Referral patterns under accountable care organizations need to consider factors beyond cost and hard outcomes so that the healthcare industry doesn’t repeat 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.

That’s the opinion of medical ethics experts at Johns Hopkins University and Brigham and Women's Hospital writing in The New England Journal of Medicine, who argue that the industry needs to learn from the mistakes of managed care.

Johns Hopkins professor Matthew DeCamp and Brigham and Women's Lisa Lehmann assert that “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.” According to Lehmann, transparency about why and how referrals are being influenced is “arguably the most fundamental ethical consideration.”

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.”

DeCamp and Lehmann 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,” says Lehmann.

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 non-financial 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,” according to DeCamp.

The full NEJM article is available here.

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