Dismantling Structural Barriers: Resident Clinics Refocused on Equity.

Disparities in health by race, ethnicity, and socioeconomic status within obstetrics and gynecology are well described and prompt evaluation for structural barriers. Academic medicine has a historical role in caring for marginalized populations, with medical trainees often serving as first-line clinicians for outpatient care. The ubiquitous approach of concentrating care of marginalized patients within resident and trainee clinics raises ethical questions regarding equity and sends a clear message of value that is internalized by learners and patients. A path forward is elimination of the structural inequities caused by maintenance of clinics stratified by training level, thereby creating an integrated patient pool for trainees and attending physicians alike. In this model, demographic and insurance information is blinded and patient triage is guided by clinical acuity and patient preference alone. To address structural inequities in our health care delivery system, we implemented changes in our department. Our goals were to improve access and patient experience and to send a unified message to our patients, learners, and faculty-our clinical staff, across all training levels, are committed to giving the highest standard of care to all people, regardless of insurance status or ability to pay. Academic medical centers must look internally for structural barriers that contribute to health care disparities within obstetrics and gynecology as we aim to make progress toward equity.

Attributing patients to accountable care organizations: performance year approach aligns stakeholders' interests.

The accountable care organization (ACO) model of health care delivery is rapidly being implemented under government and private-sector initiatives. The model requires that each ACO have a defined patient population for which the ACO will be held accountable for both total cost of care and quality performance. However, there is no empirical evidence about the best way to define how patients are assigned to these groups of doctors, hospitals, and other health care providers. We examined the two major methods of defining, or attributing, patient populations to ACOs: the prospective method and the performance year method. The prospective method uses data from one year to assign patients to an ACO for the following performance year. The performance year method assigns patients to an ACO at the end of the performance year based on the population served during the performance year. We used Medicare fee-for-service claims data from 2008 and 2009 to simulate a set of ACOs to compare the two methods. Although both methods have benefits and drawbacks, we found that attributing patients using the performance year method yielded greater overlap of attributed patients and patients treated during the performance year and resulted in a higher proportion of care concentrated within an accountable care organization. Together, these results suggest that performance year attribution may more fully and accurately reflect an ACO's patient population and may better position an ACO to achieve shared savings.

The promise and peril of accountable care for vulnerable populations: a framework for overcoming obstacles.

Accountable care organizations (ACOs) are a promising payment model aimed at reducing costs while also improving the quality of care. However, there is a risk that vulnerable populations may not be fully incorporated into this new model. We define two distinct vulnerable populations, clinically at-risk and socially disadvantaged, and we discuss how ACOs may benefit each group. We provide a framework to use in considering challenges for both vulnerable patients and health systems on the path to accountable care. We identify policies that can help overcome these obstacles: strategies that support ACO formation in diverse settings and that monitor, measure, and reward the performance of providers that reach all patients, including vulnerable populations.