History of MCO and ACO
Two distinct healthcare delivery models, Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs), have evolved to solve the difficulties in healthcare provision. These models emerged as a result of the need for payment schemes.
Managed Care Organizations
Since the 1970s, MCOs have been established to manage healthcare expenditures by regulating the healthcare delivery system and financing healthcare services. The MCO concept is built on cost reduction, accomplished by negotiating reduced costs with healthcare providers and limiting the use of healthcare services. Additionally, MCOs are created to provide services to various people, including individuals, families, and companies. Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS) plans are just a few of the healthcare options that MCOs provide to cater to the requirements of various populations.
Accountable Care Organizations
ACOs, on the other hand, came into being around the start of the twenty-first century in response to the demand for improved healthcare coordination and quality enhancement. ACOs are healthcare professionals collaborating to deliver coordinated, top-notch care to a specific patient population. These professionals may include doctors, hospitals, and other healthcare professionals. The foundation of ACOs is the accountability concept, attained by compensating healthcare providers for quality outcomes rather than the number of services rendered. ACOs, however, are designed to serve a specific patient group, such as Medicare enrollees or those with chronic illnesses.
Populations MCO and ACO Are Intended to Serve
Managed Care Organizations
MCO and ACO are made to cater to particular demographics. MCOs are designed to serve various clientele, including individuals, families, and businesses. Different populations are covered by MCOs depending on the healthcare plan type offered, such as HMOs, PPOs, and POS plans. HMOs are intended to help people and families who want full-service medical insurance and are willing to use doctors and hospitals in a specific network. On the other hand, PPOs allow more freedom in selecting a healthcare provider but at a higher price. POS plans balance cost and flexibility by combining the benefits of HMOs and PPOs.
Accountable Care Organizations
ACOs, on the other hand, ACOs are concentrated on offering coordinated, high-quality care to a particular patient population instead of providing treatment to a wide range of individuals. ACOs coordinate healthcare services, such as primary care, specialized care, and hospital services, to ensure patients receive the most suitable treatment. This helps to enhance the quality of care.
The demographics covered have changed since the commencement of these programs, and MCOs have widened their scope to serve a more extensive range of groups, including Medicare and Medicaid members. ACOs have been developed to suit a variety of groups, including individuals with multiple chronic illnesses and those with chronic diseases. Additionally, the emphasis of ACOs has changed from cost-cutting to quality enhancement and population health management.
Role in the Critical Care Area of Nursing Practice
As a critical care nurse in a specialized practice area, I play a vital role in advocating for patients enrolled in MCO or ACO programs. A crucial component of my job is assisting patients in understanding the complexity of their health insurance policies and how to receive the care they require effectively. This may include teaching patients about their coverage’s benefits and limits, assisting them with the referral process, and working with other healthcare practitioners to ensure appropriate care.
As part of my job, I assist patients in managing their chronic illnesses to avoid needless hospital stays or trips to the emergency room. Order Creating care plans suited to the patient’s particular requirements and preferences. This may entail collaborating closely with MCO or ACO case managers. I can assist patients in sticking to their treatment regimens and achieving improved health results by offering continual monitoring and assistance.
Working with patients who are participating in MCO or ACO programs, however, has the potential to provide additional issues. For instance, there can be a contradiction between the organization’s financial incentives and the healthcare provider’s aims. The quality of treatment and patient outcomes may be jeopardized in some situations due to pressure to restrict the amount or kind of care given to patients. Even in the face of these difficulties, I must stay watchful and fight for the interests of my patients.
Nursing Contributions in ACO and MCO Programs
In conclusion, Accountable Care Organizations (ACO) are intended to serve a specific patient population, such as Medicare beneficiaries or patients with chronic diseases. In contrast, Managed Care Organizations (MCO) are meant to suit a variety of populations, including individuals, families, and employers. Since the start of these programs, the populations that MCOs and ACOs serve have changed, reflecting alterations in patient needs and healthcare delivery. Nurses are also crucial in supporting patients participating in MCO or ACO programs. We can help patients get the required treatment and improve their health outcomes by offering information, coordination, and continuing support.
Reference
DeCamp, M., Dukhanin, V., Hebert, L. C., Himmelrich, S., Feeser, S., & Berkowitz, S. A. (2019). Patients’ views about patient engagement and representation in healthcare governance. Journal of Healthcare Management, 64(5), 332–346. Web.