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Perceived Ethics Dilemmas Among Pioneer Accountable Care Organizations

Westling, Craig R. DrPH; Walsh, Thom PhD; Nelson, William A. PhD, HFACHE


EXECUTIVE SUMMARY: This study of Pioneer accountable care organizations (ACOs) suggests that the ACO model is creating moral distress for physicians and business leaders in seven critical ways:

1. Incompatible reimbursement models: The combination of fee‐for‐service and risk‐based contracts creates conflicting incentives.

2. Two standards of clinical care: Patients who are enrolled in an ACO have access to more effective care management programs than patients who are not enrolled.

3. Financial incentives versus patient choice: Providers are incentivized to refer patients within the ACO network, regardless of patient preferences.

4. “Best” care disagreements: Incentives to provide only necessary care result in disagreements between physicians about the right care, and the perception of rationing resources.

5. Required ACO metrics versus evidence‐based care: Some required metrics do not reflect current evidence‐based practices.

6. Shifting resources to focus on prevention: Creating the capacity to provide teambased comprehensive primary care could result in better patient outcomes at lower cost; however, clinician burnout is a risk.

7. Limited support systems for resolving ethical conflicts: Fragmented approaches to resolving ethical conflicts result in mismatches between organizational values and clinical and business practices.

Despite an overall sense of optimism associated with the ACO model, our research identified an underlying sense of moral distress at most sites. A clear opportunity exists for ACOs to use a more comprehensive, coordinated approach to proactively resolving ethical dilemmas while continuing the march toward risk‐based contracts.

Craig R. Westling, DrPH, executive director of education, The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire; Thom Walsh, PhD, adjunct faculty, The Dartmouth Institute for Health Policy & Clinical Practice; and William A. Nelson, PhD, HFACHE, director, Health and Values Program, The Dartmouth Institute for Health Policy & Clinical Practice

For more information about the concepts in this article, contact Dr. Westling at

© 2017 Foundation of the American College of Healthcare Executives
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