An Examination of Ethics Conflicts in Pioneer Accountable Care Organizations

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  • March 19, 2019
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  • Westling, Craig
    • Affiliation: Gillings School of Global Public Health, Department of Health Policy and Management
Abstract
  • The findings of this study suggest that the Pioneer ACO model does create (or exacerbate) several critical ethical conflicts, and has the potential to mitigate others. These findings suggest that there is uncertainty associated with how to create clinical and business systems that support the ACO, how to manage and communicate the change, and how to reallocate resources. Seven major ethical issues were identified: 1. Incompatible reimbursement models. The combination of fee-for-service and risk-based contracts creates conflicting incentives to simultaneously increase and decrease utilization. 2. Two standards of clinical care. Patients who could benefit from effective care management programs may not be enrolled because they are not attributed to the ACO. 3. Financial incentives vs. patient choice. Providers are incentivized to keep referrals in the ACO network even if they or a patient would prefer to go out-of-network. 4. "Best" care disagreements. Incentives to provide only the necessary and needed care can result in disagreements between physicians about the right care, and the perception of "rationing" resources. 5. Required ACO metrics vs. evidence-based care. CMS requires some metrics that do not reflect current evidence-based practices. This creates financial incentives to provide care that the literature suggests is inferior. 6. Shifting resources to focus on prevention. The ability to provide team-based, comprehensive primary care services may result in better patient outcomes at less cost; however, clinician burnout is a risk. 7. Limited support systems for ethical conflicts. A fragmented approach to dealing with ethics conflicts results in a mismatch between an ACO's values and its clinical and business practices. Overall the issues identified by this study reveal an underlying sense of moral distress experienced by physicians; this is despite an overall sense of optimism associated with the ACO model because it is "the right" way to provide care. This presents ACO leaders both an (1) urgent challenge to reduce physician moral distress (which other research has shown to have negative consequences on both worker health and job performance), and (2) opportunity to leverage the enthusiasm expressed for the overall ACO goals of better patient outcomes at lower costs.
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  • In Copyright
Advisor
  • Nelson, William
  • Reiter, Kristin
  • Sabin, James
  • Pink, George
  • Harris, Dean
Degree
  • Doctor of Public Health
Degree granting institution
  • University of North Carolina at Chapel Hill Graduate School
Graduation year
  • 2015
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  • Chapel Hill, NC
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