What does an ACO mean in small town America?

At the end of long days I often stand gazing out my window at the beautiful, timeless Rocky Mountains in Colorado Springs and am taken by their sense of permanence. I recently returned from Nampa, Idaho, where I presented hospital Grand Rounds on Accountable Care Organizations.

The parallels between the timeless mountains and the physicians I met in Nampa struck me. Strange, you say? Maybe, but I am accustomed to the hustle and bustle and almost fleeting nature of medicine in the fast-paced world of big-city hospitals, where hyper- competitiveness often rules at the expense of quality. Why not? Patients, patient outcomes, mortality, complications etc. are consolidated, collated and analyzed; nameless and faceless. They are discussed at the weekly “safety” meeting or the monthly quality meeting structured to “hit our numbers,” meet our risk-contract goals. Sometimes, if you don’t force yourself to stand back and remember that statistics are tools to help guide us and that actual patient care is rendered “eyeball-to-eyeball,” one on one, you can get lost, lose your focus—your purpose.

In Nampa there was permanence; I could see it, feel it, the physicians exuded it. They were there for the long haul, comfortable in their own skins; they were there for their communities. They were there for each other and there for their patients. Outcomes? Quality? Their “numbers”? All had faces; their “numbers” were their neighbors, were their friends, was their community.

So what does ACO mean in Nampa, or in any small town for that matter? Did anyone really care? After all, aren’t they just “fly-over country”? When I have given the presentation before the audience reactions were predictable: at first anger, then blame, then acceptance. But not in Nampa—oh no. When we discussed the “whys” of ACOs they smiled, when we discussed the blame they shrugged their shoulders and when we discussed the ACO goals they respectfully chuckled. By the end of the presentation we all agreed that change was inevitable. Call it economic dispassion or progress or whatever; they didn’t really care. In Nampa the hospitals, physicians and, yes, patients all have to come together to see to it that their communities have a healthcare product that fits their needs; “Isn’t that what an ACO is?” someone asked.

As the meeting concluded it occurred to me that the smaller communities are the backbone of medicine in the United States, the front line; they get it because their patients are their neighbors; they acknowledge them in shops, restaurants, centers of worship; they are friends. Their hospital administrators are viewed as their colleagues, working to solve problems, to serve. They understand they have to give to get, to know their limits, to take risks and be accountable; that’s “what we do in Nampa, always have,” I was told.

In Nampa, the confusion, the pettiness and the fleeting nature of the big city doesn’t seem to exist. There’s accountability, there’s permanence—the permanence that I see when I look out my window at the Rocky Mountains.

Robert Provenzano is a nephrologist and Vice President of Medical Affairs, DaVita Inc. He blogs at the ACO Blog.

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