One of the problems with the hype regarding Accountable Care Organizations is that the rules are not yet set. One reality is the possibility of draconian managed care as remembered by old-timers who have the scars to prove they had to undergo cupping and coining before a referral to an orthopedist for a compound fracture could be obtained. In this universe there is one dire warnings to be heeded: “Remember the HMO.” The alternate universe is the one where the hospital continues to milk patients of their insurance money until dry and “accountability” is to the CEO of the health system, not to the patient.

AAFP News Now has a tale of accountability that is neither killing people with undertreatment nor overtreatment but is, in fact, a tale of successful accountability. The group, WellMed of San Antonio, is providing care for a group of 40,000 Medicare recipients and does not have a hospital affiliation. They are primary care doctors (mostly family physicians) who are paid based in part on results. And their results are impressive.

One in five Medicare-eligible seniors in the San Antonio area is a WellMed patient, and according to the Graham Center study, the mortality rate for WellMed patients is consistently and substantially lower than that of other seniors in Texas.

WellMed’s hospital admission rates average fewer than 200 patients for every 1,000 patients in San Antonio compared with 350-425 patients for every 1,000 patients 65 and older in Medicare fee-for-service programs, according to Piefer. Moreover, WellMed’s total hospital bed days for every 1,000 patients averages about 800 days compared with more than 1,800 days for every 1,000 patients in fee-for-service programs.

WellMed’s success is not a result of a healthier-than-average patient population. According to the Graham Center study, the mean age of WellMed patients in the San Antonio area is between 75 and 76 years compared with an average age of 72 years for Texas Medicare recipients. The medical group’s patient base in San Antonio is largely older and predominately Hispanic, and more than 20,000 of its patients have one or more chronic conditions.

Not only are people not forced to see them, they are sought out by patients. They spend more high quality time with these patients and deliver care using teams that would be impossible in the fee-for-service setting.

WellMed patients “get used to the fact that they have a medical home,” said Salinas. “When patients have a medical issue, they call our clinic first. They don’t immediately go to the hospital emergency room or go see a specialist. They come to us first, and then we can determine what the best option is for that patient.”

WellMed physician Chris Arnold, M.D., of San Antonio, described the WellMed ACO model as just good care. “If you provide good care, the patients will be happy. They will keep coming to you. I can’t tell you of all the self referrals we have gotten just because of the care we provide. The word gets out that patients are going to get taken care of.”

I think these ACOs will shake up some deeply held beliefs.