Regarding “What Family Physicians Need to Know About ACOs” [September/October 2011], at least three organizations are trying to create accountable care organizations (ACOs) in the southeast Connecticut area. Although ACOs have the potential to improve quality and continuity of care, they will be a major cultural change. In addition, the logistical, administrative and actuarial support costs are likely to be a constant drag on the bottom line and, in my opinion, are very likely to eat up any cost savings. If we move toward ACOs, I fear we will be trading today's inefficient system for a system in which the real producers of care, primary care physicians, are relegated to the rank and file in a top-heavy administrative bureaucracy driven by contractual requirements. Any value added will be absorbed administratively, and we will find ourselves doing a better job and rendering better care but with less control and certainly less income.

The gorilla-size loophole in the ACO model is that patients are “assigned” to a practice and their health care costs are attributed to that practice; however, the patients have no obligation to follow the advice of the doctors in that practice! In fact, the patients do not even know they have been assigned to a practice. They can receive medical care from any source they choose, including a practice that is much less efficient and more costly than the one being held accountable for their care.