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Are any of you being affected by the move to ACO's? I was just reading about independent practices in Texas having difficulty staying afloat with the changes. Do you feel pressured to join, or sell out to, hospitals and larger groups?

Yes

We're in Massachusetts which is ahead of the curve on ACO's. So far as a solo family doc I've been able to make it work. But my sense is that our days are numbered and we'll all have to join big groups sooner or later.

It seems to me that ACO's will face problems that haven't been fully appreciated yet.

For one thing, what happens when an ACO subscriber develops an illness that is clearly better treated by an institution outside the ACO? With cancers, in particular, and complex surgical issues, this is likely to be relatively common. If the patient goes outside the ACO, the cost to the ACO of reimbursing for treatment elsewhere is likely to be high.

I could see a situation where patients with more significant illnesses bail out of ACO's and turn to traditional medicare or to commercial insurances on the exchanges to be able to go out of network. This would leave the ACO's with the healthy ones (which they will surely encourage, by making it hard to get out of network care). Meanwhile Medicare and commercial insurance (which will now be obligated to take patients with pre-existing conditions) will be saddled with the sick ones. Medicare will just sink deeper into debt; the commercial insurance companies will probably raise premiums to exorbitant levels and possibly bail out of the exchanges if price controls apply there.

I just think that this whole concept of ACO's on a national level is poorly thought through and untested. I wouldn't write off solo practice just yet.

Michael Jacobson
New York, NY