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

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.