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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 |
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| container_title | Journal of general internal medicine : JGIM |
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| creator | DeCamp, Matthew Farber, Neil J. Torke, Alexia M. George, Maura Berger, Zackary Keirns, Carla C. Kaldjian, Lauris C. |
| description | 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. |
| doi_str_mv | 10.1007/s11606-014-2833-x |
| format | article |
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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.</description><identifier>ISSN: 0884-8734</identifier><identifier>EISSN: 1525-1497</identifier><identifier>DOI: 10.1007/s11606-014-2833-x</identifier><identifier>PMID: 24664441</identifier><language>eng</language><publisher>Boston: Springer US</publisher><subject>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</subject><ispartof>Journal of general internal medicine : JGIM, 2014-10, Vol.29 (10), p.1392-1399</ispartof><rights>Society of General Internal Medicine 2014</rights><rights>2015 INIST-CNRS</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c570t-efd3439fff8123506a2bd08b96ec642d479fe743b718a9ab7c29dd43b77df5853</citedby><cites>FETCH-LOGICAL-c570t-efd3439fff8123506a2bd08b96ec642d479fe743b718a9ab7c29dd43b77df5853</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4175644/pdf/$$EPDF$$P50$$Gpubmedcentral$$H</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4175644/$$EHTML$$P50$$Gpubmedcentral$$H</linktohtml><link.rule.ids>230,315,733,786,790,891,27957,27958,53827,53829</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&idt=28943392$$DView record in Pascal Francis$$Hfree_for_read</backlink><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/24664441$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>DeCamp, Matthew</creatorcontrib><creatorcontrib>Farber, Neil J.</creatorcontrib><creatorcontrib>Torke, Alexia M.</creatorcontrib><creatorcontrib>George, Maura</creatorcontrib><creatorcontrib>Berger, Zackary</creatorcontrib><creatorcontrib>Keirns, Carla C.</creatorcontrib><creatorcontrib>Kaldjian, Lauris C.</creatorcontrib><title>Ethical Challenges for Accountable Care Organizations: A Structured Review</title><title>Journal of general internal medicine : JGIM</title><addtitle>J GEN INTERN MED</addtitle><addtitle>J Gen Intern Med</addtitle><description>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.</description><subject>Accountable care organizations</subject><subject>Accountable Care Organizations - economics</subject><subject>Accountable Care Organizations - ethics</subject><subject>Biological and medical sciences</subject><subject>Content analysis</subject><subject>Ethics</subject><subject>General aspects</subject><subject>Health care policy</subject><subject>Humans</subject><subject>Internal Medicine</subject><subject>Medical sciences</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Patient Care Team - economics</subject><subject>Patient Care Team - ethics</subject><subject>Patient Participation - economics</subject><subject>Physician patient relationships</subject><subject>Public health. Hygiene</subject><subject>Public health. Hygiene-occupational medicine</subject><subject>Resource Allocation - economics</subject><subject>Resource Allocation - ethics</subject><subject>Review Paper</subject><subject>Teaching. Deontology. Ethics. 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Legislation</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>DeCamp, Matthew</creatorcontrib><creatorcontrib>Farber, Neil J.</creatorcontrib><creatorcontrib>Torke, Alexia M.</creatorcontrib><creatorcontrib>George, Maura</creatorcontrib><creatorcontrib>Berger, Zackary</creatorcontrib><creatorcontrib>Keirns, Carla C.</creatorcontrib><creatorcontrib>Kaldjian, Lauris C.</creatorcontrib><collection>Pascal-Francis</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Proquest Nursing & Allied Health Source</collection><collection>Virology and AIDS Abstracts</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Healthcare Administration Database (Alumni)</collection><collection>ProQuest Pharma Collection</collection><collection>Technology Research Database</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Research Library (Alumni Edition)</collection><collection>ProQuest Central (Alumni)</collection><collection>ProQuest Central</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>Environmental Sciences and Pollution Management</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Research Library Prep</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Healthcare Administration Database</collection><collection>Medical Database</collection><collection>Research Library</collection><collection>Algology Mycology and Protozoology Abstracts (Microbiology C)</collection><collection>Research Library (Corporate)</collection><collection>Nursing & Allied Health Premium</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>ProQuest Central Basic</collection><collection>Genetics Abstracts</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Journal of general internal medicine : JGIM</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>DeCamp, Matthew</au><au>Farber, Neil J.</au><au>Torke, Alexia M.</au><au>George, Maura</au><au>Berger, Zackary</au><au>Keirns, Carla C.</au><au>Kaldjian, Lauris C.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Ethical Challenges for Accountable Care Organizations: A Structured Review</atitle><jtitle>Journal of general internal medicine : JGIM</jtitle><stitle>J GEN INTERN MED</stitle><addtitle>J Gen Intern Med</addtitle><date>2014-10-01</date><risdate>2014</risdate><volume>29</volume><issue>10</issue><spage>1392</spage><epage>1399</epage><pages>1392-1399</pages><issn>0884-8734</issn><eissn>1525-1497</eissn><notes>ObjectType-Article-2</notes><notes>SourceType-Scholarly Journals-1</notes><notes>ObjectType-Feature-3</notes><notes>content type line 23</notes><notes>ObjectType-Review-1</notes><abstract>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.</abstract><cop>Boston</cop><pub>Springer US</pub><pmid>24664441</pmid><doi>10.1007/s11606-014-2833-x</doi><tpages>8</tpages><oa>free_for_read</oa></addata></record> |
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| ispartof | Journal of general internal medicine : JGIM, 2014-10, Vol.29 (10), p.1392-1399 |
| issn | 0884-8734 1525-1497 |
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| 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 |
| title | Ethical Challenges for Accountable Care Organizations: A Structured Review |
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