I am going to start off today’s missive by talking a little bit about communism. Perhaps telling the reader this as they re-read the above headline is a little confusing, but bear with me.

In passing conversation, I continue to determine that Americans born in 1985 and after have little solid knowledge of communism and its multiple applications in the 20th Century. Those of us of a certain age and older were often told that communism was the biggest threat to the American way of life. From Joe McCarthy and the “duck and cover” drills of the 1950’s, to the Berlin Wall, to the Cuban Missile Crisis and the Vietnam War, communism was “the enemy” which needed to be eradicated from the planet.

In the world of 2011, where our citizens consume goods made by Chinese prisoners, and we laugh at Fidel Castro in the same way we snicker at Grandpa when his false teeth slip, describing communism as a threat seems as quaint to newer generations as an Amish horse cart.

Every political system is uniquely designed to be abused. While some portions of the political left in this country embraced Marxist fundamentals in the 1960’s (with the late folk singer Phil Ochs going so far as to print English-translated poetry by Mao Zedong on the back cover of his third album and asking “Is this the enemy?”), what they failed to realize was that communism became a tool of repression in the wrong hands. What started with the idea of  collected sacrifice for the common good became Stalin’s Soviet Union, Castro’s Cuba and Kim Il Sung’s North Korea, which were better described as personality cults rather than legitimate governmental systems.

The hardcore believers of communism’s promise started communes in the United States in the 1960’s, but an overwhelming majority of them either morphed into the megalomaniacal cults of the 1970’s or were abandoned in short order, because it turns out that farming is hard work and not the preferred lifestyle of college-educated suburbanites. For a visual reference showing the ludicrous nature of these efforts, refer to the scene at the commune about 30 minutes into the film Easy Rider.

A mini-treatise on communism seems like an odd place to begin a conversation about accountable care organizations (ACOs), but after reviewing the proposed rule released last Thursday, I’m getting flashbacks of Marx and Engels. The ACO proposed rule, as written, represents a blueprint for the mass collectivization of health care.

With Medicare being the biggest and fastest growing drag on gross domestic product, it makes sense that a proposal would be put forth to lower costs by streamlining and centralizing care while eliminating duplicative testing. Yet with any large-plan, the devil is in the details.

The first barrier that is faced by providers wanting to form an ACO is the upfront cost. Quite obviously, unless there are physician practices of over 100 physicians still in existence that are not hospital-owned, the hub of all ACO activity is going to be either a hospital or a group of hospitals in a given geographical area. Using Milwaukee as an example, the biggest hospital system in this area is Aurora Health Care. While technically a non-profit, Aurora is known for its for-profit behaviors as much as its wide scope of operations. The formation of an ACO is going to be easier for the big players like Aurora than it will be for smaller hospital systems with narrow financial margins. Because you need a minimum of 5,000 Medicare patients served in order to qualify as an ACO, rural hospitals are at a natural disadvantage right out of the starting gate. With the ACO concept being a driver of both profit and savings for groups that form such an organization, far-flung providers appear to see no benefits to such a system.

With the expansion of HMO’s from the mid-1970s, we have already seen a semi-collectivization of health care in the form of commercial insurance provider networks. Privately insured patients have had to make tough decisions regarding who will act as the gatekeepers of their care. I include myself in this group. If I walk out my front door and look to my right, I can see a hospital within walking distance two blocks away. Unfortunately, that hospital is outside of my insurance provider network, and setting foot in their ER in a time of crisis could open me up to financial ruin based on the severity of my presenting problem. My network facility is three miles away. If I’m home alone when I eventually have my first heart attack (courtesy of family history), that’s a long walk.

Using this example, let’s say that a currently independent physician joins a hospital-centered ACO with a hospital that isn’t the first choice of a significant percentage of his or her patient population. From the patient’s perspective, an ACO could represent an inconvenience and a barrier to preferred care. With an older population less able to travel longer distances independently, the result of this forced collectivization of an area’s provider population quickly changes from an inconvenience to an outright threat to health, welfare and independence.

The final hurdle is adaptability. Let’s say that an ACO hospital accepts a number of new physicians into the ACO who have never been affiliated with that hub hospital. This population of new physicians will need extensive training by the hospital regarding facility standards of care, clinical documentation expectations and other treatment protocols. If this training, for one reason or another, is not undertaken, it is safe to expect that these new providers represent a new and unique compliance risk to the ACO hospital.

The most important word in the American lexicon is “independence”. If every individual provider dispensed the same level of care, and the same number of primary and specialist care physicians existed in every area of the country, the ACO model would make sense in the long term. Unfortunately, physician skill sets vary, as they do for hospitals. One strength of traditional Medicare has been freedom of choice and the ability to make decisions for oneself independently. The proposed rule as written appears to exclude patient independence from the care equation.

To put it another way, Stalin killed 20 million of his own citizens collectivizing the Soviet Union. Whither ACOs?