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Are ACOs just HMOs under a new acronym?

April 1, 2011
by H. Steven Moffic, MD
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-“It’s déjà vu all over again”
Yogi Berra

By now, I’m sure you’ve heard about Accountable Care Organizations (ACOs). Touted as healthcare reform’s hope for the future, they are supposed to control costs and improve quality. These are to be affiliations of healthcare clinicians and/or organizations, including integrated delivery systems, multi-specialty groups, hospital-based systems, and contractual networks.

Many in behavioral healthcare seem excited at the prospects, especially for more integration within primary care after being carved out over the last two decades.

But, just wait a minute, some of us old-timers might say! Doesn’t much of this sound like a reframing of Health Maintenance Organizations (HMOs), which evolved into all the varieties of managed care we’ve come to love and/or hate?

Let’s see:

  • A partnership responsible for the healthcare of a population? Check.
  • A lump sum payment to cover all the care? Check.
  • Keeping profits (whoops, that’s my editorial slip, as it’s deemed “savings”), for more cost-effective care? Check.
  • Preventive care? Check (at least in the original HMOs like Kaiser Permanente).
  • Mergers and alliances? Check (and already starting).
  • Higher insurance premiums? Check (and haven’t you already noticed?).
  • Some of the very same healthcare experts and policy experts who cheerleaded for managed care, such as Dr. Berwick, now head of the Center for Medicare and Medicaid Services? Check.
  • Transparent costs and quality information? Well, that might be new, though it was long promised in some managed care circles.

So, all this might be déjà vu for the rest of medicine, but what about those integrated medical homes that will supposedly include us? If history is any indication, we’ll still end up being excluded. Before behavioral healthcare was carved out of capitated contracts, there were many attempts at integration. I was involved in one of the federal grant projects for this in the late 1970s.
However, costs were higher, and stigma made many patients wary of seeing a mental health clinician in a primary care setting. Then again, if integration did work this time, what would happen to your current organization?

But wait! What about federally funded “Behavioral Health Centers (BHCs)? Now they’re talking about an acronym for us. These would be community mental health centers with the additional requirements of evidenced-based practice, wraparound services, and some integration with general medicine.

Now you’re talking! Unfortunately, however, this provision was dropped out of the “final” healthcare reform law, which was passed just about a year ago now. There is hope it will resurface, for this would truly be different than behavioral healthcare under managed care, as it would be a revitalization of community mental health centers and an expansion in the other direction, into overlapping medical care.
Call your political representative if you like this idea and let them know we are not fools.

Happy April Fools Day!


H. Steven Moffic

H. Steven Moffic

H. Steven Moffic, M.D. retired from the clinical practice of psychiatry and his tenured...

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