Progress of Accountable Care Organizations: A View from the National ACO Congress

Last month at the third National ACO Congress held in Los Angeles, California, national experts presented up-to-date information about the evolution of Accountable Care Organizations throughout the United States, including the Pioneer and Shared Savings ACOs sponsored by the Centers for Medicare and Medicaid Services (CMS) and commercial payer ACO products.  The discussions were focused on five overarching principles or themes that underlie successful ACO evolution and healthcare reform: payment reform, clinical integration, patient engagement and activation, partnerships and collaboration, and new delivery models.

Payment reform is the movement away from paying for volume to paying for value, i.e., transitioning from the traditional fee-for-service payment model to global payments, bundled payment mechanisms or increasing upside and downside risk on shared saving programs.  While it is widely accepted that payment reform is necessary to curb America’s healthcare expenditures, what has been less discussed is how difficult it actually is to appropriately align incentives among all of the players. As discussed at the Congress, aligning incentives continues to be a challenge even for the formal Medicare ACOs.  Mai Pham, M.D., Director of ACO Programs at the Center for Medicare and Medicaid Innovation, freely admitted that determining appropriate physician-specific incentives was a laggard issue for Pioneer ACOs. Conveners also discussed financial risk,  incentives that would control out-of-network costs, reversing the hospital mentality of “heads in beds,” and acceptance in the healthcare delivery system for tiered and narrow networks. The main takeaway from those discussions is that provider engagement is perhaps the most important component to payment reform. It is not enough that the payment system be changed; physicians and hospitals must commit to the change.  Providers must agree to the new systems and embrace being paid for value rather than volume.

Perhaps less controversial, but no less important, is the need for clinical integration to ensure ACO success in terms of improving the quality of care our system provides.  Provider organizations, health systems and payers must work collectively and collaboratively to coordinate care for patients.  Case studies presented at the Congress highlighted the importance of information technology and clinical decision support as enablers of clinical integration.  However, the culture of an organization, the importance of smooth handoffs of care, effective shared decision-making and the value of population health management were also frequently emphasized as components required in true clinically integrated system that will result in improved health outcomes and quality.

Comprehensive health reform will not take place without the involvement of patients. At the conference, Steve Shortell, PhD, University of California at Berkeley, described an interesting concept regarding patient engagement and activation.  He described how patients need to “co-produce” their care and health outcomes much like how college students must study, work, and be equally responsible for their education.  Patient engagement and activation is no easy task.  As providers, we must partner with patients, understand the role of consumerism, and provide transparency around our services both in terms of quality and cost.  Patient engagement and activation also requires having the right tools, not only technologically but also “human resource” tools, for example,  making good use of social workers, nursing staff, pharmacy staff, community health support (such as promotores, Spanish-language  community promoters), and county health services personnel.

The fourth theme of the conference focused on partnerships and collaborations. Throughout the session discussions, it was commonly believed that partnerships are necessary to bring the appropriate tools, infrastructure, and capabilities to the table in order to move us all in the right direction for the future.  The partnerships under discussion included the expected relationships and ventures between health plans, hospitals, and physician groups but they also included a look at some unlikely “bed fellows” –partnerships that had not been considered in the past, such as the Optum/Monarch collaboration as well as the Healthcare Partners and Davita venture.  The one common thread across all of the collaborations is that each partnership developed at a local level.  What may fit in one community may not fit in another, so understanding your local market well is critical for a successful collaboration.

Of course, new partnerships, clinical integration, patient engagement strategies, and payment reform experiments are all being tested in or are forming the basis of new care delivery models.  Care management and coordination is generally accepted as the key to ending the costly, fragmented, and unnecessary care that is still so common in our country.  The outstanding question is:  What is the best way to effectively coordinate care to achieve the desired outcomes of health reform?  What model is the best?  The answer still eludes us, but in addition to analyzing the status of the 152 CMS ACOs that have been piloted across the country, the conference sessions presented a variety of delivery model possibilities –including limited networks, approaches to develop and sustain primary care, the redesign of care processes and the use of “alternate site providers,” where services can be provided in community and home environments instead of more costly institutional settings.

In summary, the overall consensus among the Congress conveners was that “the train has left the station.” There is no doubt that we are heading down the track toward drastic changes in our healthcare delivery system.  The political outcomes of the election may not materially alter this course, and although the process is hampered by the various degrees of sophistication of provider organizations, hospitals, and other providers, it is important for all of us to learn and work together to collectively move the nation’s healthcare system in the right direction

John Jenrette, M.D.
Chairman of the Board, California Association of Physician Groups
CEO, Sharp Community Medical Group

Excerpted from the January 2013 edition of CAPG Health, published by the California Association of Physician Groups.

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HealthCare Reform: A Time for Innovation

Healthcare reform represents a true time for innovation for physician groups and with that comes a world of tremendous opportunity.   California medical groups in particular are now perfectly positioned to forward its message about accountable, coordinated health care driven by aligned incentives and efficient, high quality care.  It is therefore not surprising that we have advanced the California coordinated care model with the development of the six Pioneer ACOs, two shared-savings ACOs, and numerous commercial ACOs throughout our state.  California’s system of delivery is now recognized across the country as leading the way.

In leading the way, two important and substantive processes of care delivery and innovation will see increasing efforts and opportunities for improvement and change:  1) the continued strong focus on managing complex chronic illness, and 2) the need to transform primary care services to complement more accountable delivery systems of care.

The continued focus on managing complex chronic disease is of utmost importance based on the high cost of care for this subset of our population.  Whether it is the top 5% of the commercial population that accounts for 60% of costs, or the top 1 to 2% of the Medicare population that accounts for 20 to 25% of costs, the need for innovation in the medical services we provide to the chronically ill is essential.  We must continue the current effective programs and further advance new approaches to provide coordinated, accountable care in the correct setting of home and/or community, involving both patient and family.  Ultimately, care of these patients must occur outside of the acute hospital setting.  To achieve this, we need to educate the public and our physicians on the best delivery of end-of-life care and services.  When we counsel these patients, we need to be comfortable with the dialogue.  As physicians we must counter inflammatory rhetoric, such as the language of  “death panels,” to focus on meeting the expectations and desires of our patients in their time of need.

The second urgency for physician groups and healthcare reform is the transformation of primary care.  Primary care is the foundation of medicine, but it must evolve to remain vibrant.  Healthcare delivery systems around the world that have primary care as their backbone are shown to deliver higher quality medical care at the lowest cost.

The problem we face here in America, however, is the erosion of the primary care foundation.  A large portion of the primary-care workforce is now approaching retirement age, and current medical school graduates are choosing specialty practice, which is higher paying and offers greater life balance.  Residency graduates entering adult primary care have dwindled to less than half of the rate of 12 years ago, and this trend seems to be getting worse.

The erosion of the primary care workforce is further driven by the changes and demands of healthcare reform, including: greater access challenges for patients to primary-care services; additional paperwork (or EHR requirements) in primary-care offices; keeping up with medical advances; increasing demands to provide wellness services; management of chronic disease; and the need to address important social determinants of health.  These demands and the attendant increased workload should have us all concerned about the future of primary care.

So, how can we support primary care going forward?  What are our plans to replace our aging workforce and to reinvent ourselves for the future?  What innovations are needed to create success for all of us?

Ultimately, we need sustainable solutions.  We must work collectively to advance primary care.  We need primaries to be working at the “top of their licenses” and to engage their office support teams to help deliver outstanding care for patients. We must also provide the tools and technology that advance and streamline these changes and allow for greater focus on populations and gaps in care that lead to poor outcomes.

If we focus our energy and are successful in our efforts, what would primary care look like?  I envision success in the rejuvenation of primary care as a preferred career path for the majority of medical school graduates.  Our success would return joy and fulfillment to the practice of primary care medicine and remove the scut work from physicians’ desks.  It would also rectify and right-size compensation for primary-care services, recognizing and rewarding the real value of a strong healthcare delivery system with its foundation in primary care.

The California Association of Physician Groups will be undertaking many initiatives to address the advancement of primary care over the next few.  I hope that other physician groups and associations across our nation will join us in this effort.

John Jenrette, M.D.
Chairman of the Board, California Association of Physician Groups
CEO, Sharp Community Medical Group

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Good, Affordable Health Care for All: How Long Will It Take?

With the recent Supreme Court ruling on health reform, many at Group Health Research Institute (GHRI) felt relieved.  The decision to uphold most of the Affordable Care Act (ACA) should put our country on a straighter path toward improving access, affordability, and quality for all—imperatives in our Institute’s mission.

Still, we live with great uncertainty.  How will the ACA affect the business of health care?  What will the fall elections mean for health care policy?  What’s the future of research funding, given shaky economies here and abroad?  How will the federal budget impact jobs at GHRI and elsewhere?

Answers will emerge over time, but not knowing can be unsettling.  In times of hardship and uncertainty, it’s natural to wonder: How will this all turn out?

Taking the long view can help.  My friend Dr. Steven Schroeder of the University of California, San Francisco reminded me of this with his speech to the Society of General Internal Medicine (SGIM) in May.  He reflected on several recent assaults to scientific integrity, care for the disadvantaged and other values most doctors hold dear.  Despite grim evidence, he insisted, “Hope is still alive.”  He’s seen it in many places: Advances in public health; civil rights; treatment for AIDs; his medical students’ idealism.  To them, he quotes Dr. Martin Luther King: “I know you are asking today, ‘How long will it take?’  …Not long, because the arc of the moral universe is long, but it bends toward justice.”

So how long will it take to achieve our mission (and the mission of many in our industry) “to improve health and health care for all”?  You could say, “not long,” because improvement is incremental and we work at it every day.  Looking back at Group Health, we see the arc clearly: in 1947 our organization was established by labor unions, Grange farmers, and local activists “to serve the greatest number.”  During 1950s’ McCarthyism, Group Health won a legal battle with the King County Medical Society, over claims the Cooperative was un-American.  And through the 1960s, we overcame racism to integrate our medical staff.

Amidst challenges, Group Health has grown in numbers and influence.  With GHRI’s founding in 1983, it began to rigorously study its population’s health, sharing discoveries globally.  As this chart shows, the Institute’s work on prevention, cancer screening, vaccines, chronic illness care, primary care design, and more has been translated into better care for Group Health members and others nationwide.

Now, with the ACA upheld, our work and the work of many health care systems in this country who view themselves as learning institutions could not be more relevant.  A recent example: The University of Chicago’s study in the Journal of the American Medical Association (JAMA) last week linked the patient-centered medical home (PCMH) model to higher costs at 669 federally funded community health centers.  This is an important contrast to GHRI’s 2010 evaluation of Group Health’s PCMH pilot.  With colleagues, Dr. Rob Reid, Group Health’s associate medical director for research translation, found that Group Health recouped its PCMH investment through savings in emergency and hospital care.  In an invited JAMA editorial, Rob and I explained that practices in the University of Chicago study could not claim such savings because, unlike organizations like Group Health, their medical homes aren’t integrated with emergency and inpatient care.  And we stressed that primary care practices cannot achieve the promise of the PCMH—improved care, lower costs, and higher patient and provider satisfaction—without strong financial support.

Translating such knowledge into better care won’t come easy.  In his speech to SGIM, Steve Schroeder offered six suggestions for making a lasting difference in the dynamic times ahead:

  1. Work on things that are important to you.
  2. Be reliable.
  3. Model your values.
  4. Avoid the false dichotomy of having to choose between professional and personal satisfaction.
  5. Be resilient.
  6. And believe that the arc of history can be bent toward justice.

By following his advice, perhaps we can join the force that makes it so.

Eric Larson, MD MPH
Vice President for Research, Group Health
Executive Director, Group Health Research Institute

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ACA, ACOs and the Impact on Hospitals: Thoughts from California

The Supreme Court just upheld the Affordable Care Act, which contains provisions that support the formation of accountable care organizations and other delivery system models that have promise for improving value in health care delivery.  The California Association of Physician Groups applauds this decision.  We have long believed that care coordination and payment reforms are the building blocks for creating a healthcare delivery system that is efficient and achieves quality. With a small sigh of relief that the law stands in our favor, our groups will proceed with implementing delivery system reforms and will continue to work to ensure the success of their Pioneer and Shared Savings ACOS, as well as other delivery system projects already underway.

ACOs are taking shape all over the country in a variety of formations.  The nation might want to make note that of the California organizations participating in Pioneer ACOs, all are physician groups, with one exception, Sharp, which has a nice interwoven arrangement between its two groups and multiple hospitals. At present none of the other Pioneer ACOs have a conspicuous hospital partner in their structure.  In order for these groups to be successful as an ACO they will have to enter into contracts and work closely in a collaborative fashion with a strong hospital partner, which, at the outset, is not an equity holders in the ACO. This may be challenging.

Currently, all of the players in health care are trying to figure out where they fit in an evolving world – this new world of accountable care. Everyone wants to be relevant and do good work. That’s a common feature among hospitals, medical groups, individual physicians, health plans, and every other stakeholder.

But hospitals have a unique set of challenges.  Generally (acknowledging that all generalizations are partially true and partially inaccurate), hospitals do not get paid via a pre-paid capitated methodology. Most of them are accepting DRGs for original Medicare and per diems for their commercial work. So hospitals by virtue of their business model are not well aligned with capitated physician groups.

The whole concept of the ACO movement is to reward providers for living within a budget. There are no longer unlimited dollars to pay for healthcare services.  What is being tested today in the various Medicare and commercial accountable care programs is which payment methodology works best?  Is the best payment method through shared savings, or partial capitation, or a movement to global capitation?  How does a healthcare provider live and make a profit under shared savings or under capitation?  Entrenched in a fee-for-service business model (where filled beds means more profit), hospitals will need to make a paradigm shift—and that’s probably doubly true outside of California.

Hospitals are reacting  to this movement with different kinds of physician integration strategies. One of them is to hire physicians, which is permissible outside of California. Another strategy is to acquire physician groups, which under California law is the more utilized strategy here. We are seeing that reaction occur at a pretty brisk pace.

A concern of many proponents of coordinated accountable care is that we don’t want to see the movement somehow stymied by hospitals whose strategy is to acquire all the physicians in the community and lock them into the old fee-for-service model through market power.  However, I personally don’t believe that will happen for a number of reasons—the foremost of which is that the value lies in the coordination of physician care. Primary care and the ability to manage chronic diseases is almost predominantly the domain of physicians in physician groups and organized systems of physician groups.

In the end, that’s where the value of the Affordable Care Act and healthcare reform lies—in managing costly disease and preventing further disease—so that’s where the dollars will flow.  We may be watching health plans and hospitals purchase physician groups, but in the end, to be successful,  the value will float to the top, therefore physician groups will float to the top. As go the physician groups, so will go the whole industry, in my opinion.

The accountable care movement and how providers will be paid within it will be an iterative process that will unfold over time.  You will not see many instances where people will leap into full tilt capitation on day one. This will be a gradual evolutionary approach.

Clearly, models have developed over time that aren’t supportive of the Triple Aim of accountable care, that is, to improve population health, enhance the patient experience, and control the cost of care.  Many of those old models are entrenched.  The Supreme Court and the ACA have given us the reins create new models of care that address our national health care crisis and that also are good solutions for physicians, hospitals and others providers of care.

The country is asking a lot of providers to change the way they do business.  Change is difficult. It’s costly. It’s inconvenient. It’s scary. There probably will be some winners and some losers.  But at the end of the day, the reformed will produce better care and higher value. And there’s plenty of room for everybody to participate in it—individual physicians, health plans, and hospitals.  There are roles for us all moving forward, and while it won’t be pain free or easy, over time, I believe, people will accept and adapt to the new model simply because it’s a better one.

Don Crane
President and CEO
California Association of Physician Groups

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Health System Reform: Why Now?

In my previous writing for this Accountable Care column, I stated that to embrace our current healthcare challenges and move toward solutions, we must address three questions:

  • What can we do to solve the problems of health care in America?
  • What are fundamental attributes that medical groups must have to succeed in the future?
  • Why should we do it now?

You can read the answer to that first question here, and the answer to the second here.  In this column, let me address the third question:  Why should we in the healthcare industry tackle delivery system reform now?

If—as you listen to the debates and watch your peers make moves—your take-away could be as narrow as that we have to change because we are scared of the implications of the Affordable Care Act, or that we must do this to preserve our contracts. If this is your view then you don’t understand our opportunity.

One hundred and four years ago, the founder of my group, Dr. William Mayo addressed the graduating class of a medical school in Chicago. On that day he said the following: “The best interest of the patient is the only interest to be considered. . .”  I and many physicians and physician practices have embraced some version of that comment as our primary value ever since that time.  However, that was not his entire sentence. The full sentence goes as follows: “The best interest of the patient is the only interest to be considered and in order that the sick can have the benefit of advancing knowledge, a union of forces is necessary.”

The “union of forces” that Dr. Mayo was talking about then was the integrated group practice of Mayo Clinic.  Since then, many physician groups have evolved and have become successful innovators of the group practice model—such as those represented by the Council of Accountable Physician Practices and others on this website.  Now it’s our turn to take it to the next level.

Why must we change now?  Because we have known for decades that system reform is necessary because our health care costs are unsustainable, but haven’t had the national will or motivation to learn from the best, move forward, and continue innovating.

We must change because we care about our patients, and they are telling us that they have had it with the cost increases and the fragmentation of their care, which they confront daily as they interact with typical medical practices in this country.

We must change now or risk losing more control of our practices.  Physicians and physician groups are the best arbiters of healthcare for our patients, not the insurance industry, the government, or employers. If physician groups don’t claim this space and engage creatively with others, we will lose ground.

We must change because we can change.  Group practice is the prototype for an accountable health care system and, with appropriate innovation, is the best model for the future of care for America.  Many of us already know how to do effective care coordination. Some of us were the early adopters of the electronic health system, providing information to IT companies as they worked to develop user-friendly clinical information systems.  Some of our models include hospitals, and have experience in reducing readmissions. All over this country, physician groups have amassed a wealth of knowledge and experience that our nation can leverage now.

Finally, we must change because there is no choice.  Regardless of whether you want to participate in a government-approved accountable care organization or a commercial health plan project, as a physician that is part of a medical group, you WILL participate in accountable care.

System transformation and new models of care for Americans will require a union of forces. I am a staunch believer that true healthcare reform will emerge from the work of medical group practices. We are the union of forces of which Dr. Mayo spoke.

This is an historic opportunity.  Our patients are counting on us. Let’s get to work

Dr. Robert Nesse
Chief Executive Officer
Mayo Clinic Health System


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The Top 5 Things Medical Groups Can Do to Prepare for System Reform

In my previous writing for this Accountable Care column, I stated that to embrace our current healthcare challenges and move toward solutions, we must address these three questions:

  • What can we do to solve the problems of health care in America?
  • What are fundamental attributes that medical groups must have to succeed in the future?
  • Why should we do it now?

You can read the answer to that first question here.  In this column, let me discuss question number 2:  What are fundamental attributes that medical groups must have to succeed in the future?

While there are many requirements, I suggest that medical groups concentrate on these five areas to start:

    • A network of providers
    • Aligned purpose among those providers
    • Coordinated care systems
    • Aligned financial model
    • Practice analytics

In the old model, we could pick and choose what we wanted to focus on in our business. All too often this was done by taking a close look at payment for specific services, and then tailoring the business toward the most profitable ones. In our new world, the usual profit centers will become cost centers counted against payment for outcomes and the total cost of an episode of care. Your organization will need to develop a network that provides continuity for populations of patients.  Then that network needs to be aligned-culturally and financially– around the shared purpose of providing quality outcomes and cost efficiencies for populations of patients (also known as the Triple Aim). The majority of providers in this country work in groups of less than 10 physicians. Those small groups will face significant challenges as they try to successfully achieve these goals, so it is anticipated that smaller groups will continue to merge with or align with larger groups to achieve the desired results.

Once you have your network, you need to coordinate the care. Care coordination reduces waste and rework—a benefit in itself.  However, just as importantly, good care coordination embeds patients in a system that meets their needs.  They do not have to act as independent agents churning through resources as they bounce from provider to provider getting each of their body parts evaluated.

Unfortunately, all of this will just be a hobby if we don’t align the financial model with our best practices and our network. We must advocate for our accountable care model and drive the system to support it.  A good number of people are making a lot of money from our current dysfunctional system. Wherever possible, we should engage with payers and others to change rather than continue a one-sided vendor relationship with mysterious justifications for cost and payment increases and murky data.

This brings me to the last requirement and perhaps the most important:  practice analytics.  If you don’t know what your physicians and group are doing and are not able to track your performance, your future will never be in your control. You will be victimized by new payer contracts and pilloried by public displays of your performance data.  There are new technological systems out there that will support your transformation, but embracing practice analytics must be an urgent priority for your group. In our new world, clinical knowledge and data sharing not only supports our patients’ medical interests and needs, it supports our future viability as healthcare providers.

Working on developing these five attributes is, in my view, the best approach that physician groups can take now to prepare for the future.  Each of these will take time, but each is attainable and will contribute greatly to the success of the accountable care model.

Dr. Robert Nesse
Chief Executive Officer
Mayo Clinic Health System

In the next “What the Experts Say” column, Dr. Nesse will address the third question: Why should the healthcare industry tackle delivery system reform now?

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A “Wicked Problem”: Healthcare System Reform and Change

In light of the Supreme Court review of the Affordable Care Act and the political brouhaha that surrounds it, I know that many providers of health care have mixed feelings about the future of our industry. Let me share with you my cautious optimism as we work to design and then implement the new system of health care in America.

First, we must remember that we are already well into change and every healthcare organization in America must adapt and deal with our current reality. We must accept these incontrovertible facts:

  • The number of people who require care and the percentage of our patients with      chronic comorbid disease will increase, increasing the demands on our systems.
  • The government does not want to or even have the money to cover the costs of our current system, so we should expect that reimbursement for our services will decrease.
  • New payment systems will hold us accountable for the quality and safety of our care, and we will be at risk for our costs and outcomes.
  • By 2020, greater than 66% of the American public will get their health care coverage from a government-sponsored program. In 2025, the Advisory Board estimates the total will rise to 70%.

How do these facts make you feel?  I suspect that for most, optimism (even cautious optimism) is not the feeling.  Some of our colleagues are stuck in pessimism because they are in love with the problem. They painstakingly examine each facet of the problem and continue to bemoan our current state.

I believe that the healthcare industry is spending too much time trying to defend our past successes and preserving old systems.  It is time to move on.  We need to change. We need to understand the issues and accept the truth; discover and design our response; and move on.

And as we move on, we must address these three questions:

  • What can we do to solve the problems of health care in America?
  • What are fundamental attributes that medical groups must have to succeed in the future?
  • Why should we do it now?

I will address the first question in this column today:   What can we do to solve the problems of healthcare delivery in America?

The answer:  We won’t solve the problem.

Reform and change of the American healthcare system carry all of the attributes of a “wicked problem. ” “Wicked problems” are a common occurrence in other industries. The term originated in the software industry, which faces a wicked problem almost every time they release a new product. No software product is perfect, so when is it good enough to release to the public?  Success varies.  Think Windows Vista vs. Windows XP or Windows 7.

Wicked problems have the following characteristics:

Different stakeholders describe the problem differently depending on what aspect of the problem they deal with. Consider the views of healthcare costs. Providers think of patient compliance, preventive services and cost shifting. Payers think of excess utilization, provider strongholds, and waste.  The government apparently thinks we haven’t got enough regulations, and the patients think we are all at fault for the entire mess!

Changes that address one aspect of a wicked problem will influence other aspects of the problem.  Here are a couple of examples. If we are able to change the sustainable growth formula and implement new payment models,  we may finally get an opportunity to reward high-value care. However, if we increase support for primary care, specialty-care reimbursement will likely decrease. If we increase eligibility for low income populations and they join Medicaid we will decrease the uninsured in America. This is laudable but the cost of the program will increase for both the federal and state government

Wicked problems have no stopping rule. This basically says that you can’t “solve” a wicked problem. This is really hard for clinicians to grasp. In our  clinical practice all our patient problems have a stopping rule. They recover and go home. They transfer to another system, or they die. Healthcare system challenges are not going anywhere. We have discussed the many problems of health care for all of my 31 years in practice, and we will be doing it for the next 310 years.

To address the wicked problem of new health care models what we need to do is choose to work on one aspect of the entire problem that seems to have the best potential for improvement.  Fix that.  Review the result and see if other opportunities emerge based on your previous effort. Remember that changing one aspect of a wicked problem can impact other areas of the problem.

For the next few years, my choice for that one aspect to work on is to become competent in accountable care delivered through integrated physician group practice, and seek to be competitively relevant in a system that will reward outcomes and total cost of care. This, I believe, is our best first step forward.

Dr. Robert Nesse
Chief Executive Officer
Mayo Clinic Health System

This commentary was first presented as part of the opening remarks delivered by Dr. Nesse recently at the annual Amerian Medical Group Association conference held in San Diego, California. In the next “What the Experts Say” column, Dr. Nesse will address the second question: What are the fundamentals that physician groups must have to be ready for the future?

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