Over time, healthcare delivery has experienced substantial changes, with the rise of notable models such as Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs). With their unique histories, patient populations served, and financial models, MCOs and ACOs have radically changed the healthcare landscape; they have also brought attention to the complex relationship that exists between patient outcomes and financial considerations in these rapidly changing healthcare paradigms, and they have influenced the role that nurses play in providing high-quality, cost-effective care.
History of MCO and ACO
The idea of MCO emerged during the early 1900s when healthcare costs became a burden. According to Heaton and Tadi (2023), cost containment, quality improvement, and resource efficiencies necessitate a system-oriented healthcare delivery propelled MCOs. More importantly, with the emergence of health maintenance organizations (HMOs) and preferred provider organizations (PPOs) in the mid-20th century, the idea of managed competition has become prominent (Falkson & Srinivasan, 2023). The increasing rates of health care costs resulted from some reasons, for example, the aging population and technology improvements necessitating the new model. ACOs arose due to the fragmented healthcare delivery in the twenty-first century. The ACOs’ strategy was to address these problems by working with healthcare providers. This involves collaboration to achieve quality care and affordable costs (Eaton & Tadi, 2023). The direction of the ACO model is value-based care, through which providers are rewarded for offering integrated healthcare based on patients’ perspectives.
Identification of Populations Served by MCO and ACO
MCOs serve all categories of people with different healthcare needs. One of the large groups Media serves is employer-sponsored healthcare program employees (Heaton & Tadi, 2023). In this case, many MCOs encourage staff members to take charge of their health issues rather than having more costly measures afterward, such as medical checkups. In addition, most MCOs offer Medicaid users cost-efficient health care that caters to people in need. Another essential category is enrollees in Medicare Advantage. As Heaton and Tadi (2023) indicated, the MCOs provide such plans as the Medicare Advantage plans, which exceed basic Medicare benefits and often focus on wellness, care coordination, and preventative services. This fits well with the goal of MCOs, which is to reduce costs while ensuring quality services. Alternatively, ACOs aim to offer comprehensive and integrated healthcare for identified beneficiaries. One such group includes medicare beneficiaries. These seniors should have improved healthcare outcomes by promoting providers’ cooperation, aligning incentives, and a patient-centered approach (Lewis et al., 2019). In addition to private health insurance carriers, ACOs can offer their services to members of commercial health plans to capture a larger market share.
The Role of Nurses When Interfacing with MCO and ACO Clients
MCOs demand a diverse strategy from registered nurses with expertise in the orthopedic surgery room. According to Griffin (2019), nurses are essential in managing chronic conditions and implementing preventive care plans in MCOs. They work with doctors and other healthcare professionals to ensure that care is efficient and effective, making them vital care team members. The nurse’s responsibilities in orthopedic treatment within an MCO include teaching patients about preventive measures, enabling communication between the patient and the care team, and assisting with utilization review procedures (Griffin, 2019). Comprehensive postoperative care and rehabilitation are frequently necessary for orthopedic treatments such as joint replacements or reconstructive surgery. Clinical efficacy and cost-effectiveness are given equal priority in care plans developed and implemented by nurses working within the framework of MCOs (Griffin, 2019).
Conversely, as an orthopedic operating room nurse, an individual must align with comprehensive and coordinated treatment objectives while interacting with clients of ACOs (Karam et al., 2021). Nurses in ACOs are essential in patient education, prevention, and smooth care transitions. In an orthopedic context, this can entail talking to patients about what to expect before and after surgery, working closely with physical therapists, and ensuring that everyone on the care team knows the patient’s requirements and progress (Karam et al., 2021). As patient advocates, nurses work in both MCOs and ACOs to ensure the treatment meets each patient’s specific requirements. They act as a point of contact for patients and the larger healthcare team, helping to optimize the provision of treatment while taking advantage of the opportunities and limitations that each organizational model presents.
Impact of Financial Models on Patients and Nurses
The financial models of MCOs and ACOs greatly affect healthcare providers, particularly nurses. Cost containment is the key objective in most MCOs. Thus, particular patient restrictions apply. Some examples could include using a limited number of providers within the MCO network, utilizing the utilization review procedures to establish the need for certain procedures, or emphasizing preventive healthcare (Wilson et al., 2020). Patients may have to move through a system within an MCO where cost is key, which may result in fewer services or treatments. In this case, nurses must adhere to the MCO’s guidelines and ensure that patients receive proper care. Nurses have to balance affordable treatment and quality care to ensure that the patients remain happy.
However, financial models in ACOs shift towards value-based care and its implications on the quality of services for nurses and patients. ACOs also motivate healthcare professionals such as nurses to focus more on patient outcomes in general wellness. This shift aims to enhance the served population’s health outcomes, reduce unnecessary service duplication, and promote coordinated care. ACOs often take a coordinated and integrated approach to caring for patients’ healthcare journeys. Preventive measures, early interventions, and ongoing monitoring ensure a patient-centered experience. This makes it easier for nurses to render care using an integrated model (Wilson et al., 2020). It addresses emergent healthcare issues and teaches the public preventive health care, healthy lifestyle choices, and self-management.
On the other hand, nurses working in both MCOs and ACOs encounter a collision between clinical care and budgetary problems. In utilization review, they would fight for required services within a given budget, handle the MCOs, and be part of a larger care team to maximize the results (Lewis et al., 2019). Value-based care, therefore, requires nurses as an integral part of a collaborative and interdisciplinary approach. It includes engaging in care planning, patient education, and contact with other medical experts.
Conclusion
In conclusion, the development of MCOs and ACOs has significantly impacted the healthcare industry. However, health professionals, particularly nurses, should be aware of the influence of various financial options on nurses and patients because these organizations differ regarding their historical background, the populations they serve, and financial institutions. With the future evolution of the healthcare industry, nurses will need to adapt to these moves, advocate for patients, and help maintain healthy delivery models.
References
Falkson, S. R., & Srinivasan, V. N. (2023, March 6). Health Maintenance Organization (HMO). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554454/
Griffin, C. D. (2019). A Primary Care Nursing Perspective on Chronic Disease Prevention and Management. Delaware Journal of Public Health, 3(1), 78–83. https://doi.org/10.32481/djph.2017.03.011
Heaton, J., & Tadi, P. (2023, March 9). Managed Care Organization. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557797/
Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care, 21(1), 1–21. https://doi.org/10.5334/ijic.5518
Lewis, V. A., Schoenherr, K., Fraze, T., & Cunningham, A. (2019). Clinical coordination in accountable care organizations. Health Care Management Review, 44(2), 127–136. https://doi.org/10.1097/hmr.0000000000000141
Wilson, M., Guta, A., Waddell, K., Lavis, J., Reid, R., & Evans, C. (2020). The impacts of accountable care organizations on patient experience, health outcomes, and costs: a rapid review. Journal of Health Services Research & Policy, 25(2), 130–138. https://doi.org/10.1177/1355819620913141
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