Can Patients Trust Accountable Care Organizations?

The 1990s version of managed care 1.0 crashed and burned because of distrust. Physicians distrusted the utilization review systems and payment schemes imposed on them by insurers. Patients feared the care they needed would be withheld for reasons of cost, and they wouldn't even be told what was going on. When Helen Hunt riffed about "bleeping HMO bastard pieces of shit" in the 1997 movie "As Good As It Gets," audiences cheered! (You can see the segment on YouTube here.)

Prior to talking with a group of physicians, insurers, and other stakeholders involved in a pilot ACO program, I reviewed literature about trust to see how managed care 2.0 could avoid the backlash that felled managed care 1.0 in the 1990s. Two empirical studies seemed especially useful: "The Effect of Physician Disclosure of Financial Incentives on Trust," by Wendy Levinson and colleagues, and "A Trial of Disclosing Physicians' Financial Incentives to Patients," by Steve Pearson and colleagues.

Dr. Levinson surveyed the reactions of almost 3,000 interviewees chosen to reflect U.S. households, on their reactions to this vignette:

Imagine you've been experiencing headaches. You visit your doctor and talk to him about your symptoms. You also tell the doctor that you've been feeling a lot of stress lately. After doing a complete examination the doctor decides that the headaches are probably due to stress. The doctor wants to work with you over the next month to reduce your stress. You want to have an MRI to make sure everything is okay. Remember that after your complete examination the doctor thinks you don't need the MRI. Then imagine that you have the following conversation with the doctor about the MRI and financial incentives.

After hearing the scenario, one of six possible strategies was played, each beginning with this patient statement: "I'd feel better if I had an MRI. I'm worried that you won't order it because it's too expensive."

Three physician communication strategies were primarily "cognitive" - giving direct information, stressing expertise, and denying that incentives had any influence. Three were primarily "affective" - addressing the patient's emotions, badmouthing managed care as a common enemy, and negotiating with the patient for a mutually acceptable plan.

The article includes many fascinating details, but the overall conclusion is simple and clear. The interviewees overwhelmingly wanted to know about the incentives. Their preference was to be told about them at the time of enrollment in their health plan. Two physician communication strategies - addressing patient emotions and negotiating for a mutually acceptable plan - worked best to convey information and preserve trust. The authors' bottom line was that "physicians should acquire the skills needed to openly discuss if, and how, they are influenced by financial constraints and cost containment programs."

Dr. Pearson conducted an experiment in two medical groups. The chief medical officers sent letters to randomly selected patients describing the compensation arrangements for physicians in the group. Neither group put physicians at risk for cost overruns or rewarded individual physicians for withholding services. Three months later the patients to whom letters had been sent and a matched control group were surveyed.

The intervention of a one-time letter significantly improved knowledge of how physicians in the group were compensated. Nearly a quarter of the patients who remembered receiving a letter reported that it had increased trust in their primary care physician. The disclosure letter did not decrease trust that PCPs would patients' interests above concern about costs. The authors' bottom line was that "regulators, policy makers, and physician groups themselves should renew their consideration of disclosure as an instrument to advance the best interests of patients and physicians."

Some policy makers anticipate that patients will be "attributed" to ACOs without being told, hoping that being part of an ACO will be invisible. This is wishful thinking. It won't take Wikileaks and Julian Assange to reveal the ACO structure. And if, as I believe, properly run ACOs represent an ideal way of providing and receiving care, lack of transparency will breed unnecessary suspicion and distrust.

It remains to be seen if we (physicians, patients, health plans, and other stakeholders) will be able to make managed care 2.0 work better than the earlier version. But unless physicians and health plans engage patients in an open, educative, and collaborative manner, 2.0 will go down the tubes just as 1.0 did.