ACOs not shown to improve mental health outcomes: study

Accountable care organizations do not positively influence treatment and outcomes for chronic mental health conditions for Medicare patients, according to a study in Health Affairs.

For patients newly enrolled in ACOs, they saw no improvements in their depression and anxiety symptoms after one year. These patients were also 24% less likely to have their depression or anxiety treated than patients unenrolled in ACOs, and 9.8% less likely to have an evaluation and management visit for depression or anxiety with a primary care clinician.

Since mental health conditions in Medicare patients are often underdiagnosed and undertreated, some have suspected that mental health illnesses are ideal conditions for ACOs to handle, but the study found that there were no significant differences in any other measures of mental health treatment.

“ACO enrollment was not associated with any other differences in ambulatory mental health treatment, including antidepressant prescribing or visits to mental health specialists,” the study reads. “Perhaps most notably, ACO enrollment was not associated with any discernible improvements in patient-reported depression or anxiety symptoms at twelve months, which is especially concerning in light of the lower rates of ambulatory mental health treatment in this new ACO enrollee group as compared with the non-ACO group.”

Patients enrolled in ACOs with depression or anxiety had a more favorable risk and functional health risk profile, as well as were less likely to live in rural areas versus patients not enrolled in ACOs.

The study noted that while recent requirements from Medicare may lead to higher rates of depression screenings and follow-ups, those screenings may not result in desired mental health treatments like patient referrals to psychiatry and psychotherapy visits. Quality scores given to ACOs through the Merit-based Incentive Payment System are also not shown to be tightly correlated with “actual quality of patient care delivered in that setting.” Other physicians have expressed doubt that value-based payment measures improve care enough to justify the increased administrative burden.

“If patients and their providers, especially those from marginalized communities, perceive (perhaps correctly) that their values and needs are not a priority within the program, then one consequence may be continued exodus from traditional Medicare to the Medicare Advantage program,” the study added.

It called for policymakers to better monitor mental health treatment by ACOs by designing incentives differently, suggesting for an update of the CMS-HCC risk adjustment and payment model. Moreover, the establishment of mental health provider network adequacy standards, by increasing Part B payment rates for providers, could also expand the supply of mental health providers that contract with ACOs.

The researchers, from Yale, Harvard, Emory, Saint Louis University and Washington University in St. Louis, used data from the 2016-2019 Medicare Current Beneficiary Survey linked to depression and anxiety symptom instruments for diagnosed and undiagnosed fee-for-service (FFS) Medicare patients.

Approximately 13 million beneficiaries are enrolled in Medicare ACO. The model is growing in popularity as it intends hold providers accountable for spending, in turn helping providers focus on patients with severe or acute medical needs, instead of overlooking patients because they have complex needs, the study said.