Accountable care organizations and health care disparities.

UNDER SECTION 3022 OF THE AFFORDABLE CARE Act, the Centers for Medicare & Medicaid Services is tasked with developing and testing accountable care organizations (ACOs). The goal of ACOs is to group hospitals and physician practices together to facilitate and incentivize quality improvement and cost containment—critical steps for US health care. However, careful consideration and monitoring during the program’s implementation is needed to ensure that ACOs do not have the unintended consequence of reinforcing health care disparities. Racial/ethnic disparities in health care are well documented in the United States. These disparities arise, in part, because of differences in the site of care. Black and white patients tend to receive care from different clinicians who work at different hospitals and in different health care systems. Primary care clinicians for white and black patients report varying levels of institutional resources and in many settings, hospitals that treat a large proportion of black patients appear to provide lower-quality care than hospitals that treat a larger portion of white patients. The de facto segregation of the health care system has important implications for the creation and implementation of ACOs. The process of creating ACOs may reinforce racial/ethnic differences in sites of care by further concentrating patients from certain racial/ethnic groups within particular health care organizations. Although many integrated delivery systems and multispecialty group practices may already qualify as ACOs, other hospitals and independent practices must enter into contractual relationships to become an ACO. Profitable practices are more desirable partners for these relationships and wealthier hospitals likely have a greater ability to compete for these practices. Although not explicitly selecting patients by race, ethnicity, or socioeconomic status, the current reality is that profitability in health care is strongly correlated with caring for fewer low-income patients and low-income patients are disproportionately not white. To the degree that the creation of an ACO enables wealthy practices to preferentially align with one another, this process has the potential to further concentrate wealth and racial/ethnic groups within certain ACOs. Once established, the successful implementation of an ACO would depend on its ability to influence costs and quality in treating its targeted population of patients. Exerting this influence will require ACOs to develop strategies to keep their patients within their own system because patients who travel between ACOs create substantial financial risk. To the degree that these strategies are successful in limiting movement between systems, they are likely to accentuate racial/ ethnic differences in where patients receive care. This segregation is problematic on its own but becomes even more concerning if it is associated with inequity in the quality and resources of the different ACOs. Programs and infrastructure to improve value within an ACO require financial investment. Fewer financial resources within health care systems that disproportionately care for lower-income patients may impede the system’s ability to meet quality benchmarks, implement programs to reduce costs, and qualify for potential shared savings. Similar concerns have been raised for other pay-for-performance programs in health care. Without careful implementation, these programs can make the rich richer and the poor poorer, further widening racial/ethnic disparities in health care and health outcomes. Moreover, because ACOs are a demonstration project, many hospitals that disproportionately care for patients from certain racial/ethnic groups may opt not to participate, either because of limited resources or because care for these populations is too fragmented. These health care systems are rarely early adopters of innovation. Although it remains uncertain whether ACOs will produce substantial, if any, benefits for patients, it is clear that patients who receive care at hospitals that do not participate in ACOs will not have the opportunity to experience any potential gains. In a worst-case scenario, the cherry picking of practices in ACO formation and the process of owning patient panels will concentrate white patients within certain hospital systems that will be able to make the greatest investment in improving value and will receive the greatest benefit from the ACO arrangement. Although not intentional, this sce-