The volunteer's dilemma and alternate solutions for ensuring responsibility within accountable care organizations

ABSTRACT

The emphasis on accountable care organizations (ACOs) in recent health care reform increases the potential for social dilemmas such as the volunteer's dilemma within networks of providers who collectively share responsibility for a patient population. Providers in an ACO often receive financial incentives based on how well the group performs in defined quality measures. Care interventions may be indicated for certain patients, such as postdischarge follow-up to prevent readmission. However, the providers conducting the interventions may be unreliable if they vary in their belief in the intervention's effectiveness. We characterize such potential for care coordination failures as instability of an asymmetric equilibrium, illustrated by an example in which ACO patients would benefit from interventions to prevent readmission but individual providers or care teams do not perceive sufficient value in conducting the intervention. We then propose three economic mechanisms that can help ensure that patients receive indicated interventions, illustrate the impact of each with an example, and explore conditions that lead to significant improvements in overall utility.

Additional information

Notes on contributors

Brendan Bettinger

Brendan Bettinger received his Ph.D. in Industrial Engineering from Northeastern University. His research focuses on applying game theory models to describe cooperative competition dilemmas between health care providers and developing mechanism design solutions to realign incentives toward sustainable cooperative equilibria.

James C. Benneyan

James C. Benneyan is the executive director and senior scientist of the Healthcare Systems Engineering Institute at Northeastern University, including five federally funded centers supported by the National Science Foundation, CMS, AHRQ, and Veterans Health Administration. He is faculty and senior fellow at the Institute for Healthcare Improvement, past President of the Industrial Engineering Society for Health Systems, and fellow of the Institute of Industrial Engineers, Society for Health Systems, and Healthcare Information and Management Systems Society.