The much-anticipated rules governing accountable care organizations could perpetuate – however inadvertently – a care delivery system that is racially and ethnically unbalanced, according to a commentary in Wednesday's Journal of the American Medical Association.
The authors, from Johns Hopkins University School of Medicine and Bloomberg School of Public Health, point out that this de facto discriminatory system could be created as wealthier hospitals or groups of clinicians engage in "cherry picking" alignment with similarly wealthy organizations to form their ACOs.
"Primary care clinicians for white and black patients report varying levels of institutional resources and in many settings, hospitals that treat a large proportion of black patients appear to provide lower-quality care than hospitals that treat a large portion of white patients," wrote Craig Evan Pollack, MD and Katrina Armstrong, MD.
"Although not explicitly selecting patients by race, ethnicity, or socioeconomic status, the current reality is that profitability in healthcare is strongly correlated with caring for fewer low-income patients and low-income patients are disproportionately white."
"The de facto segregation of the healthcare system has important implications for the creation and implementation of ACOS," they wrote.
They added that in a worst-case scenario, the "cherry picking of practices in ACO formation and the process of owning patient panels will concentrate white patients within certain hospital systems that will be able to make the greatest investment in improving value and will receive the greatest benefit from the ACO arrangement."
It would leave lower-income patients, who are less likely to be white, more concentrated in hospital systems that are less able to form ACOs, they said.
There are mitigating factors, of course, Pollack and Armstrong said. In areas where the worst could occur, there are urban academic medical centers that "could be an important counterweight," especially if those centers participate in the ACO construct.
Additionally, they wrote, because urban, low-income populations and racial minorities often have fragmented care already, improvements and initiatives that ACOs may create could result in bigger benefits, and substantially lower costs than those patients require today.
While the proposed federal regulations for ACOs already call for risk and severity adjustments in determining benchmarks for success, and to make sure that ACOs don't try to avoid high-risk patients, federal oversight should assure that key issues are addressed, Pollack and Armstrong wrote.
First, the Centers for Medicare & Medicaid Services should mandate the reporting of quality indicators by race and ethnicity within ACOS to determine this impact, both positive and negative, on disparities, they suggest.
Second, they recommend that CMS should examine whether distribution of patients by race and ethnicity between ACOS is associated with quality of care Medicare beneficiaries receive. "Understanding these system level differences is critical for determining program effectiveness and improving its design."
Third, the program should monitor should monitor which clinicians and patients are excluded or choose not to participate. And incentives might ensure adequate representation of diverse patients and healthcare systems.
And fourth, active steps to avoid patient and practice cherry picking may be necessary, although monitoring and enforcing the practice will be challenging.
"ACOS are unlikely to reduce and may even exacerbate disparities in care without active intervention to monitor and incentivize equity within and across ACO populations," they concluded.