A major component of the 2010 Patient Protection and Affordable Care Act (ACA) is the promotion of new models for payment and care delivery that control costs while improving quality. One of the most prominent of these new models is the Accountable Care Organization (ACO). ACOs, broadly defined, are groups of health care providers and hospitals joined together as either vertically integrated systems or virtually integrated networks that are responsible for the care of a defined population of patients. A primary means through which the ACA promotes the ACO model is the Medicare Shared Savings Program (MSSP), in which ACOs contract with Medicare to provide care to beneficiaries in the Fee-For-Service program, and are financially rewarded if they lower costs while meeting quality standards (Ginsburg, 2011). The ACO concept is the newest in a series of attempts to rectify the problems of fee-for-service payment, which has been shown to incentivize the provision of excessive services rather than prevention, effective disease management, and coordinated care. However, a distinct element of the model under the MSSP is that unlike traditional managed care systems, patients may choose to see providers outside of their ACO network. This specification is clearly spelled out in the Centers for Medicare and Medicaid Services’ (CMS) Final Rule Provisions for Accountable Care Organizations under the Medicare Shared Savings Program, and is emphasized as being a “significant difference” between ACOs and private managed care plans offered under the Medicare Advantage program (The Medicare Learning Network, 2014, pg. 3). This emphasis on the protection of free patient choice may be at least partially attributable to the backlash against managed care that emerged in the US in the late 1990s (Mechanic, 2004).
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Freedom to choose one’s health care provider is highly valued in the US, and generally speaking Medicare beneficiaries have shown little appetite for plans that restrict this choice, even when those plans offer more generous benefits (Sinaiko & Rosenthal, 2010). In addition to issues of public opinion and consumer preference, arguments have been made in favor of protecting patient choice from an ethical standpoint. It has been suggested that control over referral patterns might place unreasonable constraints on patient autonomy (DeCamp et al., 2014), and that when referral practices are driven by forces outside of the physician-patient relationship it may be unclear whether they are unequivocally in the patient’s best interest (DeCamp & Lehmann, 2015). However, critics of this policy have argued that it will be difficult, perhaps even impossible, for ACOs to be held fully accountable for the cost and quality of a patient’s care when that patient chooses to receive care outside of the ACO, and that difficulties in communicating with outside providers will pose serious challenges to care coordination and the reduction of unnecessary care (Evans, 2014; Stefanacci, 2011). A study of Medicare claims from 524,246 beneficiaries enrolled in ACOs during 2010-2011 suggests that these criticisms are not unfounded. Among ACO beneficiaries, 9% of primary care visits occurred outside of the ACO, 67% of visits to specialists occurred outside of the ACO, and 33% of beneficiaries were not included in the same ACO during both years. The authors suggest that these patterns of use among beneficiaries served by ACOs may severely undermine the potential of the ACO model to control costs and improve care (McWilliams et al., 2014). Outside of the context of ACOs, it has been argued more generally that limiting patient choice is a requisite component of achieving cost savings in the US healthcare system, based on the belief that unlimited choice will invariably increase utilization and drive up costs (Karpf & Lofgren, 2012). Given the seriousness of these concerns and the available evidence regarding ACO beneficiaries patterns of care use, it is reasonable to conclude that something …show more content…
However, in light of public opinion regarding choice restriction and the apparent determination of the CMS to preserve freedom of patient choice, simply prohibiting patients from seeking care outside of their ACO is clearly not an option. Further, such a blanket restriction may not be desirable if we assume that there will likely be some patients for whom this restriction will result in worse quality of care. Therefore, strategies seeking to incentivize patients to stay within their ACO seem to be the best option moving
Freedom to choose one’s health care provider is highly valued in the US, and generally speaking Medicare beneficiaries have shown little appetite for plans that restrict this choice, even when those plans offer more generous benefits (Sinaiko & Rosenthal, 2010). In addition to issues of public opinion and consumer preference, arguments have been made in favor of protecting patient choice from an ethical standpoint. It has been suggested that control over referral patterns might place unreasonable constraints on patient autonomy (DeCamp et al., 2014), and that when referral practices are driven by forces outside of the physician-patient relationship it may be unclear whether they are unequivocally in the patient’s best interest (DeCamp & Lehmann, 2015). However, critics of this policy have argued that it will be difficult, perhaps even impossible, for ACOs to be held fully accountable for the cost and quality of a patient’s care when that patient chooses to receive care outside of the ACO, and that difficulties in communicating with outside providers will pose serious challenges to care coordination and the reduction of unnecessary care (Evans, 2014; Stefanacci, 2011). A study of Medicare claims from 524,246 beneficiaries enrolled in ACOs during 2010-2011 suggests that these criticisms are not unfounded. Among ACO beneficiaries, 9% of primary care visits occurred outside of the ACO, 67% of visits to specialists occurred outside of the ACO, and 33% of beneficiaries were not included in the same ACO during both years. The authors suggest that these patterns of use among beneficiaries served by ACOs may severely undermine the potential of the ACO model to control costs and improve care (McWilliams et al., 2014). Outside of the context of ACOs, it has been argued more generally that limiting patient choice is a requisite component of achieving cost savings in the US healthcare system, based on the belief that unlimited choice will invariably increase utilization and drive up costs (Karpf & Lofgren, 2012). Given the seriousness of these concerns and the available evidence regarding ACO beneficiaries patterns of care use, it is reasonable to conclude that something …show more content…
However, in light of public opinion regarding choice restriction and the apparent determination of the CMS to preserve freedom of patient choice, simply prohibiting patients from seeking care outside of their ACO is clearly not an option. Further, such a blanket restriction may not be desirable if we assume that there will likely be some patients for whom this restriction will result in worse quality of care. Therefore, strategies seeking to incentivize patients to stay within their ACO seem to be the best option moving