The study found that patients who were not initially enrolled in an accountable care organization and switched to one were no more likely to get mental health treatment and had no improvements in their symptoms after a year compared to those in regular Medicare.

“Overall, accountable care organizations had no effect on the quality of mental health care: All the outcome measures were zero except for one treatment measure for depression, which was actually worse,” said study senior author Kenton Johnston, Ph.D., an associate professor of medicine at Washington University, in a news release about the study.

What are Accountable Care Organizations?

Accountable Care Organizations (ACOs) were created as part of the Affordable Care Act. The goal was to create a new type of structure that agreed to be held accountable on 33 measures of quality and experience of care while reducing the costs of care. If those results were achieved, an ACO would share in the savings to Medicare. Based on the study’s findings by researchers at Washington University School of Medicine in St. Louis and the Yale School of Public Health, the current structure of the program is not improving mental health care.

“Accountable care organizations are the most important payment and care model in Medicare right now and they do not appear to have improved mental health treatment for the two most prevalent mental health conditions in our society, which are depression and anxiety disorders,” said Johnston. “In this study, only about half the people with depression or anxiety got any outpatient mental health care at all—and those in accountable care organizations got even less. People are supposed to get treatment for depression, anxiety, any kind of mental health condition in the same way they get treatment for diabetes or kidney disease but, in reality, that doesn’t really happen. There are changes that can be made to help get people the care they need.”

Other studies confirm the lack of mental health support in ACOs. Findings from a 2022 survey of ACOs across the U.S., showed that less than 50% of ACOs were able to offer mental health support services, including assertive community treatment and illness, offering and referring patients to supported employment, family psychoeducation, and management and recovery services.

The incentive structure of ACOs may also contribute to the lack of mental health support. Determining how to measure quality of care and calculate fair payment is complicated.

“Medicare risk adjustment models, which ultimately determine payment to accountable care organizations, tend to under-predict costs for people with depression and anxiety, so there’s not as much incentive and resources for treating those conditions,” Johnston said. “Right now, anxiety is not even included in the model, which often means accountable care organizations are underpaid for treating patients with these conditions. Some forms of depression are in the model, but not others. We need to have more incentives and accompanying financial resources directed toward caring for people with mental health conditions.”

New legislation for mental health coverage

The pandemic shined a spotlight on mental health challenges, and that may have motivated the government to focus more on mental health.

In July of this year, the departments of Labor, Health and Human Services and the Treasury proposed rules to drive health insurers to comply with the 2008 Mental Health Parity and Addiction Equity Act.

The law requires insurance plans that cover mental health and substance use disorder care to offer the same level of coverage for these services as they do for medical and surgical issues.

“My hope is that this study will get policymakers to look at mental-health quality measures in a more specific way,” Johnston said.