The first time I entered a major-league baseball park, I was overwhelmed by the size.


The grass in the outfield seemed to go on forever, the scoreboard was bigger than our house, and I had never seen so many people in one place.

But after I sat for a few minutes, something else impressed me even more: the coordinated bustle all around me. People streamed down the aisles toward assigned seats. The ground crew dragged the infield with perfect choreography. The teams were divided into specific groups for warm-up drills. And the vendors worked segments of the stands, exchanging money for food and beverages with the grace of magicians. 

Since that time, I’ve also seen examples of large enterprises that were not so well coordinated. For example, I lived in New York City during the 1970s, when garbage was piled on the sidewalks, major streets had no lane markings, and I was robbed three times in one week.

In this month’s hfm, the article “Emerging ‘Super-ACOs’ Fill Unique Needs,” by David G. Anderson and Neal C. Hogan, describes how smaller healthcare organizations can partner—without formal mergers—to create a large, well-orchestrated enterprise that achieves economies of scale, coordinates care, and accepts risk-based contracts.

The authors caution that achieving this level of coordination requires discipline and planning. The leaders of the ACO need to understand the market dynamics, find compatible partners, navigate legal and regulatory complexities, enlist technological support, incorporate a clinically integrated network, and be skilled in risk management. 

Quoting the adage “Culture eats strategy for lunch,” the authors stress the importance of a culture of collaboration. “Examine the potential partner’s willingness and ability to collaborate,” they write. “Super-ACO partners must place a high value on collaboration and have a long-term commitment to working together to improve clinical outcomes, population health, and financial performance.” Just because a health system is excellent in other ways does not mean it will “partner well.”

In a major-league ballpark, each entity has a carefully designed activity. Each has talent and experience to do that job well. And the activities are designed by a governing intelligence that makes sure they complement one another and serve the larger purpose of a good customer experience. The result, especially when observed from a seat up high, is elegant. In contrast, the lack of governing intelligence and the sense of fighting your way through a morass each day were hallmarks of New York when I lived there.

You can’t see the workings of an ACO from a single vantage point. But with a sound plan and a culture of collaboration, an ACO can have the same kind of beauty as a ballpark. And a well-executed ACO can serve a much larger mission: improving health and improving our healthcare system.

Publication Date: Tuesday, October 01, 2013

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