What is an ACO?

March 27, 2014

With the tens of millions of patients now covered by Accountable Care Organizations (ACOs), our Matthew DeCamp, MD, PhD discusses his research (published in JGIM and JAMA) on their ethical challenges and the importance of engaging with patients

By Matthew DeCamp, MD, PhD

When my patient asked me this the other week, I grinned – and nearly chuckled. Sitting in the exam room with me was an actual patient affected by what I had watched closely over the past couple years: the formation of Medicare accountable care organizations (ACOs), a novel health reform where physicians and sometimes hospitals share accountability for the health outcomes and expenditures of their Medicare patients.

Then – stage fright. Despite having crafted countless sentences for manuscripts, grant submissions, or lectures explaining the ACO concept, I couldn’t think of what to say.

Should I start with the emphasis on improving quality? If so, how much detail should I offer about the 33 quality measures used to evaluate his Medicare ACOs – maybe highlighting high blood pressure (the one that most closely applied to him)?

Or should I start with how ACOs provide infrastructure for better coordination among his doctors and hospitals?

And when should I mention the other goal of the ACO – cost control? And the possibility that the ACO gets a share of the savings generated by providing better care at lower cost? And should I tell him that he is always free under Medicare rules to seek care elsewhere?

Trying to balance appropriately informing him without causing unnecessary alarm, I stumbled. I’m sure “quality,” “cost,” and the idea that the ACO receives a “share” were stated in a loosely coherent manner.  Then I paused.

“Alright then,” he said.

“Well, be sure you read your notification letter…” – these are required by Medicare – “..and let me know if you have any questions.”  We went on with a regular clinic visit.

My golden opportunity to translate my research knowledge to the clinic was missed, anticlimactic, or both. He didn’t ask what the ACO would do with the savings. He didn’t ask if I would get a share of the savings (in some ACOs, physicians receive shared savings based on their performance). He didn’t even ask what part of the savings would be used to directly benefit patients like him.

Would any of this affect his trust in me and our relationship? What did he think of this new way to organize his health care? Were the 33 quality metrics the right ones? Did he truly feel free to seek care elsewhere?

These questions relate to deeply important ethical issues, including patient autonomy and consent, physician-patient trust, and the fair distribution of resources, among others. I have recently been working with colleagues to tryand think through these ethical issues. The first step is to identify them, and this was the focus of a recently published review paper in the Journal of General Internal Medicine that I wrote with a number of distinguished internists and bioethicists.

The second step is to begin offering ways to manage the ethical challenges that we have identified. As we did in our recently published paper in JAMA, by  identifying essential considerations and  providing recommendations for how to fairly distribute shared savings among clinicians within an ACO.

The experience with my patient tells me we’ve barely scratched the surface. For patients like him, what do they know (or want to know) about the ACO? For clinicians like me, how can I engage my patients in informed, shared decision-making about ACOs? Will I experience tensions between individual patients and the ACO’s goals? Will ACO leaders struggle to decide how to spend limited ACO time and resources? Critically, these and many other issues are not unique to ACOs, but ACOs do raise them in, arguably, new ways.

“What is an ACO?” There may be no single answer, because ACOs have significant design flexibility – especially in the private sector. But this is an advantage. With ACOs now covering more than 5 million Medicare beneficiaries and as many as 31 million Americans – the time is right to ensure that ACO research includes attention to ethical issues and integrates these findings into their ongoing design and implementation. I hope I do better when my patient returns, or the next time a patient asks.


Matthew DeCamp, MD, PhD, is an Assistant Professor at the Johns Hopkins Berman Institute of Bioethics and in the Johns Hopkins Division of General Internal Medicine.  A practicing internist, his current research interests include social media and medical professionalism, ethical issues in health reform (focusing on accountable care organizations), and global health (with special emphasis on short-term global health training).

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One Response to “What is an ACO?”

  1. […] See Dr. DeCamp’s previous post on ACOs: What is an ACO? […]

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