Health care transformation and comparison of the ACO and PCMH

Health care transformation and comparison of the ACO and PCMH

ASSIGNMENT: Discuss about how healthcare is transforming in an effort to provide high quality, more cost-effective care.   Discuss how Policy makers and providers are under increasing pressure to find innovative approaches to achieving better health outcomes as efficiently as possible. Include discussion about Accountable care organizations (ACOs) and the Patient centered medical homes (PCMH) to achieve this goal. Compare the 2 organizations and states how different they are, although they have similar goals. Please provide a brief conclusion at the end of the paper. (kind of summarize first article including information highlighted, then briefly discuss and compare ACOs & PCMH. Please provide a well organized paper. NO MORE THAN 2 PAGES)

“The ACO and Patient Centered Medical Home (PCMH) are both models which strive to improve coordination of are while concurrently slowing spending.  They both support use of electronic health records, patient registries and ongoing quality improvement”

“While the goals of both models are very similar in improving care coordination and access to specialties they are somewhat different in how they deliver care and track outcomes”.



  1. McClellan, M., Udayakumar, K., Thoumi, A., Gonzalez-Smith, J., Kadakia, K., Kurek, N., . . . Darzi, A. W. (2017). Improving care and lowering costs: Evidence and lessons from A global analysis of accountable care reforms.Health Affairs, 36(11), 1920-1927. DOI:10.1377/hlthaff.2017.0535

Policy makers and providers are under increasing pressure to find innovative approaches to achieving better health outcomes as efficiently as possible. Accountable care, which holds providers accountable for results rather than specific services, is emerging in many countries to support such care innovations. However, these reforms are challenging and complex to implement, requiring significant policy and delivery changes.

With advances in treatments to extend life and combat disease among aging populations and with the growing number of people with treatable and preventable chronic diseases, health care spending has increased in recent decades and is expected to continue to rise.1 Policy makers and health leaders worldwide are under pressure to provide access to high-quality care at a cost that is affordable to consumers and taxpayers. A broad range of innovations in care delivery holds the potential to improve care outcomes while lowering costs. These innovations include the use of multidisciplinary teams; shifts to less costly sites and treatment methods; the use of data analytics and patient engagement to support treatment adherence and behavior change; and the integration of social, community, and medical care to address the root causes of high utilization. However, traditional payment models, regulations, and other policies often fail to provide sustainable support for such innovations. For example, volume- and provider-specific payments, such as fee-for-service payments within fixed budgets, do not pay for or incentivize many of the investments needed to innovate.

Globally, accountable care has attracted increasing attention as a way to address the adverse financial and health consequences of policies that reward the volume, but not the quality, of medical services. We define accountable care as an arrangement in which "a group of providers... are held jointly accountable for achieving a set of outcomes for a defined population over a period of time and for an agreed cost." This can characterize a variety of arrangements besides "accountable care organizations," including primary care medical homes and arrangements for specialized populations that include accountability for patient results. Accountable care delinks reimbursement from volume-based or provider-specific payments and shifts the focus of regulations and other policies from particular providers and services to patient outcomes and resources use. This shift can enable providers to develop innovations in care such as mobile technologies that identify at-risk people before diagnosis and support patients' self-management once they have been diagnosed, health screening and promotion to reduce risk factors for people with chronic diseases, and evidence-based care pathways that efficiently link services together based on individual needs.

In the United In the United States, accountable care organizations (ACOs) have become a common form for operationalizing accountable care principles. ACOs, ranging from physician- or hospital-led groups and alliances to fully integrated health care systems. Over half of the ACOs are operating in the Medicare Shared Savings Program, which covers over nine million Medicare beneficiaries-representing an incremental shift from volume-based payment.  In addition to ACOs, the patient-centered medical home and bundled episode payment illustrate the shift from volume-based payment toward accountable care.9


  1. ***Miller, C. (2018). Accountable care organizations and occupational therapy.The American Journal of Occupational Therapy, 72(5), 1-6. DOI:10.5014/ajot.2018.725003

Accountable care organizations (ACOs) are organized networks or systems that provide services to Medicare beneficiaries under the Patient Protection and Affordable Care Act of 2010 with an emphasis on chronic care management. ACOs were instituted under Medicare to achieve value-based purchasing as opposed to simply providing high-volume, fee-for-service care. ACOs must reduce annual care expenditures through Medicarecovered services. Occupational therapy services often play a role along the care continuum of an ACO.

What Are Accountable Care Organizations?

The Shared Savings Program of Section 3022 of the ACA put forward ideas such as public-private partnerships, trials ofepisodebased payment initiatives, and primary care transformation that are tested through a new federal component, the Center for Medicare and Medicaid Innovation (Medicare Learning Network, 2014). In Medicare, one particular idea, the development of ACOs, was seen as promising because of its success in the private market (CMS, n.d.). Implementation began in 2012 and has rapidly grown to encompass care for about one-third of Medicare fee-for-service beneficiaries, which excludes those in Medicare Advantage programs (Medicare Payment Advisory Commission, 2018, p. 215). At the start of 2018, 656 ACOs were recorded as having CMS contracts, an increase from 562 in 2017.

CMS (2018a) established ACOs to improve "coordinated care [by ensuring] that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors" (para. 2). Medicare beneficiaries are entitled to all Medicare benefits through an ACO (CMS, 2018b). The goals of ACOs were similar to the overall goals of the ACA and are summarized in the Triple Aim: Improve patients' experience of care, improve health overall, and, through this, reduce cost growth (Institute for Healthcare Improvement, 2018). As CMS (2018a) defined ACOs, they addressed each of the following:

* ACOs are groups of doctors, hospitals, and other health care providers who come together voluntarily to provide coordinated high-quality care to their Medicare patients.

* The goal of coordinated care is to ensure that patients get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors.

* When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, the ACO will share in the savings it achieves for the Medicare program.

The structure of the CMS ACO APM was not a new concept. Private groups began experimenting with similar innovative care models before 2011 in an attempt to reduce costs and improve outcomes. The original inspiration for the CMS ACO payment model included health care delivery systems modeled by the Mayo Clinic, Cleveland Clinic, Geisinger Health System, and Intermountain Healthcare (Gold, 2011). The ACO model resembles that of a health maintenance organization, but ACO beneficiaries do not have to stay within a specific provider network to receive care. Integrated health networks also resemble ACOs but are funded by private insurance payers.


Patient Centered Medical home (PCMH):

  1. ****Kazak, A. E., Nash, J. M., Hiroto, K., & Kaslow, N. J. (2017). Psychologists in patient-centered medical homes (PCMHs): Roles, evidence, opportunities, and challenges.American Psychologist, 72(1), 1-12. DOI:10.1037/a0040382

The concept of the Medical Home has evolved directly from the patient-centered care movement.

This model for care was devised to sustain the patient-provider relationship to encompass comprehensive, safe, and quality care.

The patient-centered medical home (PCMH) is a model that strives to provide patient-centered, comprehensive, team-based, coordinated, accessible, and quality and safety-oriented health care delivery to individuals and families. Patient-centered underscores the partnerships essential to the PCMH and a focus on respect for patients’ personal, family, and cultural backgrounds, and attention to care that has value to patients and families. The Triple Aim (improving patient experiences, promoting the health of populations, and reducing the per capita cost of care) exemplifies the paradigm shift that undergirds changes in health care and guides objectives in the PCMH.

2.****Howard, H. A., Malouin, R., & Callow-Rucker, M. (2016). Care managers and knowledge shift in primary care patient-centered medical home transformation.Human Organization, 75(1), 10-20. DOI:10.17730/0018-7259-75.1.10

One of the most significant transformations occurring in health care in the United States is the implementation of the patient-centered medical home (PCMH) model in primary care. Becoming a PCMH practice involves change on a number of levels from business performance reorganization to individual patient empowerment. The overall goals are improving care quality, cost effectiveness, and population health outcomes. A central objective of the PCMH model is to address the rising costs stemming from the escalation of chronic diseases. Primary care thus shoulders the double burden of preventing and managing rising chronic disease while also being responsible for lowering health care costs. Successful PCMH implementation projects demonstrate that they "offset the new investments in primary care in a cost-neutral manner and...produce a reduction in total costs per patient" (Grumbach et al. 2009:1 ). Cost reductions for employers and health insurers, measured through lower hospitalizations and emergency department visits, are significant drivers behind their investment in PCMH transformation projects. Yet, the prevention and management of chronic diseases such as diabetes are increasingly multifaceted. They involve many intersecting physical and social complexities and an exponential multiplication of technologies available to address them. In this context of increasing complexity, PCMH redistributes patient interaction from physicians to a range of other health care providers, and practice transformation involves the "empowerment" of patients as well as of non-physician clinical and other staff. A team approach to patient care seeks to release physicians from the overload of chronic illness management and administrative functions by devolving the time-consuming aspects of patient care, such as education and support (e.g., dietary and self-monitoring tasks of diabetes management), to other clinical staff. This is meant to encourage comprehensive patient care and pay off in business efficiencies and quality improvements.  The PCMH moment highlights the underlying social forces which impact health outcomes as health care providers are called upon to delve extensively into the personal lives of patients and engage with community resources to promote health education, lifestyle, and environmental changes.

This includes the notion of "partnership," for example, which is a central organizing concept in becoming patient centered. It is used to frame contact between the practice and patients, the teamwork of practice staff, and relationships with others in the medical neighborhood.

medical home is an approach to providing comprehensive primary care that facilitates partnerships between patients, clinicians, medical staff, and families. A medical home extends beyond the four walls of a clinical practice. It includes specialty care, educational services, family support and more.

Patient centered medical home

3.****Tuepker, Anaïs,PhD., M.P.H., Kansagara, Devan,M.D., M.C.R., Skaperdas, E., B.A., Nicolaidis, Christina,M.D., M.P.H., Joos, S., PhD., Alperin, Michael,M.D., M.B.A., & Hickam, David,M.D., M.P.H. (2014). "We've not gotten even close to what we want to do": A qualitative study of early patient-centered medical home implementation. Journal of General Internal Medicine, 29, 614-22. DOI:10.1007/s11606-013-2690-z

The patient-centered medical home (PCMH) has gained considerable traction as a proposed solution to persistent challenges facing US healthcare in general and primary care in particular.1–3 Defined by a focus on care that is team-based, data-informed, highly accessible, continuous, and coordinated across the spectrum of care, the PCMH is associated with positive outcomes for patients. Medical home features, such as enhanced patient access, improved scheduling, care provider continuity, and care coordination activities, have been associated with lower rates of avoidable hospitalizations and decreased Emergency Department use.