Monday, January 3, 2011

What Would A Truly Patient-Centered Accountable Care Organization (ACO) Look Like?

Health care leaders are busy talking to attorneys and consultants about how to set up Accountable Care Organizations (ACOs). A recent Advisory Board survey found that 73 per cent of hospital finance executives said that creating such an organization was a top priority for their health system.

Last year my most popular keynote topic was patient-centered medical home creation; this year everyone wants a presentation on ACOs.

However not everyone has jumped on the ACO bandwagon. Bruce Bagley, MD of the American Academy of Family Practice was recently quoted as saying, “There are probably no experts about ACOs. It’s a developing concept.” And Jeff Goldsmith, PhD, of the University of Virginia stated at the same conference: “I think this is a stupid idea. Managed care without the risk – that’s like gin and tonic without the gin. How do you end up making choices if you’re not forced to make them?” (

I started thinking about what an ACO would look like if it was truly patient-centered. What if we designed an ACO that gave patients what they say they really want?

Don Berwick wrote an article in Health Affairs in 2009 that examined what patient-centered should mean, and since he became the head of Medicare in 2010 it might make sense to start there. After all, Medicare is pushing the ACO concept by creating pilot projects and encouraging the shift from fee for service payments to global payments for medical care reimbursement.

In the Health Affairs article, Berwick defined patient centered care as “They give me exactly the help I need and want exactly when and how I need and want it.” Berwick said he was ready to move beyond words like partnership and have providers become guests in the lives of their patients.

Berwick went on to imagine that really embracing patient centered care would mean having no restrictions on hospital visiting hours, inpatients choosing what food and clothes they wanted, patients participating in rounds and the design of medical services, patients really owning their medical records, and patients and doctors universally using shared decision making aids so that patients could make wise choices knowing the inevitable trade-offs involved in picking a treatment.

Such an ACO would invest heavily in patient education and self-management programs. And these presentations would go well beyond the currently offered traditional wellness curriculum.

For example, a truly patient-centered ACO would offer technology support so their patients could harness their smart phones’ computing power, audio, video, motion sensors, and GPS modules to explore new ways to self-manage their health and wellness. There are smart phone applications for fitness and weight control, diabetes management, sleep hygiene, stress reduction, and hearing and vision assistance. An ACO that partnered with their patients to fully utilize such technology could keep their clients healthier and out of the hospital. Such a strategy makes a lot of sense if your organization is accepting global payments where hospitalizations are not incentivized.

I could even imagine a truly 21st century ACO expanding their primary care team to include physicians, advanced nurse practitioners, physician assistants, and even robots and avatars. Dr. Joseph Kvedar of Harvard’s Center for Connected Health believes that we will need to embrace emotional automation and use robots and avatars to meet the manpower needs of taking care of all the retiring Baby Boomers. In a YouTube video he states that one Boston hospital has already found that hospital patients prefer a robot for discharge planning to a real life person. The robot has all the time in the world and does not make the patient feel stupid when they ask the same question over and over again.

At first, I had a hard time getting my head around this emotional automation concept, but reading MIT’s Sherry Turkle’s book Evocative Objects: Things We Think With has convinced me that humans have already formed trusting relationships with technology. “We think with the objects we love, and we love the objects we think with.” How many of us talk about love when we discuss our iPhones or iPads that have really become extensions of our brains? Admit it, do you sleep with your smart phone?

The Health System that designs an ACO that is truly patient-centered will be highly successful. In addition to consulting attorneys and payment reform consultants, I would suggest that health systems think about how the new disruptive technologies (smart phones, tablet computers, avatars and robots, video games, haptics, and artificial intelligence) could be used to better manage a geographically defined population of patients.


  1. ACO's, by definition, are supposed to be patient centered - it's the law and, as you note, it's a priority for Don Berwick, so we can expect to see the concept enshrined in regulation.

    You offer a number of important dimensions of patient-centeredness. I had the opportunity to submit comments on the regulations-in-development on behalf of the Society of Participatory Medicine (linked to from here:, calling for providers and ACOs to (a) collaborate with patients to achieve the patients’ goals and make sure that care is delivered in a manner that suits the patient, not just the provider; (b) share health data with patients while keeping it otherwise private; (c) allow for patients to participate fully in care decisions, without requiring that they do so; (d) provide additional resources to patients so that they may participate effectively in their own care; and (e) train all patient-facing staff on principles of patient-centeredness.

    I tend to agree with Jeff Goldsmith's dim view of the final statutory language describing ACO's, but I believe that the regulatory flexibility promised by Don Berwick could yield tremendous opportunities for experimentation. I wrote about Jeff's proposal for ACO reimbursement by private sector payors here,, and wonder whether the approach he espouses for the private sector could not be offered in the public sector as well.

  2. This has been helpfull in understanding ACOs. I am interested in how the Payer and IT fit in all of this. I would like to share what I just read about BCBS-MA contracting based on quality. I believe it will be the Payer/ACO contract. Go to "Private-Payer Innovation In
    Massachusetts: The ‘Alternative
    Quality Contract" by By Michael E. Chernew, Robert E. Mechanic, Bruce E. Landon, and Dana Gelb Safran, Health Affairs, January 2011. Shows Actual Quality Measurements. Also, HIMSS had a great presentation by Randy Thomas, Premier, Inc. titled "Accountable Care Organizations: An Introduction to the Impact on Health IT" HIMSS may archive this webinar. The presentation is a must see for future ACO HIT requirements and archticture requirements.