This is absolutely dead on! ACO theorists and consultants are so wrapped up in proving the model or selling services, as the case may be, that they fail to miss some core deficiencies, which include (1) anti-competitive effect of COS, (2) the hospital conflict of interest, and (3) the primary core fallacy.
ACOs are big business. The capital and organizational requirements alone are staggering. The nature of the “beast” will mean a collapse in the number of delivery systems and a strengthening of the role that big business, chiefly hospital systems, play in delivering medical care.
Hospitals have always seen the direct link between bodies in beds and profits. ACOs are theoretically forcing risk based compensation and quality measures on care deliverers in a way that is thought to create economic efficiencies, but now that it is clear that hospital systems will lead ACO development, what’s to stop them from pumping patients into beds, thus frustrating the reduction of healthcare costs? The conflict is between ACO leaders (hospital systems) that want to maintain profitability through increasing admissions and those that are committed to squeezing admissions into those which are most medically appropriate. At the end of the day, ACO leading hospital systems may find themselves in the conundrum that Humana did when they were in the hospital business (get patients admitted!) and also the health insurance business (keep patients from being admitted!).
The ACO healthcare delivery model is once again (from the 90s) based on a primary care core. And yet, primary care shortages are rampant around the country. The answer is to “extend” physician expertise via the use of PAs, NPs and the like. Moreover, as medicine has become increasingly specialized and the need for specialist consults and intervention has risen, so has cost. The primary care core depends thus on an insufficient number of professionals who lack the professional self-sufficiency necessary to reduce specialist intervention and related costs.
The beat goes on!