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1 Welcome to the Webinar Once the Webinar begins, if you can t hear the sound, please hang up and dial in again All attendees are on mute, so if you would like to ask a question, please type it into the Q&A box in the control panel on your screen If you would like to minimize the control panel so that you can see more of the screen, click on the white arrow in the small orange box and the control panel will be minimized. You can click on the arrow to open the panel if you would like to type in a question.

2 Ethical Challenges of ACOs A principle-stakeholder approach to identification and management Matthew DeCamp, MD, PhD Assistant Professor Johns Hopkins Berman Institute of Bioethics and Division of General Internal mdecamp1@jhmi.edu

3 The Ethics Lens ACO PATIENT: What does an ACO mean to me? Will it affect my choice in doctor, or my access to specialists? How can an ACO respect patient choice and clinicians professional autonomy? ACO CLINICIAN: Will the ACO s focus on certain quality metrics keep me from addressing my patient s other needs? How can the organization ensure clinicians obligations of beneficence to their patients are preserved? ACO LEADER: What is the best way to use our shared savings bonus to support our mission? Will providers and patients within the organization perceive the distribution as fair?

4 Take Home Points 1. ACOs are not entirely new, nor are the ethical challenges they face but they provide a new context for these issues to occur. 2. Flexibility afforded ACOs creates an opportunity for leaders and all stakeholders to design and implement ACOs in ethically-minded ways using a principle-stakeholder approach.

5 A PCP- ethicist s View: The ACO ACO Clinicians+/- Hospitals Shared Accountability Expenditures Outcomes Care Coordination Quality Improvement Higher Quality Care at Reduced Cost TRIPLE AIM Expenditure Benchmarks Quality Metrics (Sharing Savings) PATIENTS PAYERS Better Outcomes Better Experience

6 The ACO Explosion 12/2006 PPACA & Medicare Shared Savings 3/2010 CMS Final Rule 11/ /2006 Elliot Fisher (MedPAC) PGPD project As of ACOs >7 million beneficiaries (Private ACOs as well, million patients) 1 ACOs (and ACO-like models) continue to proliferate

7 Why Ethics? (1) Structure Determines Function Adapted from: Lesser et al. JAMA. 2010;304(24): in DeCamp et al. JGIM 2014.

8 Why Ethics? (2) Avoiding past mistakes The long-term success of ACOs depends, in part, on effectively navigating ethical issues: Gatekeeping Outright denial of care Clinicians autonomy Etc.

9 ACOs are Different, Right? Right? PROVIDER-LED COORDINATION Care Coordination Quality Improvement Higher Quality Care at Reduced Cost ACO Clinicians +/- Hospitals TRIPLE Shared Accountability Expenditures Outcomes DATA Defining Quality Metrics Calculating Benchmarks Sharing Savings PATIENT CHOICE PATIENTS AIM PAYERS Better Outcomes Better Experience Emanuel. JAMA 2012;307:2263-4

10 Introducing a Principle-Stakeholder Approach to Ethics in ACOs

11 Here are the principles BASIC PRINCIPLE MEANING EXAMPLE FOR ACOs Respect for Persons Beneficence Justice Distributive Procedural autonomy choice respect promoting patient well-being equitable shares fair decision processes - Patients choices in provider - Clinicians professional autonomy - Ensuring patients well-being is protected - Preserving clinicians obligations of beneficence - ACO leaders obligations to the population - Fairly using & distributing shared savings among ACO providers and others - Patient and clinician engagement in governance

12 add in the stakeholders ACO LEADERS PROVIDERS (hospitals, clinicians, etc.) For each level, principles help us identify and begin managing ethical issues that arise: Autonomy Beneficence Justice PATIENTS The Broader Community/Society and you have the principle-stakeholder approach.

13 Ethical Challenges in the Design and Implementation of ACOs Let s look at some examples of ethical issues with this approach. 1. Describe the regulatory background 2. Identify the stakeholder and the principle 3. Consider some management options We focus on the Medicare Shared Savings Program - where regulations provide specific regulatory context - though issues should apply to all ACOs.

14 CMS rules require EXAMPLE #1: ACO Notification ACO participants to post signs in their facilities indicating their associated ACO provider s/ supplier s participation and to make available standardized written notices developed by CMS to Medicare FFS beneficiaries ( STAKEHOLDER? Patients PRINCIPLE? Respect for persons ( informed consent and patient choice)

15 Ethics and ACO Notification Although ACOs may have to meet this minimal requirement, they can do more and maybe they should. Method PROS CONS Discuss with PCP Existing relationship Time, clinic flow Assumes clinicians aware Social media (Facebook, Twitter) Other technologies (ipad with information in clinic, YouTube videos, etc.) Disseminates quickly Could be interactive Makes information more user-friendly Will not reach all patients Labor intensive Cost

16 Unanswered Questions How much do (should) patients know? How much do they want to know?

17 Example #2: Influencing Referrals CMS rules require ACOs to encourage coordination while still providing beneficiaries the freedom of choice of providers under FFS Medicare. But, influencing referrals may be one way to better achieve cost and quality goals. STAKEHOLDER? Patients, clinicians PRINCIPLE(S)? Respect for persons (choice) Beneficence (well-being) Justice (equitable access) jama.jamanetwork.com/article.aspx?articleid=

18 Influencing referrals ethically requires. Transparency The Right Referral Criteria More than cost and hard outcomes Patient-centered outcomes and values (e.g., communication, geographic access) The Right Means Information alone Non-financial (e.g., praise) Financial

19 Unanswered Questions As a PCP, would transparent access to the right data in the right way actually enhance my patients choices and shared decisionmaking?

20 Example #3: Shifting Focus Medicare Shared Savings Program ACOs involve 33 quality metrics: STAKEHOLDER? Clinicians PRINCIPLE(S)? Autonomy & beneficence /2014/07/18/the-phillips-curvea-multi-sector-approach/

21 Preserving Clinicians Beneficence Clinicians may experience tension between the ACO focus on certain metrics, costs, and what they and their patients believe are their main priorities. Conceptually, it may help to think of two general models. COST ($) COST $ PATIENT PROVIDER PATIENT PROVIDER McCullough LB. Am J Med Qual. 2012; 27(3): Clinician engagement is critical to understanding and managing this tension.

22 CMS rules state Example #4 Sharing the Savings the statute does not specify how shared savings must be distributed, only that the ACO be a legal entity so that the ACO can accept and distribute shared savings. We do not believe we have the legal authority to dictate how shared savings are distributed [in a fair and equitable manner]. STAKEHOLDER? Leaders ISSUE(S)? Justice (distributive)

23 Fairly Sharing the Savings Different ethical values are at play in shared savings distribution plans: ETHICAL VALUE PRO CON Based on performance - Individual level? - Group level? Equal to all Based on need May be more effective Attenuates differences Does not penalize unlucky clinicians Could foster group identity Could boost clinicians and vulnerable patients Clinicians panels differ Allows free-riding May not be strong enough incentive May be less efficient

24 As of yet, there is no single recipe for success.

25 Concluding Thoughts ACOs do not raise fundamentally NEW ethical challenges nor are they by definition ethically better (or worse) than other models of care. Leadership of ACOs play a major role in defining the structure of the ACO to help facilitate meeting ethical challenges. Engaging patients, clinicians and other stakeholders in the process will be a critical part of transformation. MSSP rule changes, Next Generation ACOs, and private payers rules complicate things; and many other issues exist (e.g., beneficiary representation). But the core principles and stakeholders remain.

26 Thank You! We hope you enjoyed this presentation. To make sure that you receive invitations to future Webinars, follow us: Join us for our next Webinar on May 19, 2015 at 1:00 PM EDT. Learn from Leaders How to build a successful ACO Register now! Space is limited. No registration fee but pre-registration is required.