The Centers for Medicare & Medicaid Services released its 696 pages of regulations and their rationales on Accountable Care Organizations. As quoted on Medscape.com, the regulations were "mind numbing." Not to worry, though; Donald Berwick, who was interviewed in the Medscape article, stated that "the rule by nature is complex, but the underlying story is a very simple one." I hope that is true. Indeed, most things are simple unless the government gets involved, in which case complexity, confusion, inefficiency and apathy are a risk.

That said, there have been some positive clarifications:

1. The number of quality measures that ACOs must satisfy has decreased from 65 to 33.

2.  ACOs must no longer have at least 50% of their primary care physicians qualify for meaningful users of electronic health records.

3. Physicians can choose to participate in an ACO model where they do not risk losing money.

4.  Rural ACOs and physician-owned ACOs can receive an advance payment of future shared savings to invest in start-up infrastructure.

Berwick indicates that some of the provisions physicians found objectionable still remain, "but nobody gets everything they want … That's how democracy works." Interesting; I didn't know that government bureaucratic regulatory mandates involved democracy at all.

Since we are on that subject: I am deeply concerned that those providing the care, i.e., physicians, nurses and technicians, did not see more of their sensitivities to the actual delivery of care taken into consideration. I am confused, and it may just be me, as to what “democratic process" Dr. Berwick is referring to when it comes to advocating for the process of care required for our patients.

Don't get me wrong; the time has come for integrated care. The time has come to reward quality. The time has come to put patients in their rightful spot in the center of the care paradigm. My pessimism revolves around the bureaucracy of CMS knowing what is best, their anti–free market approach to health care, and their paternalistic approach toward the providers of health care. I can only hope that when ACOs are up and functioning, those processes that succeed are allowed to flourish, but more importantly, those that don't are quickly weeded out. In a free-market process, this happens with blinding speed. I'm not sure the same can be said of government bureaucracies.

Let's all keep a close eye on this process. It should be very interesting.

 Robert Provenzano, MD, FACP, FASN, is Vice President of Medical Affairs at DaVita Inc.This is a guest editorial for NN&I; to read Dr. Provenzano's latest ACO blog, "Is Failure an Option?" visit AccountableKidneyCare.org  or you can follow him on Twitter at #DrBobPro.