Most of Enders' work is related to one or more of the groups involved in this tug of war, as he provides guidance in provider strategy, system development and formation, JVs, and linkages between institutions.
What will determine success?
All parties in these relationships have to produce a value proposition in terms of lowering the cost trend.
"With a commercial ACO, you have to create an affordable product that employers will buy," he says. "That includes a limited network footprint.
But this evolution is not entirely commercial.
"The Medicaid space is where a lot of this is going on," he says, particularly because Medicaid is going to be disrupted by the entrance of the insurance exchanges. To what degree is still unknown, but Medicaid is already a poor payer in the eyes of providers, so if there's any way to better manage the dollars that are available, it makes sense to start there.
"Providers want to draw out fee-for-service on the commercial side, so they're going slowly," Enders says. "A lot of my clients are still high-cost so they are cautious, but they're moving much more rapidly on the Medicaid side. They are in large part the Medicaid providers already."