Ethical Challenges for Accountable Care Organizations: A Structured Review
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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.
- Ethical Challenges for Accountable Care Organizations: A Structured Review
Journal of General Internal Medicine
Volume 29, Issue 10 , pp 1392-1399
- Cover Date
- 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