JAMA: ACOs could increase care disparities

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Careful consideration and monitoring will be needed during accountable care organization (ACO) implementation to ensure that ACOs don’t widen existing racial and ethnic disparities in healthcare and health outcomes, according to a commentary in the April 27 Journal of the American Medical Association.

Racial and ethnic disparities in healthcare are well documented in the U.S., stated authors Craig E. Pollack, MD, MHS, of Johns Hopkins University School of Medicine and Bloomberg School of Public Health, in Baltimore; and Katrina Armstrong, MD, of Leonard Davis Institute of Health Economics at the University of Pennsylvania, and University of Pennsylvania School of Medicine, in Philadelphia.

In addition to a call for close scrutiny during implementation, the authors also urged a variety of hospitals and independent practices to participate in ACO programs. This is necessary because “profitable practices are more desirable partners for these relationships and wealthier hospitals are likely better able to compete for these practices,” they wrote.

“To the degree that the creation of an ACO enables wealthy practices to preferentially align with one another, this process has the potential to further concentrate wealth and racial/ethnic groups within certain ACOs,” Pollack and Armstrong stated.

In addition to strong partnerships, ACOs’ success will depend on their ability to retain patients. However, if organizations are successful in limiting patient movement, they are likely to accentuate racial and ethnic differences in where patients receive care, wrote Pollack and Armstrong.

“Fewer financial resources within healthcare systems that disproportionately care for lower-income patients may impede the system’s ability to meet quality benchmarks, implement programs to reduce costs and qualify for potential shared savings. Similar concerns have been raised for other pay-for-performance programs in healthcare,” they wrote.

The “cherry-picking” of practices in ACO formation and the process of owning patient panels may concentrate white patients within hospital systems that can make the greatest investment in improving value and will benefit most from the ACO arrangement, they said.

“Although not intentional, this scenario leaves lower income patients who are less likely to be white more concentrated in hospital systems that have relatively fewer financial resources and less ability to compete in a new world of accountable care.”

Urban academic medical centers that serve urban populations could be an important counterweight to these trends if they participate. In addition, “ACOs with more lower income patients who are not white may experience a higher return on investment if they can successfully address the burden of care fragmentation,” stated the authors.

“Given the uncertainty about the potential impact of ACOs on racial/ethnic disparities in healthcare, it is critical to evaluate and address the potential unintended consequences of ACOs during program implementation. At-risk populations should include not only individuals with high healthcare needs and expenses but also individuals from medically underserved racial/ethnic groups and individuals with low-socioeconomic status.”

Several additional steps should be considered. The authors recommended:

  • The Centers for Medicare & Medicaid Services (CMS) should mandate reporting of quality indicators by race/ethnicity within ACOs to determine the impact—positive or negative—on disparities.
  • CMS should examine whether distribution of patients by race/ethnicity among ACOs is associated with the quality of care Medicare beneficiaries receive.
  • The program should monitor which clinician and patient populations are excluded. “Incentives may be necessary to ensure adequate representation of diverse patient populations and healthcare systems,” the authors wrote.
  • CMS should take active steps to avoid patient and practice cherry-picking in ACO creation. “Monitoring and enforcing such a policy is likely to be the most challenging step, especially because ACOs are designed to reflect existing referral patterns. Recent hospital and practice consolidations ... should be monitored from a disparities perspective,” they added.

“ACOs hold substantial promise to modify existing reimbursement structures to reward high-value healthcare,” Pollack and Armstrong concluded. “Their success will require influencing the pathways through which patients receive specialty and hospital care.”