I think you can build in accountability systems for people who are paying something for their health insurance because they will have to pay more if they aren't compliant. I don't think it can be done the way Medicare is set up within the ACOs.
Q: Is the government model of ACOs sustainable?
A: I see the ACO as described by Elliott Fisher and others as a good model. This is a huge transition. For an industry as big as ours there are going to be fits and starts. This will probably evolve over the next decade or longer.
What concerns a lot of us is that you won't know what Medicare members are in your ACO until after the fact. Members can decide not to participate.
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The one person who has zero accountability in an ACO is the patient. Physicians will tell you that patients go home from the hospital, they don't fill their prescriptions or follow their diet regimen and then they end up right back in the hospital. There's nothing that I see in the ACO regs that makes the patient take accountability for care. I don't think it's going to work until we figure how to make patients have some degree of accountability for their personal care.
And, in my view, ACOs won't work until we figure out how to treat chronic illness differently than acute care illnesses. In our system we treat everything like it's an acute illness. We aren't structured as an industry to do a good job of dealing with people with complex chronic illnesses. We need to create a longitudinal model rather than an episodic model that cares for these people over time. How do you do that if you don't know for sure what patients are in your ACO?