Hospitals and physician practices that form care-coordinating networks called "Accountable Care Organizations (ACOs)," under provisions of the new health-care law could reap cost-savings and other benefits. However, experts at Johns Hopkins and the University of Pennsylvania warn that such networks could potentially be designed to exclude minorities and widen disparities in health care.
In a commentary appearing in the April 27 issue of the Journal of the American Medical Association, a Johns Hopkins physician says that as a result of new provisions in the Patient Protection and Affordable Care Act, wealthy hospitals and practices may "cherry-pick" similar, wealthy institutions and groups to form ACOs, and avoid poor and minority-heavy patient populations treated elsewhere in order to lower costs and raise quality of care.
ACOs are designed to encourage patients to seek care within their own network, further accentuating the disparities between networks.
In practical terms, writes Craig Pollack, M.D., M.H.S., assistant professor of medicine at Johns Hopkins, hospitals and physician practices that treat a disproportionate share of minorities may be unable to join ACOs and fall further behind in the cost and quality of care benefits likely to occur in such networks.
"There is ample evidence of racial and ethnic disparities in health care," says Pollack. "Hospitals and private practices that care for greater numbers of minorities tend to have larger populations of Medicaid and uninsured patients. These patients have less access to specialists, and their hospitals and practices tend to have fewer institutional resources than their counterparts."
"There is wide difference in the ability of hospitals and practices to implement the cost and quality measures needed to form ACOs," adds Pollack, who cites financial resources, management structure, and size as barriers to forming such networks. Under the law, ACOs must be able to provide all levels of care for at least 5,000 Medicare beneficiaries.
Pollack says ACOs could improve coordination of care across private practices and hospitals by encouraging hospitals and doctors to work more closely together on inpatient and outpatient care. Cancer care, for example, could be enhanced with "patient navigators" who coordinate services, he says. He notes that the potential benefits of ACOs have yet to be monitored and evaluated by the Centers for Medicaid and Medicare, and will be an important component to wider adoption of ACOs.
To monitor the impact of ACOs on health-care disparities, Pollack and his co-author, Katrina Armstrong, M.D., from the University of Pennsylvania, suggest measures to evaluate the process of creating ACOs from an antitrust/market consolidation perspective. Measures of quality should include details of the patient population by race and ethnicity within individual ACOs; across separate ACOs; and compared with patients not in ACOs.