ACOs: What Do They Mean for Nurses?
Accountable care organizations (ACOs) are an up-and-coming part of Medicare reform and the Affordable Care Act; they rolled out in January of this year, but for some reason I just now heard about them. I don’t know about other nurses, but I feel like if I stand still long enough, I’ll get hit by another new Medicare reimbursement headache, so perhaps I just tuned it out. At any rate, I’m hearing from the physicians I know personally that ACOs are a headache so far, but I had to do some research into what they mean for nursing.
What are ACOs? They are groups of providers similar to HMOs, as a starting place for understanding how they work, but there are some major differences. Possibly the most important difference to consumers is that patients can choose providers outside the ACO, thus avoiding the dreaded HMO network provider crunch. ACOs also assume financial risk, because emphasis is placed on value, as opposed to the longstanding traditional fee-for-service paradigm in which providers/hospitals make more money the more tests they order and the more procedures they do. However, because they assume financial risk, ACOs can also lose money if patients have bad outcomes.
How will ACOs affect nurses? Advanced practice nurses may be vastly affected because they can be “primary care providers” for an ACO, and ACOs may give them more inroads to plan patient care and affect patient outcomes. As for us regular RNs, the best I can tell is that no one is sure yet. The ANA was concerned about many facets of the ACO provisions as originally set forth and published a position paper on the subject; however, a later post on news.nurse.com indicates that the ANA’s concerns resulted in changes. (I cannot resist this chance to point out that ANA does in fact do actual important work for us regular nurses out there on the floor…join and support them, please!) It is not clear to me whether only the suggestions related to advanced-practice nurses were incorporated.
The ANA’s concerns were numerous, but I cherry-picked the ones that also concern me most, in case readers don’t want to devour the whole ANA paper. ACOs leave out the nurse’s role of patient care planning (leadership is “exclusive to physicians”), a core nursing skill; this oversight will almost certainly result in adverse cost effects, because nurses have repeatedly shown a unique ability to find ways to save money by doing more with less. We are an inventive and thrifty bunch. Also, currently ACO “care coordinators” cannot be RNs. Who better to coordinate patient care than professionals who have been extensively trained in the nursing process and orchestrating patient care? Also, speaking of patient care, the ANA expressed concerns that the required, apparently extensive, ACO documentation may detract from patient care. Probably any working nurse already feels the crunch of the additional required rules, regulations, and documentation for reimbursement these days—we don’t need any more. Finally, ACO reimbursement is based on value, but patients may not follow their prescribed plan of care, and providers cannot control this. This financial backlash will certainly trickle down to nurses even if we are not directly reimbursed providers. As an example, my provider may tell my obese, diabetic, alcohol COPD-er to lose weight, control her blood sugar, and quit drinking, but if she does not do that and has a poor outcome, the ACO will lose money and I may get a reverse raise.
ACOs are going to be a big deal. I’ve just scratched the surface in this post, but I encourage readers to look up some information on them. As nurses, we still probably have an opportunity to get our feet in the door and make some last-minute changes if we work together.
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