Ethical Challenges for Accountable Care Organizations: A Structured Review
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Accountable care organizations (ACOs) are proliferating as a solution to the cost crisis in American health care, and already involve as many as 31 million patients. ACOs hold clinicians, group practices, and in many circumstances hospitals financially accountable for reducing expenditures and improving their patients’ health outcomes. The structure of health care affects the ethical issues arising in the practice of medicine; therefore, like all health care organizational structures, ACOs will experience ethical challenges. No framework exists to assist key ACO stakeholders in identifying or managing these challenges.
We conducted a structured review of the medical ACO literature using qualitative content analysis to inform identification of ethical challenges for ACOs.
Our analysis found infrequent discussion of ethics as an explicit concern for ACOs. Nonetheless, we identified nine critical ethical challenges, often described in other terms, for ACO stakeholders. Leaders could face challenges regarding fair resource allocation (e.g., about fairly using ACOs’ shared savings), protection of professionals’ ethical obligations (especially related to the design of financial incentives), and development of fair decision processes (e.g., ensuring that beneficiary representatives on the ACO board truly represent the ACO’s patients). Clinicians could perceive threats to their professional autonomy (e.g., through cost control measures), a sense of dual or conflicted responsibility to their patients and the ACO, or competition with other clinicians. For patients, critical ethical challenges will include protecting their autonomy, ensuring privacy and confidentiality, and effectively engaging them with the ACO.
ACOs are not inherently more or less “ethical” than other health care payment models, such as fee-for-service or pure capitation. ACOs’ nascent development and flexibility in design, however, present a time-sensitive opportunity to ensure their ethical operation, promote their success, and refine their design and implementation by identifying, managing, and conducting research into the ethical issues they might face.
- Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff. 2008;27(3):759–69. CrossRef
- Fisher ES, Staiger DO, Bynum JPW, Gottlieb DJ. Creating accountable care organizations: The extended hospital medical staff. Health Aff. 2007;26(1):w44–57. CrossRef
- Gandhi N, Weil R. The ACO surprise. Available at: http://www.oliverwyman.com/content/dam/oliver-wyman/global/en/files/archive/2012/OW_ENG_HLS_PUBL_The_ACO_Surprise.pdf. Accessed January 14, 2014.
- Pub. L. no. 111–148, §2702, 124 Stat. 119, 318–319. 2010.
- Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; Medicare Shared Savings Program: Accountable care organizations. Final rule. Fed Regist. 2011;76(212):67802–990.
- Berwick DM. Making good on ACOs’ promise - the final rule for the Medicare Shared Savings Program. N Engl J Med. 2011;365(19):1753–6. CrossRef
- Centers for Medicare, Medicaid Services. More partnerships between doctors and hospitals strengthen coordinated care for Medicare Beneficiaries (December 23, 2013). Availabe at: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-12-23.html. Accessed January 14, 2014.
- Fuchs VR, Schaeffer LD. If accountable care organizations are the answer, who should create them? JAMA. 2012;307(21):2261–2. CrossRef
- Marmor T, Oberlander J. From HMOs to ACOs: The quest for the holy grail in U.S. health policy. J Gen Intern Med. 2012;27(9):1215–8. CrossRef
- Moore KD, Eyestone K, Coddington DC. ACOs: A wolf in sheep’s clothing? Healthc Financ Manage. 2013;67(6):138–40.
- Brook RH. Physician compensation, cost, and quality. JAMA. 2010;304(7):795–6. CrossRef
- Blendon R, Brodie M, Benson J, et al. Understanding the managed care backlash. Health Aff. 1998;17(4):80–94. CrossRef
- Neuendorf KA. Content analysis-A methodological primer for gender research. Sex Roles. 2011;64(3):276–89. CrossRef
- Lesser CS, Lucey CR, Egener B, Braddock CH III, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA. 2010;304(24):2732–7. CrossRef
- McCullough LB. An ethical framework for the responsible leadership of accountable care organizations. Am J Med Qual. 2012;27(3):189–94. CrossRef
- Byrt T, Bishop J, Carlin J. Bias, prevalence and kappa. J Clin Epidemiol. 1993;46(5):423–9. CrossRef
- Ronning PL. ACOs: Preparing for Medicare’s shared savings program. Healthc Financ Manage. 2010;64(8):46–51.
- Correia EW. Accountable care organizations: The proposed regulations and the prospects for success. Am J Manag Care. 2011;17(8):560–8.
- Sinaiko AD, Rosenthal MB. Patients’ role in accountable care organizations. N Engl J Med. 2010;363(27):2583–5. CrossRef
- Lunze K, Paasche-Orlow MK. Financial incentives for healthy behavior: Ethical safeguards for behavioral economics. Am J Prev Med. 2013;44(6):659–65. CrossRef
- Biller-Andorno N, Lee TH. Ethical physician incentives - from carrots and sticks to shared purpose. N Engl J Med. 2013;368(11):980–2. CrossRef
- Nissenson AR, Maddux FW, Velez RL, Mayne TJ, Parks J. Accountable care organizations and ESRD: The time has come. Am J Kidney Dis. 2012;59(5):724–33. CrossRef
- Young DW. Bumps along the ACO road. Healthc Financ Manage. 2011; 65(12):102,104, 106, 108.
- Barlas S. Final rule on ACOs raises concerns about medication cost-shifting: Pharmacists to play a secondary role in new physician-hospital organizations. P T. 2011;36(12):780.
- Scheffler RM, Shortell SM, Wilensky GR. Accountable care organizations and antitrust: Restructuring the health care market. JAMA. 2012;307(14):1493–4. CrossRef
- Richman BD, Schulman KA. A cautious path forward on accountable care organizations. JAMA. 2011;305(6):602–3. CrossRef
- Foglia MB, Cohen JH, Pearlman RA, Bottrell MM, Fox E. Perceptions of ethical leadership and the ethical environment and culture: INtegratedEthics staff SurveyTM data from the VA health care system. AJOB Prim Res. 2013;4(1):7–19. CrossRef
- Daniels N. Accountability for reasonableness. BMJ. 2000;321(7272):1300–1. CrossRef
- Bohmer RM. Leading clinicians and clinicians leading. N Engl J Med. 2013;368(16):1468–70. CrossRef
- Emanuel EJ, Pearson SD. Physician autonomy and health care reform. JAMA. 2012;307:367–8.
- Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA. 2005;294:716–24. CrossRef
- Larson BK, Van Citters AD, Kreindler SA, et al. Insights from transformations under way at four Brookings-Dartmouth accountable care organization pilot sites. Health Aff. 2012;31(11):2395–406. CrossRef
- Rodwin MA. Conflicts of interest and the future of medicine: The United States, France, and Japan. New York: Oxford; 2011
- Crosson FJ. Analysis & commentary: The accountable care organization: Whatever its growing pains, the concept is too vitally important to fail. Health Aff. 2011;30(7):1250–5. CrossRef
- Kisloff B. Accountable care organizations. Clin Gastroenterol Hepatol. 2012;10(4):442. author reply 442. CrossRef
- Sommers R, Goold SD, McGlynn EA, Pearson SD, Danis M. Focus groups highlight that many patients object to clinicians’ focusing on costs. Health Aff. 2013;32(2):338–46. CrossRef
- Tilburt JC, Cassel CK. Why the ethics of parsimonious medicine is not the ethics of rationing. JAMA. 2013;309(8):773–4. CrossRef
- Conway PH, Cassel CK. Engaging physicians and leveraging professionalism: A key to success for quality measurement and improvement. JAMA. 2012;308(10):979–80. CrossRef
- Komar M, Smith R, Patten E. Gastroenterologists and accountable care organizations. Gastrointest Endosc Clin N Am. 2012;22(1):39–49. CrossRef
- Smith MJ. Accountable disease management of spine pain. Spine J. 2011;11(9):807–15. CrossRef
- Kocher R, Sahni NR. Physicians versus hospitals as leaders of accountable care organizations. N Engl J Med. 2010;363(27):2579–82. CrossRef
- Press MJ, Michelow MD, MacPhail LH. Care coordination in accountable care organizations: Moving beyond structure and incentives. Am J Manag Care. 2012;18(12):778–80.
- Ginsburg PB. Spending to save—ACOs and the Medicare shared savings program. N Engl J Med. 2011;364(22):2085–6. CrossRef
- Song Z, Safran DG, Landon BE, et al. The alternative quality contract’, based on A global budget, lowered medical spending and improved quality. Health Aff. 2012;31(8):1885–94. CrossRef
- Bechtel C, Ness DL. If you build it, will they come? Designing truly patient-centered health care. Health Aff. 2010;29(5):914–20. CrossRef
- Danis M, Solomon M. Providers, payers, the community, and patients are all obliged to get patient activation and engagement ethically right. Health Aff. 2013;32(2):401–7. CrossRef
- Singer S, Shortell SM. Implementing accountable care organizations: Ten potential mistakes and how to learn from them. JAMA. 2011;306(7):758–9. CrossRef
- Springgate BF, Brook RH. Accountable care organizations and community empowerment. JAMA. 2011;305(17):1800–1. CrossRef
- Carman KL, Dardess P, Maurer M, et al. Patient and family engagement: A framework for understanding the elements and developing interventions and policies. Health Aff. 2013;32(2):223–31. CrossRef
- Baicker K, Levy H. Coordination versus competition in health care reform. N Engl J Med. 2013;369(9):789–91. CrossRef
- Lewis VA, Larson BK, McClurg AB, Boswell RG, Fisher ES. The promise and peril of accountable care for vulnerable populations: A framework for overcoming obstacles. Health Aff. 2012;31(8):1777–85. CrossRef
- Pollack CE, Armstrong K. Accountable care organizations and health care disparities. JAMA. 2011;305(16):1706–7. CrossRef
- Calman NS, Hauser D, Chokshi DA. “Lost to follow-up”: The public health goals of accountable care. Arch Intern Med. 2012;172(7):584–6. CrossRef
- Noble DJ, Casalino LP. Can accountable care organizations improve population health? Should they try? JAMA. 2013;309(11):1119–20. CrossRef
- Ethical Challenges for Accountable Care Organizations: A Structured Review
Journal of General Internal Medicine
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- accountable care organizations
- health reform
- physician–patient relationship
- Industry Sectors
- Author Affiliations
- 1. Berman Institute of Bioethics and Division of General Internal Medicine, Johns Hopkins University, 1809 Ashland Avenue, Baltimore, MD, USA
- 2. Division of General Internal Medicine, University of California, San Diego, CA, USA
- 3. Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, IN, USA
- 4. Division of General Medicine and Geriatrics, Emory University Grady Memorial Hospital, Atlanta, GA, USA
- 5. Department of Preventive Medicine, Stony Brook University School of Medicine, Stony Brook, NY, USA
- 6. Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA