In May, I flew to San Francisco and the steward, long before he offered me my complimentary beverage and six peanuts, tried to sell me an airline credit card. I was suitably outraged at this captive sales pitch. But in the non-stop flight called ACOs, the captive pitch could be the difference between success and failure. And physicians may be doing the selling.

Why? ACO patient retention is paramount, and for two reasons: Medicare fee-for-service beneficiaries can opt out of participation and commercial PPO patients can see any physician they like. FFS and PPO are the acronyms signaling the next frontier in ACO patient engagement. Narrow networks have already proven that patients, faced with a meaningful cost differential, will switch doctors. It's a system that tiers physicians the way health plans tier drugs: patients will choose an equally effective generic over the better-known branded therapy that is more expensive. Granted, how likely is a chronically ill individual who has been treated by a trusted physician or even an untrusted one to switch specialists on a whim.

So is the way to patient loyalty (i.e., retention) through their pocketbooks? Maybe, given the next long-term trend in commercial ACOs: the inclusion of pharmacy risk in total cost of care. And this is where the rubber will meet the tarmac. A handful of accountable care innovators are already there, namely Blue Cross Blue Shield of Massachusetts. But state legislation has helped drive the change: global risk is virtually codified.

Most providers and payers just aren't ready. But they see the writing on the wall. Banner Health pharmacy officials see bifurcated pharmacy risk as unsustainable. It has introduced a pilot to see if cost improves adherence for COPD patients by charging generic prices for branded drugs. Translation: Provider as broker. A Cigna pilot in five ACO-linked practices may be taking it one step further. The insurer is providing cost-savings data at the individual patient level. Yes, you heard that right. In the grand experiment called ACOs, this simply is what's next. And if you're a physician without a window seat, you may not like it very much.

Follow Laura Beerman on Twitter @LauraBeermanDRG

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