The Affordable Care Act.
Subject: Medical law (Economic aspects)
Author: Hixson, Ronald
Pub Date: 03/22/2012
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2012 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Spring, 2012 Source Volume: 15 Source Issue: 1
Product: Product Code: 9105280 Health Regulation NAICS Code: 92615 Regulation, Licensing, and Inspection of Miscellaneous Commercial Sectors
Organization: Government Agency: United States. Department of Health and Human Services
Accession Number: 282741123

Under President Obama's leadership, Congress passed the Affordable Care Act that focuses on the needs of patients by developing a system to categorize symptoms in a manageable and cost effective process. This Act links reimbursement rates with outcomes, as measured by success or failure of treatment plans, in addition to the costs of treatment. Under the guidance of the Department of Health and Human Services (HHS), the Accountable Care Organizations (ACOs) develop incentives for health care service providers to work in concert with other providers from primary care physicians, including mental health specialists, hospitals, and facilities of long-term care. HHS promises to award ACOs for maintaining or lowering the expansion of health care costs while maintaining quality care.

The first problem is that statistics by HHC suggest that half of Medicare patients are disabled or inflicted with five or more chronic diseases and/or disorders, which often include diabetes, arthritis, hypertension, kidney disease, and depression. In addition, patients often see several providers. HHC concludes that there is a failure to coordinate patient care, which can lead to duplicate services, and may offer an opportunity for medical errors. Each year one in seven Medicare patients that were admitted to a hospital have been subjected to a medical error, and nearly one in five Medicare patients discharged is readmitted within 30 days. The ACOs are touted to be the force that harnesses coordinating providers and eliminates or decreases medical errors while maintaining quality care at lower costs. HHC reports that with ACOs, Medicare can save over $960 million over three years (, 2011).

ACOs are what many view as the solution to the current inflexible, and often expensive, healthcare system. Organizations are now encouraged to form partnerships, joint ventures, associations, or expand their services and staffs in order to control costs and services. The goal is to create a regional patient-centered organization in each state that covers all patients and providers. The structure will include group practices, networks of individual practices of ACO professionals, partnerships, joint ventures (hospitals, county medical associations, or group practices), and other Medicare providers and suppliers as determined by HHC. The Act requires each ACO to include health providers, suppliers, and Medicare beneficiaries on its government board, and each ACO must take responsibility for over 5,000 patients and maintain their care for over 3 years. The ACOs would be entitled to share savings only when the savings exceeds minimum sharing rate. Other formulas for shared savings, as well as shared losses, have been developed but are less clear. One of the concerns is that there will be more audits from governmental agencies (state and federal) to monitor the improvement in care to include tools and techniques to collaborate, and to document progress of treatments and efficiencies in referrals. This could also put pressure back on patients, who habitually come to the office late or forget appointments. Threats of withdrawing federal Medicaid and Medicare funding from ACOs and/or providers that are not part of a coordination of services, who fail to have a system to verify referrals sent and received, and who are not documenting "no-shows" and reporting them in the patient files may face some type of loss of insurance funding. While the larger metropolitan communities are ahead of rural communities, the educated guess is that all providers, no matter where they practice, will be expected to show compliance. This system of rearranging the health care delivery system is awkward, confusing, and may be more costly, at least in the transition period. The next 12 months will hopefully offer much more clarification and guidance for all health care providers and institutions.

Over the past 15 years mental health providers have generally felt that they have been left out of the loop when it came to reimbursement and covered services offered to insured populations. The Act promises to make mental health a vital member of the health care industry and will include taking action against ACOs and providers for not referring to specialists when medically appropriate. Such is the case for panic attacks. Many patients are habitually turning to emergency rooms (ERs) to obtain medicine for an attack. Frequent visits to the ER are going to be a red flag. This could mean that an auditor will challenge the ER physician, or the ACO, for not doing more to stop panic attack patients from the use of the ER as the only way to deal with their anxieties, especially when psychotherapy sessions are cheaper then ER visits. Another possible example are patients taken to the ER for suicidal gestures. The ER physician will have to show that he/she referred him to a local provider and the records will need to reflect that the provider received the referral. Then the provider will be challenged to provide what, when, how, and why of their actions. For all providers there is a growing need to have a system of communication that will provide evidence of the coordination process. At the present time patients can be referred, but the referring therapist or physician may not have any idea if the patient ever got there. In many cases the beneficiary of the referral may treat the patient for 6 or 8 sessions before sending a letter to the referring source with a letter documenting diagnosis, treatments used, frequency of treatment, and prognosis. This process of communicating is being challenged by the Act. Measuring quality improvement involves five areas of patient care:

* Patient/caregiver experience of care

* Care coordination

* Patient safety

* Preventive health

* At-risk population/flail, elderly health (, 2011)

A second problem is that there is no one set of measurement tools and techniques that has general consensus, or approval, from either educational researchers, professional associations, or providers. This could open the door for MCOs and HMOs to become our auditors. A better approach would be for providers to find a system and meet the standards of the Act, and also improve the interaction between patients and providers that can be easily and quickly documented. Sharing of health care information is a topic of high priority in conference rooms across the nation. While physicians have been targeted by HIPAA and Congress to improve their electronic abilities, physicians have viewed it as an intrusion more than a legal responsibility. This is changing with all the focus on ACOs. Psychologists, psychotherapists, and social workers would be well advised to develop their electronic billing and communication system to meet the needs generated by the Act and the development of ACOs. Those therapists that can go to providers and hospitals with proof that they have a system that will respond quickly to referral sources, and that their treatment programs have tools to measure progress, will not only generate more referral business but will protect their agency when audited. Such models include that offers ways to meet HIPAA standards while improving compliance techniques in coordinating health care and case management.

Improving quality care begins with cutting through the maze of fragmented and disconnected health care services with its multiple charts, duplicated procedures, and loss of time and energy in attempting to gain access to quality care. The argument is that health care services can have added value when there is more communication and coordination between providers who are closer to the patient and his/her family. This goal may also improve the attitude of patients who often enter services and hospitals feeling isolated and not involved with their own care decisions. By forcing doctors to talk to each other, the assumption is that the patients would be exposed to more information and gain a greater sense of decision ownership. A possible corollary may occur in the treatment process where patients are being asked to accept more responsibility in their care and to depend less on the system or social acquaintances at the mall. Patients are said to have the choice of providers, and to have access to information about how well their doctors and hospitals are performing when compared to national quality standards. While these standards may not be standardized at this point in time, we can be assured that there are various sources offering suggestions for their creation and distribution. While this sounds logical, there may be a number of unseen, unknown factors that could create problems when generalized over the entire population, disorders, and diseases. This may handicap seasoned professionals more than new graduates, and it is unclear who and how these standards will be applied and enforced. Given the current managed care system, where the state takes enforcement and judicial roles to enforce corporate rules of practice, there may be an opportunity for better communication between ACOs and individual providers in the future, whereas current communications are practically non-existent. In addition, while state boards of examiners remain in the pocket of governors, ACOs may find a better way of handing ethical issues. Local cultures, traditions, and professional preferences of treatment are areas still left for later discussion. Other issues needing further work include the antitrust laws (Federal Trade Commission, 2012) and the handling of the business of health care as other business entities now trading on Wall Street. A National Quality Strategy was established last year, but its tools and techniques are yet to be developed and discussed. The Act established a Center for Medicare and Medicaid Innovation which will continue to research the effectiveness of innovative care and current service delivery models. Some have suggested that the results may lead to alternative payment models for ACOs.


The solutions are not simple nor will they come easily. There will be pain with the transformation. Today we speak of millions needing and wanting quality care. Tomorrow there will be billions, not just in America, but globally. What happens in America will be demanded in every country in the world. As an industry run by Wall Street firms one must be aware of what they see in the future. During the next two decades the transition from an American industry to a global industry will converge in the marketplace. A scenario that has never been imagined will come knocking at the doors of government agencies, graduate schools, or within professional associations. Over the next decade looms a rapid economic development in emerging markets that will have the capacity to wipe out all of the current reserves in products and create a huge demand for products and services which will not only keep the fire of reform on the center table, but this will force other American industries to change in order to meet the needs of "up to three billion people (and their spending power) that will be added to the global middle class" (Dobbs, Oppenheimer, and Thompson, 2012). Sometimes putting things into a different perspective can offer a new vision, thus giving us all pause to reflect on our own roles and goals. The whole concept and utility of value are changing; we have the opportunity to contribute to that reformation.


Accountable Care Organizations (2011). To read the Notice of Proposed Rulemaking for ACOs, visit (Accountable Care Organizations--Notice of Proposed Rulemaking on Accountable Care Organizations); also available is the press release:

Dobbs, R., Oppenheim, J., Thompson, F., (2012). Mobilizing for a resource revolution. McKinsey Quarterly, January,

Federal Trade Commission (2012). Statement of antitrust enforcement policy regarding Accountable Care Organizations participating in the Medicare shared savings program. (2011). la.html) (2012).

by Ronald Hixson, PhD, LPC, LMFT, BCPC

RONALD HIXSON, PhD, LPC, LMFT, BCPC, is a licensed psychotherapist in private practice on the Texas-Mexico border. His background includes 10 years in the military mental health field (substance abuse, crisis center, community mental health, and teaching), and for the past 23 years, he has worked in an inpatient psychiatric hospital, a biofeedback outpatient clinic, an outpatient group practice, and then in private practice. His graduate degrees are in communication studies, psychology, business management, and health care administration. He has been a regular columnist for Annals, the quarterly journal for the American Psychotherapy Association, for the past seven years. He has served as chairman, Board of Professional Counselors, the Executive Advisory Board for the American Psychotherapy Association and is a board member of the American Mental Health Alliance. He is a trained hypnotherapist and a licensed sex offender treatment provider in Texas.
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