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I'd agree with the merit of most of the contentions Dan and David raise, but I think that many communities can't even get started. In my reading of the regulations, the anti-trust provisions have effectively wiped out the possibility of ACOs working across whole communities except for rural and single-hospital areas. The illusion of competition being important is striking down efforts to integrate across time and providers. I call it an illusion because I do not see the price competition for care plans for Alzheimers, strokes, and frailty generally.

I am not sure I am right, having no experience yet with anti-trust, but I do think that one strategy might be to engineer a more reasonable assessment of the merits and nature of competition as a price control. In the current rules, what matters is the combined market force of hospitals in each of a score of service lines. However, the very patients who most need integrated care are also people for whom the government already picks up most of their costs. Thus, we already have other ways to set prices for the elderly and frail and probably also for maternal-infant care. Medicare (and the VA) covers more than 80% of us as we come to the end of life, and now more than half of all babies are born in Medicaid (and another sizable group in DoD). One might argue for the FTC and DOJ to split off some populations in the Bridges to Health population segmentation model (http://www.milbank.org/quarterly/8502feat.html) and acknowledge that a community-wide approach might not run afoul of the antitrust laws because we have other governmental ways to set prices.
Some such approach is important because the best work available on improving care across settings relies upon community cooperations in setting standards, building information exchange, and learning to support self-care as a public health endeavor.

The development of ACOs could be the occasion of important community organization activity especially in regard to the health of individuals within a given geographical/political jurisdiction(s). Promoting public health by identifying and modifying the particular determinants of good or bad outcomes would "take a village"! Multiple agencies each with its own agenda and funding streams as well as overlapping general purpose governmental structures each with many special purpose agencies leaves the health of the population as a whole as no one's responsibility. Since ACO development proposes a new "structure" with many interested parties (would you believe some of whom may not have "the common good" or "common goods" like the health of the population at the center of their concern) it might be the time to call to the attention of the community that these new entities both in and of themselves but as potentiating essential building blocks in community development and well being. The health of the public and its determinants should be all agencies' agendas. However what is needed is somebody(ies)to bring the community together.

Perhaps this could be the stuff of a Pulitzer Prize were a local newspaper to take this on as a cause.

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