IN

Accountable Care or integrated care needs to have active participation of patients for any level of success. This is particulary necessary for Medicare aged patients and the management of their chronic disease. Patients need to understand at the outset they are attributed to a specifc integrated delivery team and must have a substantial incentive to actively particiapte in their care. Many of our markets would be characterized by multiple networks of care. Under ACO models these network would remain segregated to a significant degree. Patients today would traverse across those networks in their patient directed care activities and this behavior creates challenges to fully coordinate particpant benefits in a meaningful manner. There are also historic physician relationships across varied providers, that would not likely be integrated in a single ACO. This too would create overwhelming challenges to effectively manage care across a continuum under any integrated delivery/ACO model. If the ACO shared saving program is to succeed there will need to be an ability to be clearly directive to patients as to the ACO options they may participate, and have a consequence should they wish to go outside their prescribed ACO. There also needs to be financial tools to spur engagement or provide incentive for compliance in the activities embedded in medical homes and chronic care homes that are part of the ACO. While just gaining access to these types of providers should improve utilization patterns elsewhere in the IDS, it is relatively clear from past managed care experience and current employer health benefit design experiences, that having skin in the game is a key component if the program is to be successful. Respectfully submitted