Medicare ACO Enrollment Did Not Improve Mental Healthcare Outcomes

November 28, 2023 - Medicare beneficiaries newly enrolled in accountable care organizations (ACOs) did not see any improvements in their depression and anxiety symptoms, suggesting Medicare ACOs may need better incentives to improve mental healthcare, a study published in Health Affairs found.

ACOs are now the dominant care model in traditional Medicare, with around 13 million beneficiaries enrolled in a Medicare ACO as of 2023. ACOs help accelerate the shift to value-based care by tying physician payments to care quality.

The ACO model design should result in providers focusing on patients with complex conditions and those with conditions that typically have low reimbursement rates.

Depression and anxiety disorders are the most underdiagnosed, undertreated, and prevalent mental health conditions among Medicare beneficiaries and are often comorbid with other costly chronic conditions. Thus, ACOs may be suited to improve processes and outcomes for these mental health conditions.

Researchers used data from the 2016 to 2019 Medicare Current Beneficiary Survey to assess mental health treatment rates and changes in patient-reported mental health outcomes among beneficiaries newly enrolled in ACOs.

Among 11,410 patient-years with at least two years of continuous traditional Medicare enrollment, 89 percent were eligible for ACO enrollment. Three in ten of these patient-years had a diagnosed or undiagnosed depression or anxiety disorder.

The final sample included 2,450 patient-years with depression or anxiety. Across the sample, 10.8 percent of beneficiaries had probable undiagnosed depression and 21.2 percent had probable undiagnosed anxiety. Around 42 percent of beneficiaries were enrolled in an ACO at baseline, while 49.1 percent were enrolled in an ACO in the following year.

Beneficiaries enrolled in ACOs compared to those not enrolled were older, less likely to be dually enrolled in Medicaid, more likely to have supplemental private insurance, and more likely to have incomes above 200 percent of the federal poverty level.

New ACO enrollment in the following year was associated with a 12.2 percentage point lower likelihood (24.4 percent) of having an evaluation and management (E/M) visit with any clinician for depression or anxiety and a 9.8 percentage point lower likelihood (22.7 percent) of having an E/M visit for depression anxiety with a primary care clinician.

Additionally, there were no significant differences in changes in depression and anxiety symptoms by ACO enrollment status. ACO enrollment was not associated with changes in antidepressant prescribing or visits to mental health specialists, either.

Treatment improvements may hinge on better requirements in ACO programs that bring attention to specific mental health conditions, researchers said.

Medicare quality reporting guidelines now require depression screening and follow-up for beneficiaries whose scores indicate depression. This targeted approach may help improve screening rates, but whether it will enhance downstream mental health treatments like patient referrals to psychiatry visits is unknown.

Results from the Merit-based Incentive Payment System (MIPS) indicate that quality measure scores in primary care settings may not speak to the actual quality of care delivered to patients. Given these findings, ACO performance on mental health measures may not translate to better care quality. If quality measures in ACOs and other alternative payment programs in traditional Medicare do not incorporate beneficiaries’ values and priorities, they may not achieve the goal of improving care.

Policymakers should consider incentives that focus on mental health parity in both ACO programs and traditional Medicare. For example, rebalancing and updating the CMS-HCC risk adjustment and payment model used for ACOs could improve payment for beneficiaries with depression, anxiety, and other mental health conditions.

Additionally, mental health provider network adequacy standards in ACOs could help expand the supply of mental health providers willing to accept traditional Medicare payment and contract with ACOs.