In this week’s New England Journal of Medicine (December 30, 2010, vol. 363, p.2579-2585), two Perspective articles bring us up to date on how we can change our fragmented health care system with the current incentives in the wrong places, to one where efficient coordinated care becomes the norm. A staggering figure that 10% of patients account for 64% of all US health care costs emphasizes the need for coordination between physicians caring for a patient, patient understanding and compliance, and a focus on prevention of complications and hospitalizations rather than treating only in the ‘heat of battle’.

One solution is the creation of Accountable Care Organizations (ACO) that incorporate Patient-Centered Medical Homes with the goal of providing coordinated integrated care. These can be thought of as the equivalent of a Walmart (the ACO) being the overarching coordinating center, with each isle of different merchandise being the Patient-Centered Medical Homes.  These can be virtual within an existing institution but whether a hospital takes the lead or alternatively the physician remains to be determined as discussed by Kocher and Sahni. Either way, this will be a difficult but necessary transition. Sinaiko and Rosenthal in an accompanying article bring up the patient’s role in the ACO. The patient’s participation is a must to reach the goals of quality care while saving costs.

How Accountable Care Organizations will be implemented in our current system of fee for service and disjointed care is the critical question. What is the framework? What manages and drives the ACO? Passport to TRUST may be one solution to provide the framework to manage and drive an ACO by structuring of the doctor-patient interaction and follow up.