Are you prepared to lead ACOs from the rear?

A fortnight ago, darkness began to engulf us because of early fall sunsets. We need to be very careful that the same thing does not happen in our professional lives.

Last year, CMS issued final regulations governing Accountable Care Organizations (ACOs) under Medicare. These final regulations recognize hospitals, primary care practices, federally qualified health centers (FQHCs), and rural health centers as qualified entities to form ACOs. They do not, however, recognize behavioral healthcare provider organizations as qualified entities. The Coalition for Whole Health objected strenuously to the exclusion of mental health and substance use care entities in its response to these intermediate final regulations; these comments were not heeded by CMS in the final regulations.  Now, we need to be concerned how Medicaid will handle ACOs created to develop health homes.  

This Medicare exclusion does not prohibit mental health and substance use care organizations from being included as part of an ACO. Yet, it does prevent them from forming ACOs to create health homes led by behavioral healthcare entities.

These restrictions create additional obstacles for the mental health and substance use care fields under the Affordable Care Act. However, they are not insurmountable. In military culture, soldiers frequently are placed in circumstances where they are “forced to lead from the rear”. This means that circumstances have arisen in which the nominal unit commander is not actually in charge, but rather the unit is being led by underlings who are more knowledgeable about current field conditions. Leading from the rear will be required as behavioral health entities confront the circumstances created by the new ACO regulations.

Several primary strategies are available to mental health and substance use care entities to lead ACOs from the rear. These include: 

• Becoming an FQHC, an FQHC Look Alike, or a rural health center. Numerous examples already exist where these developments are underway to promote care integration in a health home operated by a behavioral healthcare entity. The ACO regulations add considerable impetus to the need to expand these efforts rapidly.
• Create or purchase a qualified primary care practice. Efforts also are already underway to bring primary care physicians into behavioral healthcare entities to promote onsite integrated care. A logical next step would be to expand these fledgling efforts into a primary care practice, which could become the founding entity for an ACO. 
• Lead a public-private advocacy effort to create a county ACO. The founding ACO entity could be a county general hospital, a county health clinic, a county FQHC, etc. A county ACO has many things to recommend it, including the fact that the county could also bring its public health and social services departments into the ACO. 
• Lead an effort to create a community cooperative. The public cooperative could partner with a qualified entity to create an ACO. This model has the potential to be led directly by community members, including peers who are service recipients.
• Develop a hybrid ACO. The hybrid ACO could include combinations of the arrangements outlined above. For example, a community cooperative led by peers who are service recipients could undertake the formation of an FQHC, which, in turn, could become the founding member of an ACO.

You might ask why we should be so concerned about our role in forming an ACO, especially if we can join one. The reasons seem pretty obvious: 

• First, although the primary care community cares for the majority of persons who receive behavioral healthcare, it has neither the knowledge nor the skills to care for persons with serious mental illness or serious substance use conditions. As a consequence, persons with these conditions are likely to be excluded from the service populations of an ACO led by a primary care entity, or they are likely to receive services of an inferior quality. Ask yourself: How many primary care entities understand person-centered care, recovery, or community re-integration?
• Second, in order to foster consumer choice in a reformed individual and small group insurance market, where virtually everyone will have personal health insurance, some ACOs should be led by behavioral healthcare entities. Leading from the rear is just no substitute for this.
• Third, we will need all of our current human resources and even more to cope with the expected 32 million newly insured persons beginning in 2014. This need becomes even more pressing if one considers the fact that more than 11 million of these persons will already have a mental illness or a substance use condition. ACOs led by behavioral healthcare entities can provide services and support to a significant segment of these persons with the most severe conditions.

Are you working on a local ACO? I hope so. It will prepare you for the coming dawn.