Ethical Challenges for Accountable Care Organizations: A Structured Review

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 ex...

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Published in:Journal of general internal medicine : JGIM 2014-10, Vol.29 (10), p.1392-1399
Main Authors: DeCamp, Matthew, Farber, Neil J., Torke, Alexia M., George, Maura, Berger, Zackary, Keirns, Carla C., Kaldjian, Lauris C.
Format: Article
Language:English
Subjects:
Accountable care organizations
Accountable Care Organizations - economics
Accountable Care Organizations - ethics
Biological and medical sciences
Content analysis
Ethics
General aspects
Health care policy
Humans
Internal Medicine
Medical sciences
Medicine
Medicine & Public Health
Patient Care Team - economics
Patient Care Team - ethics
Patient Participation - economics
Physician patient relationships
Public health. Hygiene
Public health. Hygiene-occupational medicine
Resource Allocation - economics
Resource Allocation - ethics
Review Paper
Teaching. Deontology. Ethics. Legislation
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Summary: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.
ISSN:0884-8734
1525-1497
DOI:10.1007/s11606-014-2833-x