Can ACOs reinvent the American health care system?

The cost curve of American medicine continues to bend up. That is unsustainable. It must begin to bend downward.

Two recent headlines focus the problem:

New York Times, May 14, 2011: Health Insurers Making Record Profits as Many Postpone Care

And, CNN Money, May 11, 2011 reports “Your family’s healthcare costs $19,393.” That is for a family of four, which has a median income of $75,700  – before taxes.

Opportunity knocks, loudly. We can change our medical world now.

American medicine has been very successful. American medicine has been a dismal failure. Both statements are correct, depending on how one looks at it.

It is now our opportunity, indeed I say our professional responsibility, to preserve the best, and to scuttle the worst.

We can build a new medical world based less upon process, quantity, volume, and lucre, and more on quality, safety, speed, outcomes, and patient-centered efficiency.

In this new era of accountable care organizations (ACOs), keep your eyes on the prize.

And the prize is positive outcomes for the health of the mind, body, and spirit of the patient.

Keep healthy people healthy, vigorous, and confident; recognize and treat acute illness quickly and effectively; manage chronic illness efficiently; do not promote disease mongering, cyberchrondriasis, medical bankruptcy, or, what Nortin Hadler and Clifton Meador call “the worried well.”

Accountable Care Organizations may take many forms. I believe that physician leadership will be the key.

The three goals of an ACO are to:

  1. Increase perceived value of care
  2. Improve actual clinical outcomes
  3. Lower healthcare costs

If it saves money, the ACO gets to keep some of the savings. This truly is an exciting opportunity to do well by doing good.

With ACOs, the American healthcare non-system actually can and should be reinvented.


I recommend engaging and empowering communities to work with the healthcare sector in building ACOs for their common good.

The credo of The Lundberg Institute is: one patient; one physician; one moment; one decision; let it be a shared decision, informed by the best evidence, and considering cost.

Might ACOs make health community informed shared decision-making of the same sort possible, facilitated by participatory technologies and social media as recently suggested by Springgate and Brook in JAMA?

Exciting time. Be creative. Seize the moment. Save American pluralistic healthcare. It may be our last best chance.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Originally published in MedPage Today. Visit for more health policy news.

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  • pcp

    Is this article for real?

    The ONE goal of an ACO:

    to maximize market share.

    ACOs represent an enormous step forward in the corporatization (profit motivation) of American medicine.

  • DocB

    an “ACO” can only work if it is heavy primary care focused….

    I see a future of large healthcare conglomerations with CEOs (prior Health Ins Executives for sure….) with a board of physicians (probably consisting of plastic surgeons and cardiologist) all “driving” the ship of “ACO” care…. and PCPs working as hard as ever for 90K/yr. ACO will probably find a good way to shift malpractice risk away from themselves as well….

    health quality— Worse than ever.
    Cost— staggering….

    I really hope I’m wrong, but I kinda doubt it.

  • DrErle

    If grand platitudes can save our system, then ACO’s are a surefire success.

  • Joe

    I thought that the lead up was a joke and the last paragraph of the article would state the obvious truth that an ACO is about power and money being concentrated into smaller and smaller circles of executives.

    Come on Dr. Lundberg, take the blinders off.

  • gzuckier

    Still comes back to the same truism; in the end, the most effective way to cut healthcare costs is to cherry pick healthy people; much more cost effective than trying to optimize treatment of sick people. Folks with a certain type of bent will recognize the situation as the classic positive feedback system, aka death spiral.

    Has anybody suggested breaking the loop by instituting more carrot than stick; i.e. higher payments for taking on cases/patients definable a priori as more difficult? I know it’s been done in other countries; I can’t be the only person who knows that, can I?

  • Dorothy Green

    “The credo of The Lundberg Institute is: one patient; one physician; one moment; one decision; let it be a shared decision, informed by the best evidence, and considering cost.

    OK, so what do you do with the obese/overweight patient with diabetes type II, heart disease or other overeating issues who won’t change their eating habits?

    T.R. Reid Healing of America, 2009 – Efforts to keep people healthy……contribute more to the health of the entire population than life saving work of doctors treating patients one by one.

    My Credo – If we do not change our eating culture we will not bend the healthcare cost curve.

  • Dorothy Green

    NO, Tony, healthy behavior cannot be legislated but many many pulblic health efforts can be instituted that aren’t. Volunteers across the country are trying hard against an army of Big Food lawyers with mega $$$$$ who rule the unhealthy food roost and push back hard. Other countries have been able to institute changes successfully like removing fast food ads during kids shows etc, massive education etc. because it is a public health issue to them.

    Think about the battle with tobacco companies and finally winning – labels (strong message) and taxes (some money to pay healthcare bills but make more difficult to afford) – it was 65% of the population now down to 20%. Here we have done better than most countries.

    Sugar, fat and salt are the substances that make food addictive – food designers are paid big bucks to manipulate these substances. The resultant chronic preventive disesases from overeating are now the largest portion of our healthcare costs.

    All reform measures will help decrease costs and must go forward – no more fee for service, fight the fraud, coverage for all, etc. But Americans addiction to unhealthy food is the major driver of healthcare costs – it is called an epidemic – it is a public health problem.

    The problem is too pervasive to expect any model in healthcare reform will be able to resolve it. A food addicted person will leave the doctor’s office and probably see no less than 10 BIG signs for fast food where they can just drive in and eat cheap, tasty unhealthy food.

  • Dorothy Green


    I hear your points about physicians making more if people remain unhealthy and that fee for service keeps this going, and that ACO’s are probably a good idea. I just read an article in the NEJM that suggested combining ACOs with acadamic centers and it all sounds positive and on track to help solve healthcare problems.

    I tend to interject, whenever I see an opening, that all of it is not enough to “bend the cost curve” regardless of how clever.

    The evidence points to poor diet as the major risk factor to all Chronic Preventable Diseases (if these really are diseases or rather self-inflicted damage) and most of what is spent on healthcare. So it follows that until this major risk factor is addressed as a public health problem all the changes in healthcare reform will be frustrated at best and end of costing more at worst. It can be addressed.

    I say what MUST be done and done now along with healthcare reform measures is to tax processed sugar at least and what has been shown to be unhealthy fats and added salt and to stop subsidies to corn production for HFCS at least and cane and beet sugar – there is no nutritional value in these substances – only harm to the body becasue they are so pervasive . There are many advocates, but not enough to still the political resistance of Big Ag. Even people who overeat would not object (I love ice cream too and was addicted)- they understand the medical implications and know they need the message up front and personal. I ask whenever I can.

    I have developed a way to do this that I share whenever I can because the idea of pennies per ounce is wrong and it will fail if instituted or limited to one product. It needs to be based on the Nutrition Facts that already exist – thanks to Dr. David Kessler – using grams for sugar and fat and mg for salt. And the RISK message goes on the package as well.

    All efforts of Michele Obama and changing the food pyramid to a dish are swell ideas. But, we don’t have time to not tax unhealthy food. My estimations are, based on the volume of sugar, corn fed animals, vegetable oils and salt consummed in the US now as compared to when the obesity/overweight rate was a quarter as much, at least 100 billion dollars a year could be collected and put into healthcare reform measures. The cost and message to people will be a strong incentive to reduce their unhealthy food consumption.

    The losers of such a plan, like tobacco companies, understand this and will fight with their almighty dollars, use of ads and all the other nasties that go into politics (I say, against public health) to oppose.

    Thank you for listening.

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