In theory, the ACO is a well-tuned engine designed to eliminate waste from healthcare provider interactions and coordinate care effectively. This sounds really good, and it's little surprise that providers are jumping on to the ACO train.
However, those who are so in favor of ACOs are ignoring a basic fact of human behavior, which is that businesses operate out of self- interest -- no matter how noble their aims may sound. Specifically, I believe that an institution such as a hospital, whose mission is to fill beds, will rarely -- if ever -- cooperate effectively with an organization whose job it is to keep people out of a hospital, such as a primary care organization.
Planners seem to feel they can work past that inherent contradiction by making the incentives large enough, and the punishment severe enough. They seem to think that two industry sectors with inherently different aims can be brought together into harmony if the fruit basket you give them is large enough.
Let's face it: it will never be easy to reward an inpatient facility for keeping patients out of beds. Hospital executives may understand why care needs to exist largely at the ambulatory, primary level, but the rewards they get for doing so will never compensate for the money they lose in lowering admissions to greater use of primary care.
Yes, I know that when it comes down to it, all of us want to see patients get care in the environment which suits their needs best. But if ACOs are to succeed, they will drain patients from inpatient facilities at such a rate that we may see some credit failures or even bankruptcies. And obviously, no hospital wants to take part in a game which is essentially rigged against them.
And don't tell me about how great shared savings programs are; I'll tell you flat out that they're not. Doctors may do well in a situation that emphasizes outpatient care, but it's little wonder that hospitals aren't seeing those shared savings yet.
Until we accept the paradoxical nature of ACOs, and find new ways to compensate both medical practices and hospitals that don't pit them against one another, ACOs will be just another flavor of the year. I recommend we stop frenzied ACO building efforts and reconsider who is getting paid to do what. Then, perhaps, we will be able to build a large, coordinated system which squeezes out needless care but doesn't do so at the expense of the hospitals' operating model.