ACO Insider

Many thanks for the thoughtful e-mails from many of you readers. Some express cautious hope, some skepticism, and all the curiosity and caring that reminds me of how fortunate I am to have been a physician advocate for my legal career.

Here is one reader’s concerns about patient engagement – or lack thereof – in accountable care organizations.

– Reader: "ACOs will never work because, once again, the patient has been left out of the equation."

We hear this quite often, and it is surely true in some cases – but not all. In fact, we are convinced that patient engagement is such an essential element necessary for every successful ACO, that an ACO should not be called an ACO without it.

Patient noncompliance is a problem, especially regarding chronic diseases and lifestyle management. It is difficult to accept a compensation model based on input on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence. But patient engagement is part of patient-centeredness, which is required by the Affordable Care Act for an ACO to qualify for CMS’ Shared Savings Program.

So, what can an ACO do to engage patients?

Consider the following approaches:

– The patient compact. Some ACOs, such as the Geisinger Clinic, engage the patient through a compact, or agreement. It may involve a written commitment by the patient to be responsible for his or her own wellness or chronic care management, coupled with rewards for so doing, education, tools, self-care modules, and shared decision-making empowerment. The providers will need to embrace the importance of patient involvement and hold up their end of the engagement bargain.

– Benefit differentials for lifestyle choices. The financial impact of many volitional patient lifestyle choices is actuarially measurable. A logical consequence of the patient choice could be a benefit or financial differential reflecting at least partially these avoidable health care costs.

– Stay in contact. A Kaiser Permanente study of more than 35,000 hypertensive and diabetic patients found that the blood pressure and cholesterol levels for those who engaged in secure messaging were better than for those who did not.

– More time with your patients. Develop personal relationships. One ACO saw its results jump when its primary care physicians started using Biosignia’s "Know Your Number," a computer-generated graphic depiction of a patient’s health risks based on lab results and the Framingham Study. It is used by the treating physician at the point of care.

– Patient remote access to test results. This can be achieved with tools such as a web portal with multiple functions.

– Care navigators. We predict that the demands for care navigators, or coordinators, will skyrocket as ACOs take hold. Their use will include home visits. This may be the best patient engagement method.

– Empathetic listening. In curriculum and residency programs of medical schools, the paternalistic model is yielding to empathetic listening and communication skills in physician training.

– Educational materials. This consists of patient-friendly educational material that explains the benefits of being linked to a medical home.

I agree so much with this reader’s assertion that an ACO without patient engagement will fail, that I consider it an essential, almost definitional, element of every successful ACO. It is crucial that we emphasize the role of the patient. It is truly the "other shoe" that must fall for the new outcomes-based health care to succeed.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbit at [email protected], or at 919-821-6612.

Many thanks for the thoughtful e-mails from many of you readers. Some express cautious hope, some skepticism, and all the curiosity and caring that reminds me of how fortunate I am to have been a physician advocate for my legal career.

Here is one reader’s concerns about patient engagement – or lack thereof – in accountable care organizations.

– Reader: "ACOs will never work because, once again, the patient has been left out of the equation."

We hear this quite often, and it is surely true in some cases – but not all. In fact, we are convinced that patient engagement is such an essential element necessary for every successful ACO, that an ACO should not be called an ACO without it.

Patient noncompliance is a problem, especially regarding chronic diseases and lifestyle management. It is difficult to accept a compensation model based on input on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence. But patient engagement is part of patient-centeredness, which is required by the Affordable Care Act for an ACO to qualify for CMS’ Shared Savings Program.

So, what can an ACO do to engage patients?

Consider the following approaches:

– The patient compact. Some ACOs, such as the Geisinger Clinic, engage the patient through a compact, or agreement. It may involve a written commitment by the patient to be responsible for his or her own wellness or chronic care management, coupled with rewards for so doing, education, tools, self-care modules, and shared decision-making empowerment. The providers will need to embrace the importance of patient involvement and hold up their end of the engagement bargain.

– Benefit differentials for lifestyle choices. The financial impact of many volitional patient lifestyle choices is actuarially measurable. A logical consequence of the patient choice could be a benefit or financial differential reflecting at least partially these avoidable health care costs.

– Stay in contact. A Kaiser Permanente study of more than 35,000 hypertensive and diabetic patients found that the blood pressure and cholesterol levels for those who engaged in secure messaging were better than for those who did not.

– More time with your patients. Develop personal relationships. One ACO saw its results jump when its primary care physicians started using Biosignia’s "Know Your Number," a computer-generated graphic depiction of a patient’s health risks based on lab results and the Framingham Study. It is used by the treating physician at the point of care.

– Patient remote access to test results. This can be achieved with tools such as a web portal with multiple functions.

– Care navigators. We predict that the demands for care navigators, or coordinators, will skyrocket as ACOs take hold. Their use will include home visits. This may be the best patient engagement method.

– Empathetic listening. In curriculum and residency programs of medical schools, the paternalistic model is yielding to empathetic listening and communication skills in physician training.

– Educational materials. This consists of patient-friendly educational material that explains the benefits of being linked to a medical home.

I agree so much with this reader’s assertion that an ACO without patient engagement will fail, that I consider it an essential, almost definitional, element of every successful ACO. It is crucial that we emphasize the role of the patient. It is truly the "other shoe" that must fall for the new outcomes-based health care to succeed.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbit at [email protected], or at 919-821-6612.

Many thanks for the thoughtful e-mails from many of you readers. Some express cautious hope, some skepticism, and all the curiosity and caring that reminds me of how fortunate I am to have been a physician advocate for my legal career.

Here is one reader’s concerns about patient engagement – or lack thereof – in accountable care organizations.

– Reader: "ACOs will never work because, once again, the patient has been left out of the equation."

We hear this quite often, and it is surely true in some cases – but not all. In fact, we are convinced that patient engagement is such an essential element necessary for every successful ACO, that an ACO should not be called an ACO without it.

Patient noncompliance is a problem, especially regarding chronic diseases and lifestyle management. It is difficult to accept a compensation model based on input on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence. But patient engagement is part of patient-centeredness, which is required by the Affordable Care Act for an ACO to qualify for CMS’ Shared Savings Program.

So, what can an ACO do to engage patients?

Consider the following approaches:

– The patient compact. Some ACOs, such as the Geisinger Clinic, engage the patient through a compact, or agreement. It may involve a written commitment by the patient to be responsible for his or her own wellness or chronic care management, coupled with rewards for so doing, education, tools, self-care modules, and shared decision-making empowerment. The providers will need to embrace the importance of patient involvement and hold up their end of the engagement bargain.

– Benefit differentials for lifestyle choices. The financial impact of many volitional patient lifestyle choices is actuarially measurable. A logical consequence of the patient choice could be a benefit or financial differential reflecting at least partially these avoidable health care costs.

– Stay in contact. A Kaiser Permanente study of more than 35,000 hypertensive and diabetic patients found that the blood pressure and cholesterol levels for those who engaged in secure messaging were better than for those who did not.

– More time with your patients. Develop personal relationships. One ACO saw its results jump when its primary care physicians started using Biosignia’s "Know Your Number," a computer-generated graphic depiction of a patient’s health risks based on lab results and the Framingham Study. It is used by the treating physician at the point of care.

– Patient remote access to test results. This can be achieved with tools such as a web portal with multiple functions.

– Care navigators. We predict that the demands for care navigators, or coordinators, will skyrocket as ACOs take hold. Their use will include home visits. This may be the best patient engagement method.

– Empathetic listening. In curriculum and residency programs of medical schools, the paternalistic model is yielding to empathetic listening and communication skills in physician training.

– Educational materials. This consists of patient-friendly educational material that explains the benefits of being linked to a medical home.

I agree so much with this reader’s assertion that an ACO without patient engagement will fail, that I consider it an essential, almost definitional, element of every successful ACO. It is crucial that we emphasize the role of the patient. It is truly the "other shoe" that must fall for the new outcomes-based health care to succeed.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbit at [email protected], or at 919-821-6612.

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at [email protected].

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at [email protected].

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at [email protected].

Regardless of the fate of federal health reform, accountable care organizations will continue to develop because the current system is completely unsustainable.

These organizations are emerging because of the necessity to shift the unsustainable payment for volume in today’s fee-for-service health care delivery system to one that rewards value. ACOs will be judged on the delivery of quality health care while controlling overall costs. In general, ACOs will usually receive about half of the savings if quality standards are met.

This will necessitate a transformative shift from fragmented, episodic care to care that is delivered by teams following best practices across the continuum. Providers will thus be "accountable" to each other to achieve value (defined as the highest quality at the lowest cost), because they must work together to generate a sizable savings pool and to improve a patient population’s health status.

Why are ACOs empowering to primary care physicians?

ACOs will target the following key drivers of value:

• Prevention and wellness.

• Chronic disease management.

• Reduced hospitalizations.

• Improved care transitions.

• Multispecialty comanagement of complex patients.

Primary care physicians play a central role in each of these categories.

As Harold Miller of the Center for Healthcare Quality and Payment Reform once said: "In order to be accountable for the health and health care of a broad population of patients, an accountable care organization must have one or more primary care practices playing a central role."

In fact, primary care providers are the only type of provider mandated for inclusion in the ACO Shared Savings Program under the Affordable Care Act.

But are ACOs likely to be favorable situations for primary care physicians?

First, let’s consider the pros. Many physicians find that the ACO movement’s emphasis on primary care to be a validation of the reasons they went to medical school. Being asked to guide the health care delivery system and being given the tools to do so is empowering. Leading change that will save lives and improve patient access to care would be deeply fulfilling. There also is, of course, the potential for financial gain. Unlike physicians in other specialties, primary care physicians have many opportunities in ACOs.

On the con side, you are not alone if you feel overworked or burned out, or that you simply do not have the time, resources, or remaining intellectual bandwidth to get involved.

Many have already weathered promises from the "next big thing" that in the end did not work out as advertised. And equal numbers have little capital and no business or legal consultants on retainer, as do other health care stakeholders. Time is stretched tight in many areas of the country that are already feeling the effects of a primary care workforce shortage – and now the ACO model is asking that you take on more responsibility?

But here’s the thing: If primary care physicians do not recognize the magnitude of their role in time, the opportunity for ACO success will pass them by and be replaced by dismal alternatives.

And there are already success stories. Starting with several simple Medicaid initiatives, North Carolina primary care physicians created a statewide confederation of 14 medical home ACO networks. Although the work involved is plentiful, so have been the rewards.

Among them is a renewed empowerment and leverage for their interests when they contract with payers and facilities. In interviews with the networks’ physicians, the consensus is that although much is uncertain, the primary care physicians feel much more prepared to face the changes in health care, having first created the medical home networks that lead to medical home–centric ACOs.

For those primary care physicians who choose to join a hospital, the same pros and cons generally apply. By being on the "inside," employed physicians may actually have more influence to shape a successful ACO that fairly values the role of primary care. However, they may have more difficulty freely associating with an ACO outside of the hospital’s ACO.

Whether you are inside or outside the hospital setting, there is tremendous financial opportunity for primary care providers. Shared savings is based on all costs, including those for hospitalization and drugs. The distribution of the shared savings will be proportional to the relative contribution to the savings. Thus, the percentage going to primary care stands to be considerable.

America cannot afford its current health care system. It is asking physicians to run a new health care system, with primary care at its core. There is a dramatic change of focus, from cost centers in health care to savings centers in health care.

Empowerment is being offered, but primary care must step up in order to enjoy it.

Regardless of the fate of federal health reform, accountable care organizations will continue to develop because the current system is completely unsustainable.

These organizations are emerging because of the necessity to shift the unsustainable payment for volume in today’s fee-for-service health care delivery system to one that rewards value. ACOs will be judged on the delivery of quality health care while controlling overall costs. In general, ACOs will usually receive about half of the savings if quality standards are met.

This will necessitate a transformative shift from fragmented, episodic care to care that is delivered by teams following best practices across the continuum. Providers will thus be "accountable" to each other to achieve value (defined as the highest quality at the lowest cost), because they must work together to generate a sizable savings pool and to improve a patient population’s health status.

Why are ACOs empowering to primary care physicians?

ACOs will target the following key drivers of value:

• Prevention and wellness.

• Chronic disease management.

• Reduced hospitalizations.

• Improved care transitions.

• Multispecialty comanagement of complex patients.

Primary care physicians play a central role in each of these categories.

As Harold Miller of the Center for Healthcare Quality and Payment Reform once said: "In order to be accountable for the health and health care of a broad population of patients, an accountable care organization must have one or more primary care practices playing a central role."

In fact, primary care providers are the only type of provider mandated for inclusion in the ACO Shared Savings Program under the Affordable Care Act.

But are ACOs likely to be favorable situations for primary care physicians?

First, let’s consider the pros. Many physicians find that the ACO movement’s emphasis on primary care to be a validation of the reasons they went to medical school. Being asked to guide the health care delivery system and being given the tools to do so is empowering. Leading change that will save lives and improve patient access to care would be deeply fulfilling. There also is, of course, the potential for financial gain. Unlike physicians in other specialties, primary care physicians have many opportunities in ACOs.

On the con side, you are not alone if you feel overworked or burned out, or that you simply do not have the time, resources, or remaining intellectual bandwidth to get involved.

Many have already weathered promises from the "next big thing" that in the end did not work out as advertised. And equal numbers have little capital and no business or legal consultants on retainer, as do other health care stakeholders. Time is stretched tight in many areas of the country that are already feeling the effects of a primary care workforce shortage – and now the ACO model is asking that you take on more responsibility?

But here’s the thing: If primary care physicians do not recognize the magnitude of their role in time, the opportunity for ACO success will pass them by and be replaced by dismal alternatives.

And there are already success stories. Starting with several simple Medicaid initiatives, North Carolina primary care physicians created a statewide confederation of 14 medical home ACO networks. Although the work involved is plentiful, so have been the rewards.

Among them is a renewed empowerment and leverage for their interests when they contract with payers and facilities. In interviews with the networks’ physicians, the consensus is that although much is uncertain, the primary care physicians feel much more prepared to face the changes in health care, having first created the medical home networks that lead to medical home–centric ACOs.

For those primary care physicians who choose to join a hospital, the same pros and cons generally apply. By being on the "inside," employed physicians may actually have more influence to shape a successful ACO that fairly values the role of primary care. However, they may have more difficulty freely associating with an ACO outside of the hospital’s ACO.

Whether you are inside or outside the hospital setting, there is tremendous financial opportunity for primary care providers. Shared savings is based on all costs, including those for hospitalization and drugs. The distribution of the shared savings will be proportional to the relative contribution to the savings. Thus, the percentage going to primary care stands to be considerable.

America cannot afford its current health care system. It is asking physicians to run a new health care system, with primary care at its core. There is a dramatic change of focus, from cost centers in health care to savings centers in health care.

Empowerment is being offered, but primary care must step up in order to enjoy it.

Regardless of the fate of federal health reform, accountable care organizations will continue to develop because the current system is completely unsustainable.

These organizations are emerging because of the necessity to shift the unsustainable payment for volume in today’s fee-for-service health care delivery system to one that rewards value. ACOs will be judged on the delivery of quality health care while controlling overall costs. In general, ACOs will usually receive about half of the savings if quality standards are met.

This will necessitate a transformative shift from fragmented, episodic care to care that is delivered by teams following best practices across the continuum. Providers will thus be "accountable" to each other to achieve value (defined as the highest quality at the lowest cost), because they must work together to generate a sizable savings pool and to improve a patient population’s health status.

Why are ACOs empowering to primary care physicians?

ACOs will target the following key drivers of value:

• Prevention and wellness.

• Chronic disease management.

• Reduced hospitalizations.

• Improved care transitions.

• Multispecialty comanagement of complex patients.

Primary care physicians play a central role in each of these categories.

As Harold Miller of the Center for Healthcare Quality and Payment Reform once said: "In order to be accountable for the health and health care of a broad population of patients, an accountable care organization must have one or more primary care practices playing a central role."

In fact, primary care providers are the only type of provider mandated for inclusion in the ACO Shared Savings Program under the Affordable Care Act.

But are ACOs likely to be favorable situations for primary care physicians?

First, let’s consider the pros. Many physicians find that the ACO movement’s emphasis on primary care to be a validation of the reasons they went to medical school. Being asked to guide the health care delivery system and being given the tools to do so is empowering. Leading change that will save lives and improve patient access to care would be deeply fulfilling. There also is, of course, the potential for financial gain. Unlike physicians in other specialties, primary care physicians have many opportunities in ACOs.

On the con side, you are not alone if you feel overworked or burned out, or that you simply do not have the time, resources, or remaining intellectual bandwidth to get involved.

Many have already weathered promises from the "next big thing" that in the end did not work out as advertised. And equal numbers have little capital and no business or legal consultants on retainer, as do other health care stakeholders. Time is stretched tight in many areas of the country that are already feeling the effects of a primary care workforce shortage – and now the ACO model is asking that you take on more responsibility?

But here’s the thing: If primary care physicians do not recognize the magnitude of their role in time, the opportunity for ACO success will pass them by and be replaced by dismal alternatives.

And there are already success stories. Starting with several simple Medicaid initiatives, North Carolina primary care physicians created a statewide confederation of 14 medical home ACO networks. Although the work involved is plentiful, so have been the rewards.

Among them is a renewed empowerment and leverage for their interests when they contract with payers and facilities. In interviews with the networks’ physicians, the consensus is that although much is uncertain, the primary care physicians feel much more prepared to face the changes in health care, having first created the medical home networks that lead to medical home–centric ACOs.

For those primary care physicians who choose to join a hospital, the same pros and cons generally apply. By being on the "inside," employed physicians may actually have more influence to shape a successful ACO that fairly values the role of primary care. However, they may have more difficulty freely associating with an ACO outside of the hospital’s ACO.

Whether you are inside or outside the hospital setting, there is tremendous financial opportunity for primary care providers. Shared savings is based on all costs, including those for hospitalization and drugs. The distribution of the shared savings will be proportional to the relative contribution to the savings. Thus, the percentage going to primary care stands to be considerable.

America cannot afford its current health care system. It is asking physicians to run a new health care system, with primary care at its core. There is a dramatic change of focus, from cost centers in health care to savings centers in health care.

Empowerment is being offered, but primary care must step up in order to enjoy it.