While most people think of the Affordable Care Act (ACA) as designed primarily to expand insurance coverage, the roughly 900-page bill establishes numerous additional programs promising to change the delivery structure of American medicine. Most notably, the ACA provides clear impetus for hospitals to establish closer relations, if not integration, with medical groups providing ambulatory care and health care providers responsible for post–acute care.
Clinical integration commonly implies the presence of a defined network of health care providers working together using proven protocols and measures to improve patient care quality and decrease cost.1 The ACA legislation moves health care in this direction, first and foremost by establishing Accountable Care Organizations (ACOs), in which participating groups of health care provider organizations agree to undertake care for defined populations, meet quality standards, and share in any savings (and potentially any overages) in the cost of patient care compared with an historical baseline. The ACA also calls for pilot programs of “bundling” in which hospitals and other health care providers take on financial responsibility for the entire package of services provided to care for patients receiving coronary artery bypass graft surgery or other specific procedures. Finally, the ACA penalizes hospitals for excess readmissions, not just those that occur a few days out when faulty discharge planning and suboptimal transitional care may be most responsible for readmission, but also up to 30 days after hospital discharge, a time when care is usually directed by ambulatory health care providers.