Accountable care organizations and community empowerment

IMPLEMENTATION OF THE AFFORDABLE CARE ACT AND health care reform is under way. A central dimension of this process that has captured health sector interest is development and implementation of accountable care organizations (ACOs). ACOs are formal collaborations of health care professionals who agree to assume responsibility for providing a specific and potentially comprehensive set of health care services to a defined population of at least 5000 Medicare recipients. ACOs are considered to have the potential to reconfigure care-delivery systems to align incentives among physicians, other health professionals, hospitals, and payers (primarily the federal government through Medicare and the federal share of Medicaid) with the goal of increasing perceived value of care, improving clinical outcomes, and lowering health care costs (the triple aim). The Centers for Medicare & Medicaid Services has indicated that the secretary of the Department of Health and Human Services will share some portion of savings derived from lower costs of ACO care with ACO clinicians. Less apparent to the public during this period of historic change are the struggles occurring in US board rooms among hospital groups, specialty physicians, and primary care clinicians—debating quietly but intensely over how to form these ACOs, how to be accountable for care delivery, and how to divide anticipated savings derived from ACOs. However, in most of these settings, important constituencies—middle class and other working patients whose health and welfare are at stake—are not included in the discussions. This suggests a number of provocative speculations. Would the discussions be any different if this community of patients participated as equal principals in forming ACOs alongside their physicians and hospital representatives? In many ways, the ACOs proposed today were anticipated by the models of community-oriented primary care debated nearly 3 decades ago except that community-oriented primary care more explicitly expected “involvement of the community in the promotion of its health.” Group Health Cooperative, a Puget Sound health care system, well known for high quality of care, has for nearly as long ensured community involvement and leadership through its elected patient board and patient councils. If presented with the option, would communities of patients require specific benefits, roles, and responsibilities in exchange for participating in an ACO? Would the behaviors of community members resemble those of blocs of shareholders in a corporation, partners in a group venture, or patient-board members of neighborhood health centers? Would this kind of patient relationship with the formal care delivery system potentially change the social contract of health care delivery and increase the likelihood of achieving the triple aim, ie, improving the health of the population, enhancing the patient experience of care, and reducing or controlling the per capita cost of health care or some piece of it? Would communities of patientshareholders perceive each of these aims as equally relevant or valuable? Would they perceive the aims in the same way or differently from how they are perceived by provider groups? Might engaged and empowered communities be more motivated to work with clinicians to receive needed health care services or to engage in healthpromoting behaviors if granted an equitable voice in discussions about how the health care system to which they subscribe is configured and implemented? Would it make a difference if that opportunity came now, before the ACOs have been fully developed, as opposed to bringing in these communities as partners after the ACO was already functioning? Would this opportunity to participate in decision making—to argue, to vote, to express opinion freely about an individual’s own health care system in a forum with real power—have an effect on health and potentially represent a step toward more effective and more patient-centered care? The freedom of individuals to participate in decisions that have significant influence on their lives has been proposed as an important way to improve health and economic functioning. Similarly, patients are believed to benefit from playing active roles in health care choices and decision making. Patient-centered medical homes have been widely pro