Accountable Care Organizations and Medical Ethics In New Hampshire

The action in health reform has passed to the states.

Twenty states, nineteen of them led by Republican Attorney Generals cultivating future election prospects, are hoping to return to the past, and are fighting a rear guard action against the federal reform law. (See here.)

Others, like New Hampshire, are moving forward.

In July, Governor John Lynch announced a five year pilot program to move the state away from fee-for-service reimbursement by establishing five accountable care organizations in different parts of the state. Here's what the Governor had to say about launching the ACO experiment:

"Right now, we're not spending our health care dollars the right way and through this pilot project we are going to work together in New Hampshire to change that. Our current health care system rewards providers for seeing as many patients as possible. We're going to change that. Under this pilot project, we are moving to a system where health care providers will profit from spending time with their patients and keeping them healthy - and that's the way it should be. This Accountable Care Health Organization Pilot Project seeks to be competitive in getting a piece of incentive grants in the federal Obama health care reform law to reward providers that bend the cost curve.

Two years ago, I challenged health care and insurance industry leaders to work with us to develop a New Hampshire solution for improving quality and reducing the growth in health care costs. Everyone at the table recognized that our current health care system was not working for business, for providers or patients. That's why we are taking action to change our health care system now, the New Hampshire way, by working together."

The key phrase in the Governor's comments is "working together." Improving our health system requires a population health perspective and new forms of collaboration among stakeholders. Reform isn't rocket science, but it requires cooperation and substantial political courage. That's what the tea leaves suggest is happening in New Hampshire. The provider community, citizen health organizations, employers, health insurers, and the University of New Hampshire Institute for Health Policy and Practice are all part of the initiative.

The first year of the five year pilot is devoted to planning. I expect that anticipating the ethical opportunities and challenges of the ACO structure will be part of the planning process. Heather Staples, who supports the ACO pilot on behalf of the New Hampshire Citizens Health Initiative, pointed the way to the ethics discussion:

"Right now, we pay for care when someone shows up. We don't pay for care when they don't ever come in. What we want is for people to be managed in a thoughtful way outside of when they come into the emergency room."

Having health and health care "managed in a thoughtful way" is exactly what the health system needs. But different parties will hold different perspectives on the right way to manage. Physicians will want wider information about their patients. Insurers will want to be able to reach out to the insured population. Employers will want to encourage employees to be active on behalf of their own health. And each of us, as individuals, will have our own views about privacy and the relationships we want to have with our physicians, insurers and employers.

In the 1990s, the U.S. asked insurers to take the lead in having health care "managed in a thoughtful way." The experiment blew up because we didn't have all stakeholders at the table for open deliberation about competing values. New Hampshire, with its strong tradition of respect for individual autonomy (the state motto is - "Live free or die"), isn't going to repeat the mistake we made with managed care 1990s style!