Perceived Ethics Dilemmas Among Pioneer Accountable Care Organizations.

INTRODUCTIONThe Centers for Medicare & Medicaid Services (CMS) defines an accountable care organization (ACO) asgroups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program (CMS, 2015).The ACO concept has been compared with the managed care organization (MCO) experiment in the 1990s, which was extremely unpopular and eroded trust among patients, providers, and payers (AHC Media, 1999). The ACO and MCO models share a basic intent to help control healthcare costs. However, the ACO model is designed to preserve trust and reward providers for improving the quality of patient outcomes while being mindful of costs. The ACO model is intended to result in (1) healthier patients and (2) a reduced growth rate in healthcare spending.A typical ACO combines fee-forservice (FFS) with risk-based contracts. Consequently, in order to generate revenues to support current business operations, the ACO must increase utilization for FFS contracts while adjusting utilization of all services to appropriate levels for shared-savings contracts. This tension creates opportunities for ethical dilemmas.Traditional biomedical ethics has focused on single patient-provider episodes of care. The American College of Physicians Ethics Manual states, "The interests of the patient should always be promoted regardless of financial arrangements. . . . A sense of duty to the patient should take precedence over concern about compensation" (Snyder, 2012). This patient-only focus may contribute to overutilization of healthcare services in an FFS environment in which personal income is driven by the volume of services provided.ACOs aim to create incentives for physicians to be stewards of common resources, which leads to a populationfocused ethic. This approach is also expressed in the American College of Physicians Ethics Manual, which defines a population-focused ethic as stewardship: "Physicians have an obligation to . . . [be] steward[s] of finite healthcare resources so that as many healthcare needs as possible can be met, whether in the physician's office, in the hospital or long-term care facility, or at home" (Snyder, 2012).This tension between the single patient-provider emphasis and the stewardship of limited resources exists in every health system (Daniels & Sabin, 2002). The purpose of our study was to more fully understand the various domains of ethical dilemmas present in organizations participating in the Pioneer ACO model of care. The Pioneer program is of particular interest because it was designed for leading health systems to be early adopters of the ACO model.METHODSOne of us (C.R.W.) designed the research study and conducted all of the semistructured interviews with key informants at Pioneer ACOs. Invitations to participate were e-mailed to senior leaders at all 32 of the original Pioneer ACO sites, including the 10 that dropped out of the program before or during our data collection period (i.e., May to September 2014). We sought interviews with administrators who were responsible for finances or operations, as well as with physicians making patient care decisions.We searched public records via Google to identify leaders at each of the original Pioneer ACOs. We e-mailed invitations to these leaders to participate in the study and sent reminders to nonresponders 2 weeks and, if necessary, 4 weeks later. An interview guide was developed, and interviews were conducted face-to-face or via telephone. All sessions were recorded with the participant's permission. …