Managed And Accountable Care

QUESTION

In what ways does the Managed And Accountable Care MCO manage cost, and does it do so without diminishing the quality of care? How would your future role as an APN/APRN interface with the MCO?

In what ways does the ACO manage cost, and does it do so without diminishing the quality of care? How would your future role as an APN/APRN interface with the ACO?

Instructions: This is a discussion post, so a page to 1 1/2 pages is enough. APA format. Please use 3 references. Has to be at least three.

ANSWER

Introduction

Healthcare models such as Managed treatment Organisations (MCOs) and Accountable Care Organisations (ACOs) are created to control costs while preserving or enhancing the standard of treatment. This discussion will examine how MCOs and ACOs influence spending and how it affects the standard of care. It will also look at how advanced practice nurses (APNs/APRNs) will interact with MCOs and ACOs in the future.

Managed Care Organizations (MCOs)

Cost Management

a. MCOs use prior authorization, pre-certification, and utilization review to ensure proper and cost-effective healthcare service utilization.

b. Provider Networks: MCOs form agreements with a network of healthcare providers, enabling them to keep expenses in check through negotiated reimbursement schedules and subsidized rates.

c. Case Management: MCOs use case managers to coordinate care, find affordable substitutes, and avert unneeded hospital stays or readmissions.

Quality of Care

 a. Quality Metrics and Incentives: To ensure that the quality of care is not compromised, MCOs implement quality measurements and incentivize providers to reach or surpass these metrics.

b. Disease Management and Preventive Treatment: To improve outcomes and lower long-term costs, MCOs put a strong emphasis on managing chronic illnesses, encouraging preventive treatment, and providing wellness programs.

c. Care Coordination: MCOs strongly emphasize care coordination between healthcare providers to enhance patient safety, improve communication, and optimize care delivery.

 

Future Role of APNs/APRNs with MCOs

Future interactions with MCOs as an APN/APRN may include:

• Developing and implementing evidence-based guidelines and practices with MCOs to provide effective and affordable care.
• Taking part in utilisation management actions to guarantee the proper use of healthcare resources, such as prior authorization and utilization review.
• Coordinating care to improve communication and continuity of care amongst different providers within the MCO network.
• Assisting in the creation and execution of programmes for quality improvement and result metrics that align with MCO goals.

 

Accountable Care Organisations (ACOs)

Cost Management

a. Care Coordination: ACOs strongly emphasize care coordination among various healthcare providers to eliminate wasteful testing, cut down on duplicative procedures, and streamline care delivery to cut costs.

b. Financial Incentives: ACOs put in place shared savings programs that pay providers for reducing costs while keeping or raising quality results.

c. Health information technology: To find cost-saving opportunities, improve care coordination, and boost efficiency, ACOs use electronic health records and data analytics.

Quality of Care

a. Performance Metrics: ACOs provide high-quality performance metrics and measures that motivate providers to hit milestones for patient outcomes, preventative care, patient satisfaction, and care coordination.

b. Care Management: ACOs employ treatment managers to coordinate patient care, smooth transitions, and promote self-management, raising the calibre and consistency of treatment.

c. Patient-Centered Approach: To improve the patient experience and support better health outcomes, ACOs place a high priority on patient engagement, shared decision-making, and personalised care plans.

Future Functions of APNs and APRNs in ACOs

Future interactions with ACOs as an APN/APRN may include:

• Collaborating with the ACO leadership to create and implement performance indicators, care management techniques, and evidence-based recommendations to improve outcomes and save costs.
• Taking the helm of or contributing to care teams to deliver thorough, well-rested, patient-centered care within the ACO model.
• Utilizing health information technology, making data-driven decisions, and taking part in quality-improvement projects to improve how care is delivered and resources are used.
• We should encourage patient education, self-management, and collaborative decision-making to increase patient engagement and improve health outcomes.

 

Conclusion

Both MCOs and ACOs use a variety of tactics to control spending while maintaining or raising the standard of care. While ACOs emphasize care coordination, financial incentives, and health information technology, MCOs emphasize utilization management, provider networks, and care coordination. Future responsibilities for APNs/APRNs include:

• Working with these organizations.
• Participating in quality- and cost-improvement programs.
• Providing patient-centered care within the relevant models.

 

References:

J. Goldsmith, E. Dietrich, and others (2020). controlled care. Middle Range Theory for Nursing, 4th ed., S. B. Peterson, T. S. Bredow, and N. I. Abu Al Hamayel (Eds.), pp. 465–479. Publishing house Springer.

D. D. Maeng, S. R. Snyder, and P. B. Batalden (2019). Lessons from early ACOs on the value-based accountable care organization. 381(19), 1798–1800, New England Journal of Medicine.

J. M. McWilliams (2017). Medicare shared savings program savings changes between 2013 and 2014: Variations by a financial calculation method. JAMA, 317(16), 1677-1679.