Following the release of the ACO regulations by CMS and the concurrent release of guidance documents from the IRS, FTC, DOJ and OIG, much of the attention of the health care industry has been focused on the practical implementation of ACOs, tax considerations, fraud and abuse concerns, improved quality of care, and the potential for increased revenue.  However, in an article recently appearing in the Journal of the American Medical Association (subscription required), authors Drs. Craig Pollack and Katrina Armstrong bring to the forefront of the conversation the potential for ACOs to reinforce and intensify racial/ethnic disparities in U.S. health care.
In their article, “Accountable Care Organizations and Health Care Disparities,” the authors point out that the quality of health care already varies greatly between black and white patient populations.  They argue that the process of creating ACOs could lead to a reinforcement of this variance as hospitals pursue alignment with profitable medical practices, which often treat populations that are disproportionately white.  Furthermore, given that hospitals with greater resources may be more likely to align with these profitable practices, the authors express concern that ACOs will develop among hospitals and practices with few resources and disproportionately minority populations, leading to continuing lower quality of care for these populations.  They do express some hope that urban academic medical centers may serve as an “important counterweight” to this problem.  Nevertheless, the authors argue that the potential for an increase in racial/ethnic disparities as a result of the development of ACOs warrants close scrutiny among government agencies.
I recently blogged on the definition of “at-risk” patients, pointing out a number of questions that this definition raised.  Under the ACO rules, if an ACO avoids these patients, it could be subject to numerous penalties, including termination from the Medicare Shared Savings Program.  Drs. Pollack and Armstrong add one more concern about the definition of such at-risk patients; it does not currently include a category for individuals from medically underserved racial/ethnic groups and individuals with low-socioeconomic status.
While the authors mistakenly characterize the Medicare Shared Savings Program as only a “demonstration project,” this mistake emphasizes that the authors’ concerns are all the more important as the health care industry progresses in its development of ACOs.  This article is definitely a must read and a great reminder that, among all of the legal concerns in developing ACOs, the reality of ethnic/racial disparities in health care must not be forgotten.