4 Overall, the ANA envisioned the model as offering opportunities for nurses to have a greater role in providing higher­value patient care.

The ANA urged the CMS to consider several is­ sues in the development of Medicare ACOs4: • The central role of nursing in care coordination

should be recognized as a key component in the ACO model of care and a standard of practice

By Mary Ann Hart, MSN, RN

Accountable Care Organizations: The Future of Care Delivery?

Nursing’s role in an evolving model emphasizing primary care, integration, and measurement.

POLICY & POLITICS

24 AJN ▼ February 2012 ▼ Vol. 112, No. 2 ajnonline.com

for nurses. Current examples of care coordination include the work of case managers, school nurses, public health nurses, and home care nurses. Cit­ ing the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health,5 the ANA called for emerging care co­ ordination roles for nurses to include “health coaches, informaticists, health team leaders, and primary care providers.”

• Care coordination should be adequately compen­ sated, as also recommended by the IOM report. Without fair compensation, health care providers will not have as strong an incentive to hire nurses as care coordinators. In addition, care coordina­ tion should be measured and be part of the qual­ ity metrics used by the ACO.

• Quality should be measured in part by nursing­ sensitive indicators, which will capture “struc­ tural, process, and outcome measures which contribute to achieving patient­centered health outcomes.” Examples might include preventing avoidable adverse events such as “pressure ul­ cers, falls, medication errors of omission and commission, and emergent care.”

• ACO leadership should include nurses, physi­ cians, and other health professionals in order to “facilitate interprofessional collaboration as pa­ tients transition across settings.”

• An explicit policy should make clear that all health care professionals be “permitted to practice to the full extent of their training, skills and scope of practice,” with patient surveys using “provider­ neutral language.” About scope of practice, the IOM report says the following5:

ACOs that use APRNs and other nurses to the full extent of their education and train­ ing in such roles as health coaching, chronic disease management transitional care, pre­ vention activities and quality improvement will most likely benefit from providing high­ value and more accessible care that patients will find to be in their best interest.

• Small, solo, nurse­led practices should be able to participate in ACOs through the development of

networks of RNs, care managers, social workers, nutritionists, and community health workers.

• Patient­centeredness should be demonstrated by giving patients a choice of providers and allow­ ing them “shared decision­making” in the plan of care.

In March 2011, the CMS issued a proposed rule for the Medicaid Shared Savings Program.6 In the public comment period that followed, key stake­ holders, including the ANA, raised concerns that the proposed rules were too burdensome and would discourage ACO development.7 On October 20, 2011, the CMS issued the final ACO rule, drawing support from health industry groups through con­ cessions that will make it easier for health care pro­ viders to participate in Medicare ACOs.6 These changes include • enabling ACOs to share savings with Medicare

earlier. • reducing the number of quality measures ACOs

will have to meet for quality performance bo­ nuses.

• informing ACOs which Medicare beneficiaries are likely to be part of their system.

• enabling community health centers and rural health clinics to lead ACOs.

NURSES AND THE FINAL RULE The final rule can be found at http://1.usa.gov/ tVUJdD. The ANA has praised its adoption of some of its recommendations and those of other nursing groups.8 For example, it explicitly enables the Medi­ care beneficiary to continue to receive primary care from an NP or clinical nurse specialist within the ACO. In addition, “qualified health professionals,” including RNs, may act as leaders in quality assur­ ance and process improvement initiatives within the ACO—a change from earlier language that only au­ thorized physicians in this role.

The ANA’s take. According to ANA president Karen A. Daley, the “CMS has strengthened the plan outlining how accountable care organizations will operate by recognizing the crucial role of nurses as primary care providers and care coordinators in this health care delivery model. ACOs must be more than just a business structure for compensating members of the health care team, but a means to achieve the larger goal of providing true patient­centered care that is essential to improving quality and reducing costs.”8

Concerns about NP autonomy. However, the CMS did reject a recommendation from nursing groups that a “qualified health professional” could lead the clinical management and oversight of an ACO; the final rule says that a “full­time senior

Nurses are likely to have key roles in

ACOs as leaders, managers, clinicians,

and care coordinators.

[email protected] AJN ▼ February 2012 ▼ Vol. 112, No. 2 25

level medical director” is required for this key ACO leadership position. As Penny Kaye Jensen, presi­ dent of the American Academy of Nurse Practi­ tioners (AANP), told me in an e­mail, the “AANP has continued concerns over the fact that patients of NPs cannot be assigned as beneficiaries in this pro­ gram. It is important that this flaw be corrected and that NPs be at the table in the development and im­ plementation of ACOs.”

In response to the final rule, the ANA also urged the CMS to further improve Medicare ACOs “by creating processes and incentives that specifically recognize and measure nurses’ integral contribu­ tions to improvements in quality of care and care coordination.”8

A BUNDLED PAYMENT MODEL Medicare ACOs are expected to begin in January 2012. In addition, the new law allows states to es­ tablish ACOs to manage pediatric care under a Med­ icaid demonstration program. Other activity at the state level includes expanding the ACO model be­ yond Medicare. For example, in Massachusetts, policymakers expect to consider legislation filed by governor Deval Patrick that will encourage the de­ velopment of ACOs for privately insured individu­ als of all ages and change how public and private insurers pay health care providers—replacing fee­ for­service payments with a “global” or “bundled” payment system.

The predominant fee­for­service payment system rewards health care providers for providing more health services, even when they’re not always neces­ sary. In many ACO models, bundled payments would supplant this piecemeal and inefficient system. The insurer would pay the provider a set amount to cover most aspects of the patient’s health care and reward providers if certain quality goals are met. These are strong incentives to coordinate care, reduce medical errors, and improve patient outcomes.

Isn’t this just managed care by another name? Yes and no, according to proponents of redesign. While the managed care movement in the 1990s was also an attempt to move away from the fee­for­ service model and provide incentives for care deliv­ ery within a fixed budget, the ACO model offers some significant differences. A backlash directed at managed care was partly based on inadequate pay­ ments that did not take into account the higher cost of serving a sicker population. Because of advances in health information technology and better quality measures, payments to ACOs will be more appropri­ ately adjusted for risk. The hope is that, compared with managed care’s capitated approach to pay­ ment, this model will offer providers less incentive to

withhold care, allowing the ACO more freedom to focus on what the patient needs to stay or become healthy.

For example, someone in the ACO may decide that the older adult who lives at home without air conditioning and has been hospitalized repeatedly for respiratory problems during the hot summer months will be best served if the ACO buys the pa­ tient an air conditioner to reduce more costly ED visits and hospitalizations. In addition, quality out­ come measures could be tied to higher payments— the ACO can be rewarded for providing better care.

AN EVOLVING MODEL Across the country, providers are joining together to experiment with ACO models. While they may differ in structure, they are all designed to deliver high­quality health care in a more cost­effective way. Descriptions of five thriving ACOs operating from Arizona to Massachusetts can be found in a report prepared for the 2010 Massachusetts Health Policy Forum, at http://bit.ly/uFzBZ6.

Physicians and their professional medical soci- eties are heavily engaged stakeholders in the design and implementation of ACOs and are leading the way in shaping policy related to payment and deliv­ ery reform. In addition, many currently operating ACOs are physician­led organizations or group practices.

Will nurses be heard? While the ANA and other nursing groups have weighed in with the CMS about the rules for Medicare ACOs, and recognize both the opportunity and peril for nursing in a redesigned system, it is not clear what impact nursing is having on policy development at the state level or at the organizational level as providers develop linkages with other providers to establish ACOs. For exam­ ple, in Massachusetts, physicians, insurers, health care executives, unions, and even a consumer advo­ cacy group have dominated stakeholder discussions, and there is every indication that these groups will continue to be powerful players in future delibera­ tions on payment reform and the development of ACOs.

ACOs are designed to deliver

high-quality health care in a

more cost-effective way.

POLICY & POLITICS

A recommendation of the IOM’s Future of Nurs­ ing report is that nurses must5

• make “significant improvements in public and institutional policies at the national, state, and local levels to improve health and health care.”

• foster interprofessional collaboration, so they “can act as full partners with physicians and other health care professionals in conducting re­ search and redesigning our health care system.” The Robert Wood Johnson Foundation’s Cam­

paign for Action and its development of Regional Access Coalitions to “ensure a prepared and effec­ tive health care workforce” hold promise in the fur­ ther development of nursing political leadership to ensure that nursing is “at the table” in system rede­ sign initiatives such as the emerging ACO model of care.5 The time is now for nurses and nursing orga­ nizations to engage at the federal, state, and organi­ zational levels and be effective leaders and advocates for patient­centered, cost­effective, and high­quality health care. ▼

Mary Ann Hart is the graduate program director in health ad ­ ministration at Regis College, Weston, MA. Contact author: mary. [email protected]. The author has disclosed no potential con flicts of interest, financial or otherwise.

REFERENCES 1. U.S. Congress. Patient protection and affordable care act

(enrolled bill [final as passed both House and Senate]— ENR). Washington, DC; 2010.

2. Berwick DM. Launching accountable care organizations— the proposed rule for the Medicare Shared Savings Program. N Engl J Med 2011;364(16):e32.

3. Schneider CD. Accountable care organizations 101: a primer. Massachusetts medical law report 2011 Jan; 8. http:// mamedicallaw.com/wp­files//medlaw_jan2011_mmlr.pdf.

4. Weston M. Medicare program: request for information regarding accountable care organizations and the medicare shared saving program. American Nurses Association; 2010. http://www.nursingworld.org/comments.

5. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 2011. http://www.nap.edu/catalog.php?record_id=12956.

6. Centers for Medicare and Medicaid Services. Medicare program; medicare shared savings program; accountable care organizations. Federal Register vol 76, no 212 2011 67802­990.

7. Weston M. Medicare program: medicare shared savings pro­ gram: accountable care organizations. American Nurses Asso­ ciation; 2011. http://www.nursingworld.org/ACOcomments.

8. American Nurses Association. Final ACO rules adopt ANA’s recommendations on nursing leadership, patient­ centered care [press release]. 2011 Oct 25. http://nursing­ world.org/FunctionalMenuCategories/MediaResources/ PressReleases/2011­PR/ACO­Rules­Adopt­ANAs­ Recommendations.pdf.