Study: early ACOs may have little impact on mental health care

Some have suggested that accountable care organizations (ACOs), which reward improved health outcomes while seeking to lower spending, would be a more effective method of providing mental health care for individuals who often receive poor care under traditional fee-for-service arrangements. However, a Commonwealth Fund study that examined the initial years of an ACO in Massachusetts found that the new health care contractual model had little impact on the delivery of mental health care.

Bridging the gap

Mental illnesses often go undetected in the primary care setting and mental health services are frequently poorly coordinated between primary and specialty care under fee-for-service arrangements. It has been suggested that the ACO model could improve mental health care by creating invectives for providers to bridge the gap between mental health and other care. Additionally, better coordination could improve treatment of mental health and other chronic conditions such as cardiovascular disease and diabetes.


Section 3022 of the Patient Protection and Affordable Care Act (ACA) (P.L.111-148) provides for the creation of ACOs and encourages the use of global payment approaches that include performance bonuses that seek to reward improved quality of care and to control spending. In 2009, Blue Cross Blue Shield of Massachusetts (BCBSMA) established the Alternative Quality Contract (AQC), which is an ACO that pays provider organizations a risk-adjusted prospective payment for all primary and specialty care for a five-year period.


The Commonwealth Fund-supported study, which examined how the BCBSMA AQC model affected mental illness care, found that enrollees were actually “slightly less likely” to use mental health services than enrollees in non-AQC organizations. The study also found that while there was a small decline in total health care spending, there were no changes in mental health spending. Also, no significant improvements were seen for AQC enrollees who had mental health conditions and other chronic illnesses, such as diabetes or cardiovascular disease.

Early years

AQC leaders acknowledged that during the initial years of implementation the organizations did not focus on the integration of mental health care into primary care. However, several organizations are taking steps to increase integration by adding behavioral health clinicians to primary care practices.