Growing number of accountable care organizations (ACOs) in the United States are aiming to achieve higher quality care at lower cost, partly by influencing where patients receive care. Experts from Johns Hopkins Berman Institute of Bioethics and Division of General Internal Medicine said, "ACOs can influence referrals in an ethical manner that simultaneously enhances choice and improves patient outcomes if they consider three basic issues: transparency, appropriate metrics, and the right incentives."
Co-author of the study Matthew DeCamp said, "In ACOs, physicians and other providers assume responsibility for patients' health outcomes and expenditures, and can earn financial bonuses by meeting specific quality measures while spending less than a benchmark. This is meant to encourage reducing unnecessary tests or increasing high value ones. For example, a traditional fee-for-service payment system may not discourage repeating diagnostic tests, such as X-rays, at both the primary care office and the specialist's office; under the ACO model however, an incentive exists to communicate, coordinate, and not repeat such tests. Influence over referrals must be done in ways that preserve physicians' primary duties to their patients' well-being and the inherent value of choice"
Another study co-author Lisa Lehmann said that we should learn from the mistakes of the managed care model of the 1990s, including the ethically problematic 'gag rule' contracts, some of which prevented physicians from referring specialists outside the organization. Having a transparency about why and how referrals are being influenced is the most fundamental ethical consideration.
The authors emphasized that the process of creating preferred referral lists is important, as there may be tension between choice and the ACO's quality and cost goals. DeCamp said, "As a physician, I want to be sure my patient sees a cardiologist who prescribes the right medicines and doesn't do unnecessary tests, but I also want to be sensitive to other values of interest to my patient, such as scheduling convenience, racial or cultural concordance, or communication style."
Lehmann said, "Providing physicians and patients with referral lists based on appropriate metrics could be incentive enough to achieve patients, physicians, and ACOs shared goal of high value care." The researchers were of the opinion that financial incentives are not inherently unethical, but should be employed only after nonfinancial options like information sharing and organizational recognition are tried, and patients must be informed.
DeCamp said, "In the existing system it is unclear how much choice patients really have and whether referral practices are truly in their best interest. ACOs have an opportunity to develop referral systems based on transparency, appropriately chosen metrics, and carefully employed incentives. This could make health care not just more effective, but more ethical."
The study appears in 'The New England Journal of Medicine'.