Chasing Unicorns: The Future of ACOs

By Ian Morrison

The accountable care organization is like a unicorn, a fantastic creature that is vested with mythical powers. But no one has actually seen one.

I have re-blogged and re-tweeted (twitter@seccurve) this so often that I received all the credit for the line. Welcome to the Internet age. But in all fairness to me, re-tweeting someone else’s intellectual property is as close as most of us get to original thought these days.

And that, my friends, brings me to why chasing unicorns is so important. The rising cost of health care is a national security threat greater than any other. It will kill the budget, the economy and, some even argue, the patients because of unaffordability, excessive iatrogenic interventions and profligate use of resources. We desperately need some big new ideas about how to practically meet Don Berwick’s noble triple aim of better care, better population health and lower per capita costs.

One of those big new ideas is the accountable care organization, or ACO.

Well, actually it is not an entirely new idea. And many in health care can (and do) legitimately claim to having been one for a long time. Kaiser, Geisinger, Mayo, Cleveland Clinic, capitated delegated medical groups of California, and even a few network model HMOs, among others, can say they were doing this all along.

I gave a little after-dinner talk to an elite group of ACO thought leaders in Los Angeles (basically, the talk is the rest of this column) and it was a combination of both a roast and homage to Dr. Eliot Fisher of Dartmouth (who was there, I may add) and whom I always describe as a national treasure, not only for leading the wonderful Dartmouth Atlas work, which in many ways was the intellectual underpinning of and the compelling case for meaningful health reform, but also widely credited with coining the term “accountable care organization.” But, as Eliot would be the first to modestly admit, many others in the room that night (Enthoven, Shortell, Levine, Crosson, Margolis, O’Kane, Robinson, and too many more to acknowledge adequately here) are all part of the intellectual and practical foundations of this re-emergence of the accountable care organization vernacular.

At their very best, ACOs could be a powerful, successful, re-tweet of Enthoven’s managed competition, which a lot of us thought was a pretty decent American compromise the first time around (see a previous column, “The New American Compromise“). At its worst, it could be a badly defined mishmash of half-baked ideas and experiments that is an orgy of excess for lawyers and consultants. As one colleague noted to me, probably half of the 1,500 attendees at the 2010 ACO Congress in Los Angeles were lawyers and consultants (including me) eager to arm themselves with a new PowerPoint for an assault on the dazed and confused delivery system. (Do a Google search for “ACO video” and you will find a brilliant cartoon about this on YouTube.)

So, here’s my take on ACOs and what we have to do to make them work. I frame my suggestions simply and modestly, first as a central two-part problem, and second as Morrison’s 10 Laws. (When you are a futurist, you’re allowed to make up your own laws.)

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