I would need fingers and toes to count the number of conferences I?ve attended where the key message was this: The growth of healthcare costs in the United States is unsustainable and we?ve got to move away from fee for service.

That message was running through nearly all of the sessions at the June 12-14 National ACO Summit sponsored by The Dartmouth Institute for Health Policy & Clinical Practice in Washington, D.C. And, yes, while there was evidence that providers and payers are moving away from volume and toward value in healthcare reimbursement, it was evident there is a lot of work to do.

For example, a large physician group practice in the Southeast is making the move away from the traditional volume game, but it borrowed $25 million to invest in staff and technology to move its 300-physician group into risk-bearing contracts. So far, operating in upside risk, the group has dramatically lowered per-patient Medicare costs, and now it's ready to go the extra step into downside risk.

But how many group practices are willing and able to find that kind of capital to invest? Such investment favors the largest of practices, and those with large sums of cash?a fact that explains the consolidation among practices and large health systems.

Meanwhile, it's not easy for even large health systems to make the leap. While they have access to capital, these systems have a hard time convincing leadership that they need to invest millions to develop care systems that will fill fewer hospital beds. The Medicare Shared Savings Program (MSSP), serving more than 3.4 million seniors, basically requires investment for up to three years in electronic records, new staff and other IT enhancements; after all that, they might (but there is no guarantee) recoup their money four or five years down the road.

Luckily for patients and the system as a whole, it's not all about immediate profits, or the accountable care movement might fall apart altogether in its first years. Said one participant at the conference: ?We are almost managing hospitals into oblivion, but to tell the truth, it's the right thing to do.?

So what's ahead? Many speakers believe the MSSP will have to evolve into a deeper level of risk with a per-member, per-month global payment coming sooner rather than later. Payers and providers alike are paying a lot of attention to reducing unnecessary costs around end-of-life care, which is encouraging. And the other oft-repeated conference theme ? putting patients at the center of care?is actually getting some legs through the MSSP quality measures and other measures that tie physician bonuses to patient and family satisfaction.

But patients still aren?t taking care of themselves like they should (a ridiculous number don?t take meds as prescribed, for instance). Physicians are still mostly billing for each service, and many complain they are overworked. Far too many people use the emergency department as a front door for their care.

Nevertheless, if you take the presentations to heart, cracks in fee-for-service are starting to show, as providers gradually experiment with new reimbursement models that focus on quality and efficiency rather than volume.

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