Do Organizations Forming ACOs Have Mental Health Providers?

To the Editor: Since passage of the Affordable Care Act, accountable care organizations (ACOs) have received significant attention in the quest to achieve the “triple aim”: better care and better health at reduced cost. As described by Berwick (1), ACOs are “groups of physicians, hospitals, and other health care providers . . . willing to assume responsibility for the care of a clearly defined population.” The Centers for Medicare and Medicaid Services (CMS) assigns a patient to an ACO when its physician members are the primary providers of the patient’s health care and then calculates an annual cost target for the ACO’s population. In the ACO “pioneer model,” for systems with the most experience offering integrated care, organizations are eligible for a larger share of the savings in return for also sharing financial risk (2).

ACO success will require special attention to the most high-cost, high-risk patients, many of whom have mental disorders (3). Yet ACOs are not required to include mental health providers, and of the 33 quality indicators, just one measure is related to mental health: presence of a depression screen and follow-up plan (4).

By linking financial success to population health and quality as opposed to simply fee-for-service volume, ACOs provide new incentives to improve care for patients with mental disorders (5). However, little is known about the impact of ACOs on patients with mental disorders or even whether ACOs include mental health providers. We aimed to describe the extent to which organizations that have formed pioneer ACOs have mental health providers and whether this has changed since they began operation in 2012.

Using the list of 32 CMS pioneer ACOs established in 2012 (2), we searched organization Web sites and ACO provider lists (available for 23 [72%]) to determine whether they included any mental health providers. We repeated the search for the 23 pioneer ACOs operating in 2014.

Of the 32 initial pioneer ACOs, 11 (34%) were organizations with no mental health providers. By 2014, nine organizations (six without mental health providers) had left the pioneer program, and one non–mental health provider ACO began to offer mental health services. Of the 23 current pioneer ACOs, four (17%) do not include mental health providers.

This is the first report to describe the proportion of Medicare pioneer ACOs that have been formed by practice groups without mental health providers. In the initial cohort, one-third did not include mental health providers; by 2014, this proportion had decreased to 17%. Given the small number of ACOs, it is not possible to determine whether this change over time is significant. Patients with mental disorders are particularly at risk of fragmented and poor-quality care, and thus they stand to gain significantly in successful ACOs. Likewise, ACO success may depend on the ability to manage these potentially high-cost, high-risk patients (5). Given the potential to improve the quality of mental health and medical care for these patients, it is critical to further characterize the interface between ACOs and patients with mental disorders.