What Would A Truly Patient-Centered 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.

Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billion health care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his new blog, Kent Bottles Private Views.

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basi midi karaokegoogle plus appsBill DeMarcoSnippetPhysTherpcp Recent comment authors
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basi midi karaoke

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google plus apps

You are so interesting! I don’t suppose I have read through something like this before.
So good to find another person with genuine thoughts on this subject.
Really.. thank you for starting this up. This web site is one thing
that is needed on the internet, someone with a little originality!

Bill DeMarco

Dr Bottles truly a challenge to move the system to a patient centered approach. In the early 1970s we used the word MEMBER to make a distiction between those that joined the HMO and those who could go anywhere for care. This meant the patient is now a consumer who has made an exclusive commitment to your physician panel. Now we have ACOs. Dr Berwick has promised he will announce to all patients that are attributed to a particular ACO based upon thier current use of care with that particular doctor. This will provoke the question in the seniors mind… Read more »


I can understand and respect the need for change. I’m not in the 65+ age group yet, but the way health care is today, it can’t be easy for this group of individuals to feel as though their concerns are addressed in a timely manner. The rule of thumb is that only one physical complaint can be addressed at a time (due to the payment system structure) and necessary time really isn’t allowed during an office visit for a real discussion on how to self-manage a condition. And for those individuals who have multiple conditions and specialists involved, they really… Read more »


@pcp –
“I think that the public will quickly get the perception (true or false) that ACOs make money by providing less care. It will be very easy to demonize ACOs.”
The Kinder and Gentler capitation/HMO model.


“from the patient’s perspective, ACOs are a non-event. Patients already assume/expect that physicians and hospitals are accountable for the care they deliver . . .”
I think that the public will quickly get the perception (true or false) that ACOs make money by providing less care. It will be very easy to demonize ACOs.

Steve Wilkins

Kent, I would make the case that from the patient’s perspective, ACOs are a non-event. Patients already assume/expect that physicians and hospitals are accountable for the care they deliver…or at least they should be. The notion of having to pay providers in order to get accountable ( good?) care is foreign to all but to the medial community. In any other industry, if the provider of a service gives sub-standard service, they are not paid. How do you think patients at your hospital would react Dr. Bottles if you were to tell them that you and your peers would now… Read more »

Kent Bottles

Alan J. Burgener of Iowa City is one of the smartest people I know in health care. He is not an early adopter of technology, so he shared his criticisms of this post in an email which I now share. He thinks I got it all wrong. “You’re really on a roll when it comes to the production of interesting and thought-provoking blogs and other articles over the past several weeks. However, I don’t think that you could be any more off target than you are in your thinking about what patients want from a truly patient-centered ACO. As an… Read more »


I just don’t understand the thinking behind ACOs.
Who (insurers, hospitals, docs) is going to be the one to volunteer to take a smaller slice of the pie?

Margalit Gur-Arie

Great concept – offering something that people actually like will increase customer retention. However, how about the flip side? How about ACOs building something that healthy(er), (better)educated, (more)affluent people like, while taking a broad detour around those who do not sleep with iPhones (and don’t take their pills)? Also, the assumption here (I assume) is that what people really want is cheaper than what they currently get… “..we will need to embrace emotional automation” With all due respect to Dr. Kvedar, I don’t believe we will “need” to transfer our emotions back to objects (toys?), no matter how automated and… Read more »

Gregg Masters

A good primer by Mark McClellan, titled ‘Key ACO Principles’ is worth a viewing:
Is preso from First Annual ACO Congress held in Century City, California, October 2010, co-sponsored by Integrated Healthcare Association (IHA) and the California Association of Physician Groups CAPG. Good stuff!


@Richard B. Wagner, JD
“Without focusing on the patient, ACOs are different from managed care in name only. And we all know the latter’s track record.”
Copy that. First time I heard of the ACO thing my reflexive reaction was “smells like Teen Spirit capitation.”
I would recommend Dr. Toussaint’s book “On The Mend” for some fine examples of the payoffs from true patient-centered care.

Don Kemper

Thank you, Kent Bottles, I could not have said it better. (except perhaps for the sleeping with I-Phone part.
Patient-centered does not mean a ring of professionals all looking in at a patient. It means the patient at the center looking out at all the people, information and tools that will help them make the best medical decisions and achieve the best health outcomes.

Richard B. Wagner, JD

This article underscores an important point that I think many aspiring ACO participants are overlooking. Savings distribution among participants, legal protection, and governance issues are all important considerations. However, these all take the backseat to the query of whether the patient benefits from an ACO system. If not, patients will seek care outside of the ACO (since there are no restrictions on “patient drift”) and the entire accountability system unravels. Value has to be shown to the patient in order to keep him or her in the ACO “network.” The suggestions that Dr. Bottles makes should be at the fore… Read more »