Medicare ACOs’ Approach to Mental Health Treatment Found Lacking 

Accountable care organizations (ACOs) have become the “de facto” strategy for traditional Medicare. Their incentives for proactive care were designed to improve quality and access to care by aligning incentives among clinicians, hospitals and behavioral health providers.

But a new Health Affairs study found that being enrolled in an ACO was not associated with any measurable improvements in patients’ anxiety or depression. The study’s authors say that this finding is “especially concerning in light of the lower rates of ambulatory mental health treatment in this new ACO enrollee group.”

ACOs incentivize proactive treatments for chronic conditions that, if left untreated, would create complications for patients and require higher costs of care for payers. The design should, in theory, improve processes and outcomes for mental health conditions like anxiety and depression, which are among the most prevalent yet undertreated conditions in Medicare patients.


The study found that new ACO enrollees were 24% less likely to receive depression or anxiety treatment at an evaluation and management visit during the initial year they were enrolled – primarily due to lower rates of primary care visits addressing depression and anxiety.

As part of their work, researchers analyzed claims and enrollment data from the Medicare Current Beneficiary Survey (MCBS) from 2016 to 2019. The sample was limited to patients who were not originally enrolled in ACOs so year-over-year rates of mental health treatment could be studied.

The study was limited because it only included patients who were unable to respond to the required surveys, meaning the results were not generalizable.


Researchers found no improvements in self-reported depression or anxiety symptoms at 12 months after ACO enrollment.

Patients with anxiety or depression who were still enrolled in ACOs the following year did have a more favorable social risk and functional health risk profile.

ACO’s’ lack of fee-for-service care does not necessarily improve patient well-being, the study’s authors said. It could, however, increase administrative burden.

“Other recent evidence from the Merit-based Incentive Payment System suggests that quality measure scores in the primary care setting have little relationship to the actual quality of patient

care delivered in that setting,” the authors wrote. “Furthermore, recent surveys of physician leaders indicate that ACO leaders are unsure whether physician value-based payment measures actually improve care but do report that they create a substantial administrative burden and that incentives are not proportional to this burden.”

To remedy the problems found by the study, the authors said that incentives should focus on mental health parity and equity.

Additionally, provider network standards should be established to increase the supply of mental health providers willing to accept Medicare and contract with ACOs. To do so, the study’s authors recommend increasing Part B payment rates for providers.

“Better-designed incentives are needed to motivate Medicare ACOs to improve mental health treatment and to engage and serve low-socioeconomic-status, disabled, and rural patients with depression and anxiety disorders,” the authors said. “Policy makers should reconsider whether current mental health–related quality measures publicly reported by ACOs have adequate real-world impact on patients’ mental health care and on alleviating their symptoms.”

The implications of insufficient mental health care through ACOs will continue to increase, as the Centers for Medicare & Medicaid Services (CMS) plans to enroll all its beneficiaries by 2030.

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