It’s the health care holy grail: higher quality care at lower cost, and there are a growing number of accountable care organizations (ACOs) in the United States aiming to achieve it, in part by influencing where patients receive care. This carries risk to patient well-being and choice, but medical ethicists at Johns Hopkins and Brigham and Women’s say ACOs can ethically influence referrals, under certain conditions.

According to their study, “ACOs can influence referrals in an ethical manner that simultaneously enhances choice and improves patient outcomes if they consider three basic issues: transparency, appropriate metrics, and the right incentives.”

In ACOs, physicians and other providers assume responsibility for patients’ health outcomes and expenditures, and can earn financial bonuses by meeting specific quality measures while spending less than a benchmark. This is meant to encourage reducing unnecessary tests or increasing high value ones, explains Matthew DeCamp, co-author of the article, an assistant professor at Johns Hopkins Berman Institute of Bioethics and Division of General Internal Medicine. For example, he says, a traditional fee-for-service payment system may not discourage repeating diagnostic tests, such as X-rays, at both the primary care office and the specialist’s office; under the ACO model however, an incentive exists to communicate, coordinate, and not repeat such tests.

“Influence over referrals must be done in ways that preserve physicians’ primary duties to their patients’ well-being and the inherent value of choice,” DeCamp says.

The authors raise the specter of the managed care model of the 1990s that was plagued with issues, including ethically problematic “gag rule” contracts, some of which prevented physicians from referring specialists outside the organization. “We need to learn from the mistakes of managed care. Transparency about why and how referrals are being influenced is arguably the most fundamental ethical consideration,” says Lisa Lehmann, DeCamp’s co-author, the Director of Department of Medicine Bioethics Program at Brigham and Women's Hospital.

The authors emphasize that the process of creating preferred referral lists is itself important, as there may be tension between choice and the ACO’s quality and cost goals.

“Ethically, it’s not just about telling patients and physicians about preferred referral lists, but also about basing these lists on more than cost and hard medical outcomes,” says DeCamp. “As a physician, I want to be sure my patient sees a cardiologist who prescribes the right medicines and doesn’t do unnecessary tests, but I also want to be sensitive to other values of interest to my patient, such as scheduling convenience, racial or cultural concordance, or communication style.” The authors suggest that these factors should also be considered when influencing referrals.

“Ideally, we should be engaging physicians and patients in the process of choosing criteria to evaluate specialists. This will help preserve the value of patient choice and the ACO’s commitment to cost and quality, while also engendering trust in the organization,” Lehmann adds.

Further, the authors propose that providing data on how specialists perform according to these criteria could provide enough incentive to influence the referral. According to Lehmann, “Providing physicians and patients with referral lists based on appropriate metrics could be incentive enough” to achieve patients’, physicians’, and ACOs’ shared goal of high value care. DeCamp and Lehmann do not say that financial incentives are inherently unethical, but should be employed only after nonfinancial options like information sharing and organizational recognition are tried, and patients must be informed.

“In the existing system it is unclear how much choice patients really have and whether referral practices are truly in their best interest. ACOs have an opportunity to develop referral systems based on transparency, appropriately chosen metrics, and carefully employed incentives. This could make health care not just more effective, but more ethical,” DeCamp says.