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Ethical Challenges for Accountable Care Organizations: A Structured Review

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ABSTRACT

BACKGROUND

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.

Methods

We conducted a structured review of the medical ACO literature using qualitative content analysis to inform identification of ethical challenges for ACOs.

Results

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.

Discussion

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.

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Acknowledgements

This work was completed while the authors were serving on the Society of General Internal Medicine (SGIM) Ethics Committee. The authors are grateful for the administrative support that SGIM provided. The views expressed in this article are those of the authors and do not necessarily reflect the position of SGIM.

Dr. DeCamp’s work on the manuscript was funded by a Greenwall Foundation Post-doctoral Fellowship in Bioethics & Health Policy and NIH Grant 5T32HL007180-38. The funders had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Financial Support

Greenwall Foundation Post-doctoral Fellowship in Bioethics & Health Policy and NIH Grant 5T32HL007180-38.

Author information

Authors and Affiliations

  1. Berman Institute of Bioethics and Division of General Internal Medicine, Johns Hopkins University, 1809 Ashland Avenue, Baltimore, MD, USA

    Matthew DeCamp MD PhD & Zackary Berger MD PhD

  2. Division of General Internal Medicine, University of California, San Diego, CA, USA

    Neil J. Farber MD

  3. Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, IN, USA

    Alexia M. Torke MD MS

  4. Division of General Medicine and Geriatrics, Emory University Grady Memorial Hospital, Atlanta, GA, USA

    Maura George MD

  5. Department of Preventive Medicine, Stony Brook University School of Medicine, Stony Brook, NY, USA

    Carla C. Keirns MD PhD

  6. Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA

    Lauris C. Kaldjian MD PhD

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  1. Matthew DeCamp MD PhD
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Correspondence to Matthew DeCamp MD PhD.

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DeCamp, M., Farber, N.J., Torke, A.M. et al. Ethical Challenges for Accountable Care Organizations: A Structured Review. J GEN INTERN MED 29, 1392–1399 (2014). https://doi.org/10.1007/s11606-014-2833-x

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  • DOI: https://doi.org/10.1007/s11606-014-2833-x

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