Reimagining “Covered Lives” as Communities: Communitarian Ethics for ACOs

ABSTRACT

US health care has long sought to balance the health needs of individuals and communities, and efforts in bioethics aim to address tension between individual autonomy and the common good. In population health management, accountable care organizations (ACOs) are designed to create efficiencies by integrating and coordinating provider networks for defined patient populations often based on geography and physician practice patterns. From an ethical perspective, a lack of patient engagement in ACOs is problematic in that population health becomes something that happens to them, instead of the patients taking a participatory role in their health. Previous ethical frameworks have analyzed autonomy at the level of the individual, leading to ethically questionable conclusions around constraining patient autonomy to protect the common good. An approach based on responsive communitarian ethics, in which autonomy is conceived at the community level, is better suited to address the common good. One way forward is to reconceive of “covered lives” in ACOs as patient communities capable of engaging in moral dialogue about population health priorities.

Am J Accountable Care. 2023;11(2):32-38. https://doi.org/10.37765/ajac.2023.89383

The US health care system has long struggled with a tension between the autonomy of individual patients and the fair distribution of health care resources, specifically the recognition that individuals’ decisions may run counter to the common good—conceived of as “those goods that serve shared assets of a given community.”¹ In aggregate, these individual decisions are impactful: Between 2000 and 2020, US health care spending doubled and its share of gross domestic product increased from 13.3% to 19.7%, with individual spending varying substantially by factors such as geography and income level.² Scholars and policy makers have questioned whether this spending provides commensurate value, with some calling for greater focus on social drivers of health in communities.^3-6 Although health professionals have long known about the impacts of societal factors on health,⁷ in recent decades this work and that of others such as Marmot and colleagues⁸ has coalesced into the emerging field of population health science.

The term population health is now used to express distinct but related concepts. These include public health, capitated payment models, value-based contracting, and cross-sector efforts to address community-level societal factors, often referred to as social determinants of health.^9,10

A commonly referenced definition of population health was offered by Kindig and Stoddard as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”¹¹ This definition identifies the core of population health, although practice has become more expansive, with health care delivery systems increasingly seeking to align their population health management programs (ie, health care services oriented around a defined population of patients) with initiatives to address health-influencing factors for the communities they serve.¹² This evolution is reflected in the Pathways to Population Health framework developed by a multistakeholder group (Figure 1¹³), in which 4 portfolios of population health interventions are oriented around 2 reinforcing poles: community well-being creation and population management.¹³

In the Pathways to Population Health framework, 1 of the 2 major approaches to population health is population health management, in which health care services are (re)designed for defined patient populations. Existing efforts that take this approach include managed care organizations and patient-centered medical homes. Since the passage of the Patient Protection and Affordable Care Act,¹⁴ the most noteworthy model is accountable care organizations (ACOs), in which clinically integrated networks of providers seek to create efficiencies aligned with the Triple Aim of decreased health care costs, better population health outcomes, and improved patient experience of care¹⁵; increasingly, health systems have added an additional aim of clinician satisfaction, resulting in a Quadruple Aim.¹⁶

Movement to value-based care models including ACOs is expected to accelerate, with CMS recently calling for all Medicare beneficiaries to be enrolled in an ACO by 2030.¹⁷ As organizations focused on quality and efficiency, ACOs operate to advance their goals through coordinated efforts to “manage risk by compiling comprehensive dossiers on individuals within defined populations and redistributing accountability for their health outcomes.”¹⁸ Their health priorities are established by their administrators, but ACOs are required to collect and submit data for required quality metrics annually. In 2022, ACOs participating in the Medicare Shared Savings Plan were newly required to submit the Alternative Payment Model Performance Pathway Measure, a composite measure including clinical quality data, Consumer Assessment of Healthcare Providers and Systems survey results, claims, and administrative data.¹⁹ Although ACOs may establish priorities beyond those required by CMS, the complex nature and high stakes involved with measurement are influential for program administrators and may become an outsized focus for ACOs. Patient populations have little direct influence on determining ACO health priorities.^20,21

This article argues that because of the importance of patient communities in health-related priority-setting activities, reconceiving patient populations as patient communities instead of “covered lives” is needed to address the issues that arise from the unique situation of population health management programs. The analysis will be limited to the context of setting health priorities within ACOs as exemplary population health management programs.

Population Health Management: Priority Setting in ACOs

Advancing the Triple (or Quadruple) Aim goals of population health outcomes, decreased cost, and improved patient experience of care through ACOs is achieved through collaboration among clinical and social care providers (eg, community outreach, social care providers, community health workers) as well as administrative leaders. One approach that ACOs have taken to advance these goals is patient and family activation and engagement (PAE), which aims to involve patients in health promotion policies and activities, decisions about their own care, quality improvement efforts, and preferences about end-of-life care.^22,23 Shortell and colleagues found that some early ACOs viewed PAE as integral to their value-based care strategies and were invested in using these approaches with individual patients and their families despite challenges in implementation and evaluation.²²

Patients enrolled in an ACO are required to be informed of their inclusion, but enrollment of patients typically occurs through physician attribution on the basis of claims data²⁴ and researchers have noted that attribution to an ACO is something that “happens to” patients who may be unaware of their enrollment.²¹ Although CMS requires that patients be informed of their physicians’ participation in an ACO, this requirement has been delayed due to confusion about how providers should comply with the requirement.²⁵ If patients are unaware of their status as ACO participants, they may not have opportunities to provide input in health priority selection, even in ACOs that enthusiastically use PAE.

In response to this tension, ACOs could more intentionally notify patients of their enrollment in an ACO. An even more robust form of engagement would include seeking to actively engage patients in the identification and selection of ACO health priorities—“upstream” from an ACO’s care delivery and related PAE activities. This level of engagement will not be feasible, however, until ACO patient populations are conceived of as more than “covered lives.” One promising reconception would move toward seeing patient populations in ACOs as communities themselves.

A community is “a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings.”²⁶ According to this definition, ACOs (as geographically arranged groupings of professionals with common perspectives and shared interests) rely on the notion of community for the health care professionals they organize. Patient populations, by contrast, are framed as “covered lives.”

Applying this conception of population health as comprised of communities—and extending this view to the patient side—has practical and ethical implications for population health. Patient engagement and participation have long been shown to have significant impacts on outcomes and cost,²⁷ including in ACOs.²⁸ From a perspective of promoting the common good, adopting a community frame is strategically impactful for population health because it allows a focus on autonomy at the community level, instead of focusing only on questions of distributive justice and individual choice. At the same time, a focus on community-level autonomy with an aim for the common good may not be in itself adequate for resolving this core tension in population health.

Jotterand and colleagues recently noted that individuals’ free pursuit of health goals can “lead to a hyper-individualism that does not take into account our moral obligation toward others to build communities and enhance the common good” (italics in original).²⁹ Citing Jennifer Prah Ruger, Jotterand and colleagues argue that accounting for disparate views about health-related priorities requires “selection and valuation as means for deliberation of public policies.”^29,30 This is at least partly because different groups within a larger population have distinct health needs stemming from societal, environmental, and biological factors that must be met to successfully survive and flourish. From a justice perspective, meeting the unique health needs of specific groups is ethically important because meeting these needs—which are, importantly, not simple individual preferences—is what enables human beings to flourish.

Finally, it is important to take account of the institutions and structures that contribute to both community-level patterns of health needs and a community’s capacity for health. Philosopher Iris Marion Young makes the case that such justice includes not only tangible goods and services but also access to decision-making power and procedures.³¹ Such decision-making power is best seen through a structural lens because although decision-making power is actualized through individuals, it is implemented through a structure of relationships. Young’s point is apt for ACOs in that decision-making power structures are kept from patients, even when they are actively engaged in the clinical care processes in which they participate.

Review of Ethical Frameworks for ACOs

To date, limited scholarly attention has focused on the ethical and practical considerations of identification by ACOs of health priorities for their patient populations. In a proposal for ethical leadership of ACOs, medical ethicist Laurence McCullough suggests a framework oriented around “co-fiduciary responsibility” among physicians, health system administrators, payers, and patients.³² For McCullough, the development of medicine as a profession rested on the notion of the physician as a fiduciary of the patient—one obligated to elevate the patient’s interests while keeping their own interests “systematically secondary.”³² McCullough argues that in population health, physicians, administrators, and payers have fiduciary obligations due to their decisions’ impacts on the availability of resources for others in the population, and patients (as well as their surrogates) have similar obligations as “co-fiduciaries.” Accordingly, those who receive care in population health models are better seen as “co-managers of resources” than consumers, because the view of patient as consumer “obscures the patient’s social responsibility in health care.”³²

By taking medical professionalism as his point of departure, McCullough sees the patient in an ACO as an object of services, even while they have a co-fiduciary responsibility; population health management is still something that “happens to” patients. Moreover, by aiming to protect the health care common good (viewed as the just distribution of resources) while applying a framework based on the individual patient/surrogate or physician, McCullough is forced to argue for constrained patient autonomy despite their exclusion from influence on the ACO’s health priorities. In effect, the co-
fiduciary approach leads to sacrificing patient autonomy for the sake of distributive justice, without patients’ values or opinions having influence on the ends for which this sacrifice is made.

Analyzing population health programs including ACOs,^21,33 DeCamp and colleagues have identified challenges at the levels of leader, clinician, and patient.²¹ For leaders, the key issues relate to fairness in decision-making and resource allocation as well as to ensuring that professionals are protected from threats to their own ethical obligations. Clinicians’ ethical issues relate to balancing responsibility to patients against perceived pressures to meet financial goals and market competition and preserving autonomy against ACO incentives. Individual patients also experience challenges related to autonomy, privacy, and confidentiality, as their health data are shared across a network of providers. Finally, lack of patient engagement reflects an ethical challenge, and DeCamp and colleagues recognize that addressing this calls for “proven patient engagement strategies for ACO design, governance, and policymaking,”²¹ although the level of such engagement is not specified.

In an analysis of Pioneer ACOs, Westling and colleagues identified perceived ethical dilemmas in ACOs, which included the inability of clinicians to guide patients’ choices due to their complete lack of engagement.²⁰ Summarizing the challenge, one physician administrator interviewed for the study said, “In no way, shape, or form are patients engaged. They don’t even know they’re in an ACO.”²⁰

The ethical approaches to ACOs put forth by DeCamp, McCullough, and Westling identify ethical tensions—those leading to potential conflicts for administrators and clinicians and pointing toward insufficient patient engagement—as an important problem (Table^20,21,32,33). However, because these analyses take the individual as their point of departure, they struggle to find an ethically appropriate balance between autonomy and distributive justice. Both autonomy and distributive justice are important considerations in population health but may exist in ethical tension with one another. This tension can be addressed through recognition of the centrality of autonomy at the community level.

Communitarian Bioethics as a Way Forward for Population Health Ethics

In contrast to the above approaches, which focus on the individual, a communitarian analysis takes community as its starting point.³⁴ A communitarian ethical perspective is suited to population health management because it balances the inherent tension between individual autonomy and the common good by seeking to meet the unique needs of communities to enable the flourishing of their constituents. Communitarian ethics has been criticized for not giving due attention to the rights and values of individuals.³⁵ For example, scholars have cited the forced isolation of HIV-positive patients during the HIV/AIDS epidemic as exemplary of communitarianism run amok.³⁶ According to sociologist Amitai Etzioni, it is necessary to differentiate “authoritarian communitarianism” from “responsive (or liberal) communitarianism.”¹ In its authoritarian form, communitarian ethics can tend toward adopting community preferences a priori over individual autonomy (or vice versa); however, for Etzioni, responsive communitarian ethics acknowledges that neither the common good nor individual autonomy should be preferred a priori.³⁷ Instead, “one can reconcile liberalism and communitarianism by respecting universal principles: by recognizing the validity of universal individual rights but also holding that, in addition, people have particularistic social responsibilities that they ought to discharge their obligations to the common good.”¹

Communitarianism is not binary, and the extents of different factors are best viewed on a spectrum. For example, in selecting health priorities, autonomy can be constrained or maximized to different degrees and can likewise be considered at a variety of locations between the solitary individual through the broadly conceived community (Figure 2). When autonomy is at the level of the individual, the tension is between the pursuit of one’s own health interests regardless of the impact on others’ well-being and the narrowing of available choices an individual can make. At the community level, when autonomy is constrained, the result may be prohibition of activities deemed to endanger the common good. When community autonomy is maximized, consensus priorities can emerge through dialogue.

For Etzioni, the latter option is operationalized through “moral dialogues” in which preferences are “shaped through interactive communications about values—that is, through moral dialogues that combine passion with normative arguments and rely on processes of persuasion, education and leadership.”¹ According to Etzioni, moral dialogues are appropriate for building consensus around shared values, when important and value-laden decisions lead to disagreement and conflict in “wicked problems” such as balancing individual interest and the common health care good.^38,39 This approach is explicitly consensus-driven and anti-authoritarian. It also recognizes that although power differentials are both real and impactful, the consensus process can operate in the face of such power imbalances.⁴⁰ As Adrienne Maree Brown notes in Emergent Strategy, “consensus does not mean or require equal status. It requires equal voice.”⁴¹

Moral dialogue is distinct from other decision-making processes, notably rational deliberation, in the weight it places on nontechnical knowledge. In rational deliberation, technical and specialized expertise may be given priority, which can lead to bureaucratic and administrative direction of value-laden priority-setting processes. The process of moral dialogue also takes into consideration this type of expertise, but it explicitly gives at least equal weight to moral voice and communities’ shared values.³⁹ One way in which ACOs could seek to implement moral dialogues with their patient communities would be to build on the literature and documented experience of public health with community-based participatory research.^42,43 Once moral dialogue between a patient community and other stakeholders leads to consensus health priorities in an ACO, professional expertise could be brought to bear on how to achieve those priorities effectively and efficiently.

This is not to suggest that applying a communitarian perspective to population health management programs would be a panacea for US health care or even for addressing the aforementioned issues of justice in terms of access to decision-making power structures. This is particularly so for contexts in which an “organic” community may not exist among an ACO’s patient population. In such cases, priority-setting processes relying on moral dialogues should seek to assess the extent to which values are shared among a population. Although a cautious approach to engaging in health priority decision-making may be warranted in these contexts, there is still value in clearly communicating to patients that they are enrolled in an ACO and describing to them the general composition of the ACO’s patient population.

For ACOs, applying responsive communitarian ethics calls for moving toward a view of patients as communities with common interests and shared goals—in other words, as the provider community is already seen in ACOs. This reframing makes it possible to engage in moral dialogues to develop a shared understanding of how to balance individual health preferences with that community’s conception of the common good.

Limitations

This analysis has some limitations. First, it does not attempt to comprehensively address the full range of population health management programs or even all current iterations of the ACO model, including the ACO Realizing Equity, Access, and Community Health, or REACH, model, which includes a focus on equity and extending ACOs to underserved communities.⁴⁴ However, given the longstanding challenge of addressing the tensions between autonomy and the common health care good in US health care and bioethics, the choice to focus on ACOs in general enabled a more manageable unit of analysis. Second, limited data exist on the state of ACOs across the United States, and as a result some ACOs may be operating more in line with the above communitarian ethical principles. As such models are identified, they can serve as important case examples for other institutions and communities.

Conclusions

Due to efficiency concerns, ACOs have been oriented around clinician communities but lack meaningful engagement of the patients they aim to serve. This represents an area of ethical concern, but the frameworks proposed to date do not adequately address these concerns because they operate at the level of the individual. An ethical framework oriented around responsive communitarianism would advance bioethical scholarship on population health by addressing the tension between respect for autonomy and fair distribution of health care resources. It would further enable the use of a mechanism—moral dialogues—to establish consensus around population health priorities based in communities’ shared values for the common good.

Acknowledgments

The author wishes to acknowledge and thank those who reviewed and provided insightful comments on previous versions of this paper, including Lena Hatchett, PhD; Nancy Myers, PhD; Nanette Elster, JD, MPH; and attendees at the 2022 American Society for Bioethics and Humanities Annual Meeting. Their suggestions have greatly improved this paper, while any flaws or errors that remain are the author’s sole responsibility.

Author Affiliation: American Hospital Association, Chicago, IL.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; analysis and interpretation of data; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.

Send Correspondence to: Andrew J. Jager, DBe, MA, American Hospital Association, 155 N Wacker Dr, Chicago, IL 60606. Email: ajager@aha.org.

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