DeCamp, M, et. al. (2014). Ethical Challenges for Accountable Care Organizations: a Structured Review, Journal of General International Medicine, 10, 1-9.
The authors, researchers at the Berman Institute of Bioethics and Division of General Internal Medicine, Johns Hopkins University, reviewed literature on Accountable Care Organizations using a structured approach to identify the ethical issues that the organizations face. The researchers’ hypothesis was that the issue of ethical challenges has not received the scholarly attention for a long time, despite being a myriad of them in the United States alone. The research identifies nine main challenges that ACO faces. The first challenge is allocation of resources. ACO has gained prominence as the health cost in America escalates and among other challenges, leaders in the organization face the ethical dilemma of allocating resources fairly amidst other competing needs. The second challenge is professional code of ethic, especially concerning awarding financial incentives to workers.
Other challenges include those that other organizations face such as conflict of interest between running healthcare as a business and still keeping with the professional ideals of saving lives ahead of other considerations. The issue of competition is also prevalent as clinicians may engage in unethical practices to win over clients. The research by the Berman Institute of Bioethics is credible and usefu,l but also fails in certain aspects. The challenges it highlights, for instance, are not unique to Accountable Care Organizations. On the issues of professional autonomy, resources, and financial incentives, one may rightly argue that people in other professions, leave alone nursing, are also experiencing the same. The structured approach of using literature review rather than conducting on-field research deprives the research of a very important element that would have enhanced the article’s usefulness in the field of medical ethics.
Haislmaier, E. (2013). The Complexities of Providing Health Insurance, the National Catholic Bioethics Quarterly.
The author, Edmund Haislmaier senior research fellow at Center for Health Policy Studies, Heritage Foundation, draws from his experience and research to highlight new ethical issues in healthcare financing. He acknowledges the existing ethical issues in healthcare, mainly topical issues such as abortion and assisted suicide. However, he goes further to identify new ethical issues such as sex change treatment and cloning. His major ethical concern is the precept that all members of the society should have access to medical care. Yet, there has never been a resolution on who should fund the entitlement to such rights. On issues that raise ethical contestations, it is a further ethical question on why the public should fund a process it does not agree on. The article recommends that the primacy of needs should guide ethical questions.
Outline: ACOs vs. HMOs
- Introduction
Accountable Care Organizations seek to improve quality of medical care and lower cost. The program is reportedly an improvement of the HMOs. Despite its promises, ACOs has structural and implementation challenges that may make realization of its objectives impossible
- History
ACOs came into force following the Patient Protection Care Act 2009. The model is in line with the universal care policy of Obama administration. In contrast, HMOs have been in place since 1973 through prepaid health plans. HMOs led to a situation in which financial incentives superseded the ethical imperative of health before profits
- Proponents
- Bob Edmondson, the Vice President of innovation at West Penn Allegheny Health System
-Believes that ACO are an improvement to HMO because they improve access, improve quality, and reduce bureaucracy
- b) Jenny Gold, a medical researcher and journalist.
-Reiterates improvement of quality and access, integration of physicians
- c) Pavarini, McGinty, Schaff, & American Health Lawyers Association (2012), a leading medical advocacy group
-ACOs promote unity in profession, help in coordination and networking
- Opponents
- Richard Amerling, a researcher and managing director at Albert Einstein College of Medicine in New York
-ACOs are HMOs are the same, only cosmetic changes
- b) Konschak, a researcher and practitioner in the medical sector for more than three decades
-ACOs promote unethical practices, as bad/good as HMOs
- c) Crosson, private medical practitioner and policy researcher
-ACOs have structural issues and providers will ultimately move back to their original programs
- Conclusion
ACOs have a great promise but more is necessary to ensure value for time and money (Ruggiero, Shields, In Donovan, & Healthcare Intelligence Network (2011)
ACO vs. HMO
Introduction
Despite being the most developed nation on earth, America continues to grapple with health issues with the latest efforts by the Obama administration, chiefly through Obamacare, facing stiff opposition from different quarters. Ironically, the most pressing issues have never been about discovery and invention but funding and access. The lack of uniformity in funding and access to healthcare has led to the emergence of many payment models, the most popular ones being the Health Maintenance Organization and lately, the Accountable Care Organization (Spooner, Reese, Konschak, & Halamka, 2012). Health Maintenance Organizations, or HMO, refer to a payment model in which an organization takes over management and planning of health care for individuals and other entities. Accountable Care Organizations, on the other hand, entails healthcare providers coming together voluntarily and in a coordinated manner to provide care for patients. An intense debate has raged on concerning the two models, ACO and HMO, and this paper will delve into it to demonstrate that the two bear some similarities but remain quintessentially different. To do so, the paper will rely on opinion from respected medical care authorities.
Background and History
Accountable Care Organization came into being in 2009 when the Patient Protection Care Act came into force. Research attributes the coinage of the term to Elliot Fisher. The medical doctor and health policy analyst was contributing on access and affordability of primary care in United States where he first used the term. ACO and HMO are related terms that are often difficult to differentiate. The two emphasize a payment and access model where providers are responsible to patients. However, HMO has been in existence since 1973 with the passage of Health Maintenance Organization Act. Its earliest manifestations were in form of prepaid health plans. While HMOs have had a mixture of success and failures, ACO has presented unprecedented implementation challenges. Moreover, some health policy analysts have argued that ACO is simply HMO in a different name. This paper will borrow on experts’ opinion to provide the pro and cons of Accountable Care Organizations.
Proponents
Bob Edmondson, the Vice President of innovation at West Penn Allegheny Health System, argues that ACOs are quintessentially different from HMOs despite their similarities. He starts by acknowledging that at face value, the two models of health management share some fundamental principles. He particularly points out at the principles of risk management, consideration of patients’ health, and coordination of physicians as the underlying principles on whose premise ACOs and HMOs operate. Moreover, he acknowledges the members’ fears that ACOs may be HMOs I disguise and having seen the latter failed to deliver value to its members, he is very keen to differentiate the two.
Edmondson believes that ACOs are creating value and eliminating the bureaucracy that has been the hallmark of HMOs. He believes that at the core of ACOs agenda sits the desire to reduce cost of healthcare without compromising quality. He opines, “Quality and patient satisfaction are essential components of ACOs” (Edmondson, 2011, par 2). The vice President at West Penn Allegheny Health System believes in ACOs because they do no withhold services to force members into paying, as is the case with HMOs. Moreover, he believes that ACOs are the best because they reduce the bureaucracy inherent in the healthcare system, arguing that their design allows for management of health in “small and manageable settings” (Edmondson, 2011, par 5). A big proponent of ACOs, Edmonson is aware of the reasons people are apprehensive about it but remains adamant that it betters HMOs in many ways.
The other proponent of ACOs is Jenny Gold, a medical researcher and journalist. The writer explores the frequent questions that people have on Accountable Care Organizations and stress that their primary aim is to improve access without increasing the cost. He argues that under the umbrella of ACOs, doctors and care providers come together in a coordinated network that “shares financial and medical responsibility for providing care while limiting spending” (Gold, 2015, par 5). Gold (2015) cites the CEO of the Network for Regional Healthcare Improvement analogy of equating ACO to buying a TV from Sony but through its many contractual partners. Just as one can buy a full TV set from a local subsidiary of Sony, one can also get medical care locally through ACOs.
Furthermore, Gold (2015) argues that ACOs are now an integral part of American laws following the integration of a provision for their operation through Obamacare. Through Obamacare, the government guarantees universal access to health by providing for local management of health through ACOs, in which case an organization handles up to 5,000 beneficiaries. Gold (2015) justifies the passage of ACOs by congress arguing that with statistics showing the number of elderly people soaring, medical care will be available to all.
The other major proponents of ACO are Pavarini, McGinty, Schaff, & American Health Lawyers Association (2012) leading medical researcher and advocacy group. The renowned researcher argues that ACOs have made it possible to align incentives and create wider consensus among physicians. HMOs had created a situation in which each medical organization pursued its own incentives for doctors and members. However, the disproportionate balance of power ensured that organizations looked into their own affairs and not those of members. Members who could not afford to pay hefty charges found access to care prohibitive. With ACOs, however, incentives target to drive the cost down and promote health. This has assured access and promoted ethical care in that profits do not override care. The fact that ACOs allow diverse payment models has been access even easier.
HMOs suffered disunity of physicians but with ACOs, physicians are ready to work together to improve access. During the era that HMOs became popular, which is the 80s and 90s, employment was available and thus predictable hence the preference for smaller groups. With scanty job opportunities however, physicians are in favor of ACOs because they allow them to network. Graduates can now predict where to find the next job opening, a fete that would be very difficult under HMOs.
Opponents
Among ACOs’ fiercest opponent is Richard Amerling, a researcher and managing director at Albert Einstein College of Medicine in New York. The researcher also holds the position of director of American Physicians and Surgeons and outpatient dialysis at Beth Israel Medical Center. Amerling’s fears about ACOs largely stems from the optimism that greeted introduction of HMOs and the dashed hopes that ensued. He argues that ACOs are the “new version of HMOs, the same lofty concept dressed up in a new way” (Amerling, 2013, par 5 ). Just like HMOs restricted access to care, ACOs may fall into the same trap because picking the healthiest people, as members would guarantee low cost, a license to incentives. Amerling fears that the difference between HMOs and ACOs is merely cosmetic and with time, it would be as useless and restrictive.
Amerling argues that ACOs would not solve the ethical dilemma that has confronted America because despite localization, medical care will still be in the hands of cartels that would make access as easy as they can get money. The ethical concern of putting health before profit will dissipate as physicians learn that lowering costs will only be dependent on the health of members and not physicians’ best efforts.
The other fierce opponent of ACOs is Konschak in Flareau, Bohn, & Konschak (2011), a researcher and practitioner in the medical sector for more than three decades. The researcher has participated in international forums about healthcare policy, a fact that makes him a credible authority on matters of healthcare policy. Konschak cites results from pioneer ACOs to argue that despite the hullabaloo around them, the new health model is as restrictive, and hence unethical, as the HMOs. He lauds ACOs for improvement on quality measures, but argues that their primary objective of reducing cost remains unrealistic. “Of all the 32 health systems in the pioneer ACO program” he says, “only 18 were able to lower costs for medical care patients they treated” (Konschak, 2013, p. 65). Of the 18 hospitals, 2 lost money and 7 could not wait to pull out of the program.
ACOs are a big financial risk to organizations, especially when dealing with serious ailments such as cancer and high blood pressure. Medical ethics argue that the wellness of a patient should supersede financial consideration, but from even the government perspective, physicians need to make a living out of their profession. Asking medical organizations to forfeit profits would be tantamount to kicking them out of business and in the final analysis; access to medical care would be difficult.
The last critic of the ACOs is Crosson, in Tollen & Crosson (2013), a private medical practitioner and policy researcher, who argues that the new model has many implementation and structural challenges. He states that the lure of the new will attract many people who will ultimately quit once they do not make the financial rewards they hope to make. The incentive that only comes with lowering costs will ultimately prove impossible to achieve and out of exasperation, providers will pull out of the program. Only the government is in the business of healthcare for the sake other than the financial rewards that come from the sector. Other providers, even no for profit ones, charge a fee that would allow for sustenance. Consequently, those who join the ACO program will ultimately walk out on it because of lack of financial reward.
Conclusion
The controversy surrounding ACOs and HMOs has raged on for a long time with no end in sight. The proponents of the ACOs model argue that the program will improve quality of care and lower cost. Moreover, the model augurs well with the universal healthcare policy that seeks to make medical care accessible. ACOs reduce the bureaucracy inherent in HMOs but critics fault it for structural and implementation issues. Aligning incentives with reducing cost for instance will make providers avoid seriously ill patients. This would restrict access. Ruggiero, Shields, In Donovan, & Healthcare Intelligence Network (2011), an authority on health policies, argue that there is need to relook ACOs so that they do not proliferate the same problem they should cure.
References
Amerling, Richard. (2013). Are ACOs Really Different from HMOs? Retrieved from http://www.healthleadersmedia.com/page-2/HEP-298746/Are-ACOs-Really-Different-from-HMOs.
Edmondson, Bob. (2011). 6 Ways ACOs Differ from HMOs. Retrieved from http://www.beckershospitalreview.com/hospital-physician-relationships/6-ways-acos-differ-from-hmos.html.
Flareau, B., Bohn, J., & Konschak, C. (2011). Accountable care organizations: A roadmap for success, guidance on first steps. Virginia Beach: Convurgent.
DeCamp, M, et. al. (2014). Ethical Challenges for Accountable Care Organizations: a Structured Review, Journal of General International Medicine, 10, 1-9.
Gold, Jenny. (2014). FAQ on ACOs: Accountable Care Organizations, Explained. Retrieved from http://kaiserhealthnews.org/news/aco-accountable-care-organization-faq/.
Haislmaier, E. (2013). The Complexities of Providing Health Insurance, the National Catholic Bioethics Quarterly.
Pavarini, P. A., McGinty, C. L., Schaff, M. F., & American Health Lawyers Association. (2012). The ACO handbook: A guide to accountable care organizations. Washington, DC: American Health Lawyers Association.
Ruggiero, J. R., Shields, M., In Donovan, P., & Healthcare Intelligence Network,. (2011).Blueprint for ACO success: Clinical, quality and compliance considerations for an accountable care organization.
Spooner, B., Reese, B., Konschak, C. B., & Halamka, J. D. (2012). Accountable care: Bridging the health information technology divide. Virginia Beach, VA: Convurgent Publishing.
Tollen, L. A., & Crosson, F. J. (2013). Partners in health: How physicians and hospitals can be accountable together. San Francisco, Calif: Jossey-Bass.
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