6 Reasons Your ACO Will Fail (A Series) – Any One Will Do!

By Gregg A. Masters, MPH

No. 1 – The ‘O, G & E’ Card

At UC Berkeley in the 70s, the secretary in the Department of Psychology pasted a bumper sticker on her desk positing the humility laced question: ‘…you may be correct [in your storied judgment], but are you asking the right questions?’

For some reason, this subtle invitation to examine one’s assumptions [story] remains with me today, echoing amidst the ACO fervor of ‘…better care at lower costs’.

‘…the good news is we’re making great time, the bad news is we don’t know where we are going.’ | Eastern Airlines Pilot

As is often the case, and perhaps so today, when you need to ‘do something’ (since movement in the absence of same, seems like progress), but are not quite clear what that ‘something’ looks like, there’s a tendency to default to the familiar, i.e., this is how we roll. The more conservative among us will hedge that risk by choosing ‘advisors’ with conventional standing when considering what that something is.

In healthcare that more often than not, begins the lawyers and accountants, and generally starts with legal vehicle and organizational structure matters. While ‘mission, vision and values’ are a part of that conversation, they generally do not lead the process by which the engagement unfolds.

Invariably, one or more savvy (entrepreneurial) physicians step forward to claim the ‘organization, governance and equity’ card (OG&E), and off we go on structure of the entity vs. the more open ended, and perhaps, even chaotic but culture enabling, process of engaging physicians in the emotional, philosophical and ‘sweat equity’ journey of infusing a ‘patient’s first’ culture into the new, or re-purposed, entity’s mission.

The temptation to put form ahead of function is a real, and a distinct warning sign. Any ‘check the box’ deliverable schedule that does not have the ‘buy-in’ of those (primarily independent physicians) who will determine whether proforma assumptions materialize, is fantasy.

‘It is not necessary to change. Survival is not mandatory’. | W. Edwards Deming

The behavioral sciences tell us that if you are not part of the decision process, the odds are that you are less likely to honor any decisions made on your behalf. So, ‘trust the force Luke’. Go the extra mile and engage in the discomfort of process, and avoid the top down tendency of command and control execution, against an unreasonable timeline.

Next up:  ‘building the physician bridges’.


Join the Conversation


  1. Gregg, this post is spot on. Too often I have seen organizations rush to make something without really knowing the vision or having any meaningful discussions about culture. I certainly believe that change is afoot and we must look for new and innovative care models. I only hope we are able to create them before we are all led blindly into the ACO corral.


    1. Thanks Mark! If it is to be truly different this time (after-all industry stakeholders really have a gun to its ‘collective heads’), we need to understand why previous efforts to restrain the ‘whack-a-mole’ resistant GDP gravy train continues its unabated march forward. Most of us agree as to the root causes. The question remains, can we work together to manifest this complex tapestry of a values, vs. volume based healthcare eco-system?

      Appreciate your comments!

  2. Gregg —

    I agree with your bottom line: Whether we’re talking about ACOs or any other new vehicle or structure for health care collaboration, it is critical to first develop and execute a participatory process through which we can determine where the parties are today, where they want to be in the future, whether they are in fact capable of getting there, and what the work is that they need to do together in order to get from point a to point b.

    Often, as you describe, a champion identifies the point b s/he wants to get to and drags everyone else along with no discussion. The results cannot be good in such circumstances.

    In my experience, letting the stakeholders work through the process laid out above will strengthen the group, strengthen the group’s conviction that the choices made are the right ones, and increase the chances of seeing new initiatives work.

    1. So agree David! That piece too often seems to get lost in the shuffle. The cultural differences (whether hospital to physician, or primary care to specialists, or hospital based v. community) are real and an intangible, to both acknowledge and factor into the relationship and cultural building process.

      Thanks for your thoughts! Always appreciated.

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