ACOs are like HMOs with "No Child Left Behind" mixed in. Li'l story:

In 2002 I went to get a physical. Why? Because I hadn't had one in a while. So I used my insurance referral system and went to see a doctor. It was the weirdest thing - the doctor spouted PSAs every second sentence - in broken english, through a heavy Korean accent. "Raise arm, make fist - don't do drug. Breathe in - now breathe out. Always wear condom. Turn cough - wear seatbelt." 20 minutes of this. I never could figure it out.

Then I started dating someone who worked in the health insurance industry. Because of the way HMOs work, he got to check off a box for every PSA he laid on me - that was a billing code. By saying "don't do drug" he was able to check off "counseled patient about illegal substances" or something and hit them for $50. So while I was just going to make sure I was healthy, he was playing Billing Code Bingo... which is how you make money when you take insurance.

But wait, there's more! Since I had no reason not to let him designate himself as my "primary care provider" he got a monthly check from my insurance company just because he was "my doctor." Note that this is a person I never saw again... but for three straight years, he got ~$50 a month because I'd seen him once. For half an hour.

Fast forward 10 years and that girl is my wife. I put her through medical school. She's a naturopathic doctor and a midwife, licensed in the state of California. California doesn't require insurance companies to cover naturopathic care, of course, so all that is cash'n'carry. Midwifery care? Well, she takes AIM, which is for disadvantaged mothers. She gets about 1/3rd of her fee through AIM but she's cool with that because she'd giving back to the community. Okay.

In order to get that 1/3rd of her fee she has to make sure fifteen different things are done right and that everything is handled in advance. Keep in mind that a home birth through her costs about 1/15th as much as through a hospital (any hospital). And there are labs that she can bill through insurance and the like, but these are things where the patient is actively taking an interest in their own health, actively working to make their own life better, and stepping outside of the system in order to improve their condition.

Under ACOs, health care organizations are punished for this. They're spending money that isn't directly related to their metrics. Meanwhile, since my wife is out-of-network, nothing she does is even recognized by the ACOs. It's like No Child Left Behind - if you go to Sylvan in order to improve your test scores, the government rewards the school district but Sylvan gets no credit and no money and you're out-of-pocket on the expenses.

And how has NCLB done by our education system?

The way to improve an overly-bureaucratic and ineffective healthcare system is not to increase the bureaucracy and ineffectiveness.

A quick bio:

" Dr. Landon graduated summa cum laude from the Wharton School at the University of Pennsylvania with a major in finance. He received his M.D. from the University of Pennsylvania School of Medicine, and an M.B.A. with a concentration in health care management from the Wharton School. He also received an MSc in health policy from the Harvard School of Public Health."

http://www.commonwealthfund.org/Bios/L/Landon-Bruce-E.aspx

So. Degree in finance from Wharton. MBA in health insurance from Wharton. MS in health policy from Harvard and MD from UPenn. Ask yourself: is this guy more interested in patients or money?

I'm gonna go with "money."