• Managing Crises
• Sticker Shock
• A Bouncing Baby Hospital
• Changes and Challenges
• A Touch of Healing
• Home Front
• Louisiana's Mental Health Makeover
• Electronic Medical Records: Meaningful Use & Usability
• The Elusive ACO
• What's In A Name - Palliative Care Growing

The Elusive ACO
Sightings in Baton Rouge?

Casting about for a solution to tackle the problem of rising healthcare costs, in March, 2011, the Centers for Medicare and Medicaid (CMS) released a proposed model for healthcare delivery dubbed Accountable Care Organizations (ACOs). The concept was simple and undoubtedly on the right track, but the creature itself has proven to be chimerical at best.

“When they came out with the healthcare reform legislation it basically sent a message to the healthcare delivery system that how they are going to get paid is going to change,” said Ed Silvey, Administrator and CEO of the Baton Rouge Clinic. “Unfortunately the federal government had written some guidelines that in reality didn’t work.”

The CMS ACO is framed as a group of healthcare providers who are held jointly accountable for achieving measured quality benchmarks and reductions in the rate of spending growth while improving outcomes for a defined population. An ACO would typically include a strong primary care base, specialists, a hospital, long-term care, and ancillary services, all of which would share in savings realized by providing a more coordinated care approach.

To participate in the Medicare Shared Savings Program, ACOs would need to meet 33 quality standards in four key domains:
• Patient/caregiver experience
• Care coordination and patient safety
• Preventive health
• At risk population/frail elderly health.

Originally CMS had proposed 65 quality measures in five domains.

The idea of shared savings is an attractive one as nobody disputes that many healthcare costs can be reduced or eliminated through better coordinated care. In fact, CMS predicts Medicare savings of as much as $960 million over three years. Tapping into a piece of that is certainly a carrot, but not if the cost of creating the infrastructure to deliver that coordinated care counteracts any potential savings. Ochsner Medical Center-Baton Rouge CEO Mitch Wasden said that CMS estimated it would cost Ochsner about a $1.8 million investment to comply with the regulations and set up an ACO. Wasden said Ochsner’s own estimates are closer to $11 to $26 million.

“The infrastructure that it’s taking to do it doesn’t justify the expense or the economic reward that the government has set up,” agreed Silvey. It is also possible, since CMS has seemed to underestimate the costs of implementing an ACO, that they have also overreached on the projected savings. At the moment the savings are offered as a bonus above and beyond regular Medicare reimbursement. An ACO’s performance would be measured against a series of benchmarks to determine if it was eligible for a share of the savings or would be held accountable for losses.

CMS has used all the right words: accountability, reduced spending, quality improvement, coordinated care, patient safety. In fact, no one disputes those factors are necessary parts of any real healthcare reform. However, CMS went on to define the structure, operation, and functions of ACOs in a 439-page regulation that had everyone a little bewildered. “I think if you look at the concept of accountable care organizations, as CMS defines it, they have a lot of great core concepts, but they had so many restrictions and regulations as they really got to finalizing the document that we are not pursuing an accountable care organization status as defined by CMS,” said Baton Rouge General Executive Vice President & Chief Business Development Officer Dionne Viator.

After reviewing more than 1300 comments on its proposed rules, presumably many of them unflattering, CMS released final rules in October, 2011 that reduced some of the burden and increased some of the incentives for those creating ACOs. They also expanded the field of those qualified to form these types of organizations to include Federally Qualified Health Care Centers and Rural Health Clinics that provide primary care. One of the biggest changes to the rules was to revise the two-track shared savings program to allow for one to be completely without risk. In the proposed rule, Track 1 included two years of one-sided shared savings with a mandatory shift in year three to performance-based risk or shared losses under a two-sided model. Track 2, which offered a higher percentage of shared savings (60%) as an incentive, called for three years under the riskier two-sided model where ACOs also share in losses. Under the final rules, Track 1 offers ACOs an opportunity to avoid the two-sided risk altogether for the first three years. CMS will also begin shared savings on the first dollar for all ACOs regardless of whether they choose the one-sided or two-sided model.

Another significant change removes the requirement that 50% of primary care physicians must be defined as meaningful users of electronic health records by the second year in order to participate. Despite incentives to implement EHRs, this requirement potentially posed a significant barrier for independent physicians, although, according to Silvey, defining meaningful use is a bigger challenge than achieving it. While the change reduces some of the burden, Silvey believes most people implementing EHRs will try to attain meaningful use regardless, as it “tracks so many of the quality metrics you need to hit anyway.” To counteract the loss of the meaningful use requirement, CMS assigned much greater weight to EHR implementation as a quality measure—higher than any other, in fact.

A third change, aimed at addressing infrastructure concerns, was the introduction of an Advanced Payment model under which physician-owned and rural ACOs, as well as some critical access hospitals, could be pre-paid a portion of future shared savings to help them get up and running more quickly and therefore providing greater access to coordinated care. Providers could receive the payments in one of three ways:
• Upfront fixed payment
• Upfront payment based on the number of Medicare patients served
• Monthly payment based on the number of Medicare patients

The advanced payments would be recovered from any future shared savings the providers incurred.

“Probably the biggest area where there were changes was that the anti-trust, anti-kickback, and Stark provisions were all relaxed substantially,” said Silvey. Concerns about how these collaborations might inadvertently challenge those laws had many providers approaching the ACO concept with considerable caution. The final rules provide more guidance from CMS, the Federal Trade Commission, and the Department of Justice and make available an expedited review process to address antitrust concerns. “It’s still fairly complicated,” said Silvey. “You would obviously still want to get a lot of legal interpretation before you did anything.”

Despite some attempts to reduce risk and make implementation less burdensome, the final rule still requires that each group of providers be held accountable for at least 5000 beneficiaries annually for a period of three years—a considerable commitment. The good news is that, for the moment, participation in an ACO is voluntary, with shared savings as the incentive, but providers are rightfully watchful, with expectations that reimbursement will eventually be contingent on operating in an ACO-type delivery system. “Whether it be a government or a private payer they will incent this in whatever direction payment reform might take,” said Silvey. “Then at some point they won’t incent it any more; it will be an expectation.” So, while few are trying to emulate the CMS model, most local hospitals, physician groups, and payers are exploring ways to work together to achieve some of the same goals. “I think people are trying baby steps to payment reform to see if it achieves some of the goals that the government’s concept of an ACO does,” said Silvey.

“The best explanation is there is the big ‘ACO’ which CMS adopted for their shared savings model and which is now an ugly word,” said Richard Vath, MD, VP of Medical Affairs at Our Lady of the Lake Regional Medical Center (OLOL). “And then there’s the little ‘aco’ which is a concept. I still like the little ‘aco’ concept.” Wasden said Ochsner, too, agrees with the spirit of ACOs, noting that, “we need to get out of this model of getting more revenue for patient services just because people are doing more, because that’s not necessarily the same thing as quality.” However, Ochsner, like others, is finding the mechanics of it are going to be very costly and may not even work or be effective.

“If ACO regulations are created that are viable, then I think everybody’s going to want to do it,” said Wasden. “Until CMS is able to accomplish that, we will probably explore activities locally that accomplish the same thing. If they are able to improve the regulations I think you will see the ACO model and local efforts dovetail and become the same thing eventually.”

Exploring local options is exactly what everyone seems to be doing. In fact, Silvey believes that’s the critical factor CMS has failed to recognize—that models need to be tailored to the unique environment of each market and that a one-size-fits-all model is not a comfortable fit for anyone. In cities like Baton Rouge where large health systems have already explored partnerships with other entities, some form of ACO will potentially be easier to craft than in areas where there are a lot of independent practices.

“We, like many others, had been in conversation for a while before the CMS proposals came out,” said Vath. About two years ago, OLOL started the conversation with independent physicians about clinical integration and accountable care as a concept. “We approached it as sort of a natural progression of what we have been able to achieve working with the independent physicians — getting around the table and improving inpatient quality of care,” said Vath. OLOL has been working with physicians in the community on trying to develop what an accountable care model would look like. They have progressed far enough in that process to request an informal decision from the Federal Trade Commission (FTC) on how to model the finances. Included in the discussions are the Our Lady of the Lake Physician Group, St. Elizabeth Physicians, and the Baton Rouge Clinic. One of the keys to the integrated model is that all of them will be on the same EMR. Later, any other community physician that wants to be on that record could join. “We’re developing how that model could work now. How do we implement it, what would the cost be to join?” said Vath. “What I’ll continue to push for is a little ‘aco’. We’ve been very transparent about the journey for this whole quality outcome delivery model to be introduced into the community. We’re really committed to this. The question is how many will be joining us?”

OLOL has also been working on a separate model as part of its collaboration with LSU and a commitment to take care of the population that health system serves. This model includes the OLOL Physician Group and St. Elizabeth Physicians, but also the LSU providers and some of the specialists in the community that weren’t represented in those groups. OLOL also included Capital Area Human Services and Health Care Centers in Schools to discuss what an accountable care model for this population would look like. “With the help of consultants we really came up with a nice model and even some mechanisms for how to coordinate the care between the ambulatory environment and the inpatient arena,” said Vath. “But then the decisions made by the state on coordinated care networks (CCNs) have to some extent put us on hold. If we apply for an ACO how does that work with the CCN or not work with the CCN?”

“ACO is kind of an amorphous term, but accountable care is what we are talking about…there’s a lot of different ways you can package it,” said Kenneth Phenow, MD, Chief Medical Officer at Blue Cross and Blue Shield of Louisiana (BCBSLA), which is primarily focusing on primary care as the accountable care providers. However, the payer will soon launch a new product with Ochsner that is set up very similar to an ACO. “We’re not calling it an ACO, but it really kind of is an ACO because they have the hospital, they have the specialists, they have the primary care, they have the ancillary,” said Phenow. “They are taking risk with us as partners on actual premium dollars. There’s going to be a quality piece where they are going to have to hit certain thresholds across all physicians. They would have to maintain or improve their quality index and then there would be distribution of funds based on the partnership agreement.”

In addition, BCBSLA is forming narrow ACO-like networks, as part of a new product called Community Blue. The network includes Baton Rouge General as the key hospital, First Care Primary Care Physicians, the Baton Rouge Clinic, and various specialists. “It is an ACO; we are just not calling it that,” said Phenow. “In a true ACO there is risk sharing going on between the components of the ACO. Here there is no risk sharing, but there are potential savings they’ll share in. They reduce their rates a little bit, so we can reduce the overall rate from a premium standpoint, so we can attract more people that want to pay less for a little more narrow, high quality network.”

However, said Phenow, BCBSLA believes sustaining primary care by transforming practices to deliver patient-centered medical home-type care is the way to go to reform healthcare delivery. To that end, BCBSLA is helping physician practices adopt the medical home model though funding certification by the National Committee for Quality Assurance (NCQA) and paying a per patient bonus based on the level of certification attained. The payer is also helping primary care practices with the costs of implementing EMRs and is providing data through which providers can measure their performance against others in the market. In an ACO, said Phenow, everybody’s accountable for improving cost, improving quality, and sharing potential savings, whereas in a medical home it’s the primary care physicians who are doing it. “We’re giving them information on how to improve their referral patterns—which hospitals to use, which ancillaries to use—it’s very similar except they are just working within their group. They are being the accountable care organization.”

Blue Cross also plans to start replacing fee for service with a per member, per month care coordination or care management fee based on the risk of the population. Then it will start to introduce a pay for performance bonus based on quality and cost savings. “As we move down the road to more integrated delivery models such as ACOs, whatever they are going to look like, there will be shared incentives,” said Phenow. “We are not holding anybody at risk in the medical homes yet. But in the future we will.”

Viator said the accountable care concept goes even beyond the hospital walls; it involves earlier coordination and reducing fragmentation in an effort to prevent hospital stays. “But if it happens, how we coordinate with home health agencies, rehab hospitals, nursing homes, and other systems of care is important. Communication is very important,” she said. Baton Rouge General is exploring whether it can improve care by working with a small group of health partners with whom they have strong communication and expectations of each other regarding quality of care. The idea is to improve the overall health status of that group, said Viator, who also noted that the only way to truly achieve those goals is for the patient to be an involved participant in their own care.

In the Community Blue partnership with BCBSLA, Baton Rouge General will be part of a narrow network of lower cost, high quality providers throughout the continuum of care, but will also include requirements like annual health assessments for the participants. “The intent is this very affordable health plan will be able to have savings passed back to the participants or priced at a premium. To me, that product has the underpinnings of a solid, accountable care approach,” said Viator.

“In the old models of integration in the ‘90s hospitals just owned everything, owned the doctors, owned other hospitals,” said Wasden. “We’re trying to create some models where you don’t have to own everything, but where you can partner and collaborate, such as sharing electronic medical records.” Ochsner is also looking at collaborating with other entities to create councils around different disease states. For example, a cardiovascular council would meet to discuss and agree on what the best and most cost-effective ways are to take care of people with cardiovascular disease. The councils would hopefully reduce variation in care, and like the integrated EMR, help everyone to be on the same page. “Even if the ACO initiative is slow to be adopted or is changed dramatically you are going to see integration efforts in all communities across America,” said Wasden. “People are realizing that we have to provide high quality healthcare at the lowest possible cost.” “Personally, I think we could probably get very similar outcomes to ACOs by focusing on accountable, coordinated, collaborative care through some of the primary cares, some of the specialty cares,” said Phenow. “I think we could get there and the hospital would not be part of it.” He said that BCBSLA sees its role in the future as a type of collaborator, arming primary care physicians and specialists with the information they need to provide more coordinated care and improve referral patterns. The payer is also in a position to reward physicians for value. The plan is to eventually create virtual networks of medical homes by providing and funding a shared care coordinator to coordinate between patients, practices, and the health plan to manage that population in a more cost effective way. BCBSLA would also provide the data physicians need to make sure patients get the right care; provide information on preferred ancillary services; have them work with Blue Cross nurses in disease management; and work with other community resources. BCBSLA also plans to create an advance primary care ICU made up of primary care physicians that specialize in certain areas, who could co-manage difficult patients.

Blue Cross has already created a Blue Distinction hospital program that ranks hospitals for quality and will eventually rank them for cost effectiveness. The plan is to also rank specialists. These rankings would be provided to medical homes to change referral patterns. “Health plans have resources and informatics to drive high value care by rewarding for appropriate care and sharing info about good performers,” said Phenow. He predicts that as primary care providers become more accountable for quality and cost effectiveness, the patients will migrate to them. “Those losing business will probably start to lower their rates and that’s how we will kind of recalibrate the entire market,” said Phenow. “I think the same thing might happen with the specialists, but it’s not going to happen overnight. I think it’s going to be a slow, arduous, ugly process. But it’s either that or the government is going to take over and decide how much each specialty is going to make a year and nobody wants that.”

Contrary to Phenow’s vision, area hospitals feel they are an important part of the mix in the ongoing reform of healthcare delivery. “There are a lot of models out there, but I think the strongest models are going to include as many pieces of the care continuum as possible,” said Wasden. “I think a model that includes physicians, hospitals, home health, and the entire continuum is probably going to have a better opportunity to create quality and savings than one that focuses on just one piece of the delivery system, whether that’s hospitals or whether that’s physician groups.” Silvey agreed that, “Some of it is just economies of scale—the larger the network is, the better able to implement things like EMRs or sophisticated chronic disease management programs.”

One of the concerns physicians have had with forming ACOs is that the hospital is generally the largest, most powerful partner. “In the past, the way the collaboration worked, hospitals would buy physician groups because all they cared about was getting their volume. That was the old model of ‘If I do more I make more money.’ I think what we are looking for with these new models is how we collaborate on a population’s health, which at times means not doing as much,” said Wasden. “I think when you look at some of these models where hospitals are partnering with independent physicians and where physicians remain independent, but have a more symbiotic relationship with the hospital, it can work.” In addition, said Wasden, hospitals are more likely to have the capital for infrastructure changes like implementing high quality EMRs.

Hospitals, too, could be alarmed at a model geared toward reducing the number of people that have to be admitted. “It is counterintuitive for any hospital to be committed to this, but fortunately the leadership here has been able and willing to commit to this, realizing what the ramifications are,” said Vath. He pointed out that hospitals have taken other actions prior to CMS requiring reporting or refusing to pay for those incidents. “We decreased things that we were being paid for then.”

The carrot for some might be the shared savings, but, said Vath, “No one believes with the shared savings that they will be making as much as they are making today.” The real incentives are to do the right thing for the population and the realization that something has to change, he said. “My idea is if you can get all the physicians around the table, and start talking about what’s the best way to manage a hypertensive patient or diabetic patient, and then provide external resources that they can tap—all the same as the ones in a medical home, but shared—you can accomplish the same thing and share costs without trying to recreate the medical home in each practice. If you are going to approach it differently, then who better to capitalize to a great extent the formation of this external entity than hospitals?” One oft heard criticism of the ACO model is, “Haven’t we tried this before?” The answer is yes, and the memories are not generally fond. However, there is one major difference this time, noted Silvey, and that’s the focus on quality and the fact that payment will eventually be tied to outcomes, ACOs or not. “It didn’t work in the ‘90s because it was all about money,” agreed Vath. “This at least has been approached a little differently. Yes, everyone is saying it’s about the costs, but nobody is talking about the individual premium. It’s still about how do we get the outcomes that we want?” Besides, noted Vath, “Everybody who has been around long enough and knows how it was in the ‘90s knows that they don’t want to recreate that.” Viator noted that there will be payment reform involved in all aspects of the pilot programs we are seeing locally. Instead of incentivizing providers to be paid per healthcare event, there will be reform that pays for the overall health of the population.

There is also general agreement that whether ACOs are the way to go or not, there has to be a change in the delivery system. “All of the stakeholders are getting frustrated, especially the employers; they want better value,” said Phenow. “We spend a lot of money on healthcare, 17% of the GDP, but we are not showing good outcomes. That’s not good value. Our healthcare system is not a system; it’s a hodgepodge of financing, insurance, delivery, and payment mechanisms that are not standardized, not coordinated. A system is a network of integrated components that work together in a cohesive, coordinated, and collaborative fashion. That’s what we need to get to and we have to start to develop a delivery model that does that,” he stressed. A coordinated delivery model that focuses on prevention of disease, avoiding hospitalization, and managing chronic illness rather than on specialty and procedural care is what’s needed, said Phenow.

“I think the biggest challenge for this to work is whether the specialists are at the point, where they weren’t in the 90s, to say, ‘Look, I get it.’ The reality is if I’m just a left ankle surgeon and that’s all I do, I’m either going to have a boutique practice and take cash only, or I’m going to have to play with others in a different sandbox,” said Vath. “It has to change and if it has to change this is the only way we can control it.” He noted it is better to sit down with potential partners and design a model than to just wait to see what happens. “Even if it means groups come together, form a venture, and work with commercial payers or Medicare Advantage or anyone else to begin to move that model of making sure that everybody holds you accountable for the quality stuff.”

One of the other reasons this approach is given more hope than the models of the past, is the focus on enhanced communication through electronic medical records. Interestingly, even if they are not officially exploring collaborations (although many are), most of the major providers in the area have chosen to implement the EPIC EMR. Among them are the Baton Rouge Clinic, St. Elizabeth Physicians, Our Lady of the Lake, OLOL Physicians, LSU Health System, Ochsner, and North Oaks. In addition, those entities can arrange to grant access to physicians outside of those networks. Ochsner is even helping to subsidize up to 85% of the cost of physicians implementing EMRs that will be compatible with EPIC so they can be integrated. “It’s not out of my thought process, that 80% of South Louisiana could soon be on this, which is really kind of ‘Star Wars’ for South Louisiana,” said Silvey. “I’m excited about it.” He should be excited. With EPIC, once a patient has a record in the system, that is his or her unique record. That means that anyone else using EPIC sees and adds to that record. The avoidance of confusion, miscommunication, lost data, and reproduction of work alone, has to not only improve the community’s healthcare, but also create cost savings.

Whether they are pursuing a shared savings model or not, local healthcare leaders are in agreement that there are plenty of savings to be had through better care coordination. “According to some of the experts out there who study this stuff for a living there’s an estimated 30-50% of waste, duplication, unnecessary services, in the system already,” said Phenow. “Employers, who are the ultimate payers, don’t want to contribute any more into this very inefficient, ineffective system. They feel it’s time for the doctors, the hospitals, the health plans to step up and do this stuff. There’s so much waste out there that I think there’s years of fruit to be taken off of the ground.”

Some of the most commonly cited areas for potential savings with coordinated, accountable care include:
• Eliminating duplication of services
• Improving the generic prescribing rate
• Reducing readmission rates
• Reducing emergency room visits
• Reducing supply sensitive care
• Improving chronic disease management to avoid hospital admissions/readmissions
• Improving wellness and prevention

Although there is consensus on the ways ACOs could improve healthcare and generate cost savings, there remain concerns about their viability. The model basically requires binding agreements between parties that have historically been at odds, particularly where reimbursement comes in. “The shared savings discussion is where you get the tough conversations,” said Vath. “What we’ve committed to do with our community physician group is to bring in an outside consultant. Because the doctors don’t want to listen to what the Lake thinks is a good way to share savings and the Lake doesn’t necessarily want to listen to what the physicians think is fair, the best thing is to bring in a neutral party to provide some options for shared savings.” Phenow agreed that getting all these people to convene and work together when they don’t have business relationships could be the real bugaboo. “The other thing is who’s going to be the keeper of the purse? Is it going to be the hospitals, is it going to be the specialists, is it going to be the primary care physicians?” said Phenow. Silvey said for this to work, the different entities are going to have to learn how to play in the sandbox together. “I think so long as that is clear on the front end with providers then I think that becomes non-contentious,” agreed Wasden. “I think if you create an ACO or a clinic integrated network that says for all savings that are created this is how it splits and everybody understands that, then that eliminates potential conflict.”

ACOs will also have to have some sort of board that holds everybody accountable, said Vath. “We have a whole structure—of quality committee and rules that they follow. We’ve developed the whole structure even down to the level of if you don’t meet the expected targets what happens.”

Silvey believes that funding issues will prevent ACOs from taking flight until the federal government finds a way to help pay for the infrastructure changes that are required. “It’s hard to ask the providers to go out and spend all this money on infrastructure when they don’t know how they are going to get their investment back.” He compared it to the slow acceptance of EMRs until the government offered to help pay for implementation. “That’s what’s going to have to happen if they want a change in the delivery system,” said Silvey. “If it can be made simple enough, if it makes clinical sense and truly benefits the patient, I haven’t found a provider that’s digging in their heels. They want to do what’s right. When they get frustrated is when they get a 500 page document that makes no sense.” Despite the improvements made in the final rules, Silvey does not believe there will be an additional rush to implement the CMS ACO model. However, the rules do provide a frame of reference as to where the healthcare delivery system is moving in the future, he said.

“I think there is agreement among my peers that the core concepts are moving in the right direction, but I think the problem is with our current forms of reimbursement,” said Viator. “I think we all have to look at partnering with the payers so that we can move forward in a way that does change our reimbursement to incentivize the objectives we have for care of the community. Unless we get together with payers and work on how to bridge from the current system and what it incentivizes to the future state then that will probably be one of the biggest barriers to moving forward.”

ACOs are a moving target, said Vath, because every time you turn around either CMS releases a new model to play under or an insurance company comes up with another way they might approach physicians and physician groups. “For us it’s still a concept and we are trying to take it from a concept down to the detailed part of actually sitting down and forming say, a physician hospital organization.” Silvey agreed that “ACO” is a generic term, but said it sends a message that the country wants a change in the delivery system and the payment system. “If someone asked us are you developing yourselves to fit the CMS definition of an ACO, our answer would be no. But if you ask if we are preparing for the eventual payment reform that is coming, the answer would be yes. Whether enough cost and reward can be wrung out of the existing system to make it work, nobody knows.”

Vath said he doesn’t really believe you can financially incent providers to do the right thing, nor can you regulate reform of the delivery system. “All they are going to do is meet some regulatory standard and that’s not doing the right thing. Ultimately that’s why the CMS thing is ridiculous. They had the right idea, the right concept, then they put 439 pages of things you had to do, to basically regulate doing the right thing,” he said. “They are going to have to regroup.”

“I hate to say you’ve got to get on board with an accountable care organization or be left behind,” said Viator. “Because that terminology is being thrown around to mean so many things. But I will say if you don’t get on board with the concept of preventable care and the sharing of information technology so that decisions can be made by caregivers with a more complete set of information, then I think you will be at a deficit to move forward. We also expect the CMS model to evolve over time, so as long as we just take some of the core concepts and what makes sense for the patients and this community, I think we will end up evolving into a better system of care, regardless of what label you put on it.”

Sources: “Accountable Care Organizations: Improving Care Coordination for People with Medicare,” http://www.healthcare.gov/news/factsheets/2011/03/accountablecare03312011a.html; “Everything You Needed to Know About Accountable Care Organizations, American Academy of Family Physicians and TransforMed, http://www.transformed.com/accountable_care_organizations.cfm; Evans, Melanie, “Forging the Way,” Modern Healthcare, Aug. 29, 2011; “The Family Physician’s ACO Blueprint for Success,” American Academy of Family Physicians, www.lafp.org.