Walker J, McKethan A. Achieving Accountable Care — “It’s Not About the Bike”. N Engl J Med. 2012;366:e4.

“In his memoir It’s Not About the Bike: My Journey Back to Life, seven-time Tour de France champion Lance Armstrong argues that winning the world’s greatest bike race does not depend in the final analysis on sophisticated bicycles. Although advanced equipment is very important, winning depends more on athletes’ riding skills, physical conditioning, and race-day effort.

Accountable care organizations (ACOs) are the bicycles of modern health system reform, attracting considerable attention as promising vehicles for achieving better care, better population health, and lower costs. Indeed, we have argued that health care delivery organizations do need new payment models like ACOs to improve their performance. Yet the success of ACOs — as they are defined by health care providers, private payers, and now the Centers for Medicare and Medicaid Services (CMS) — will depend on whether they can enable and sustain care delivery organizations (the analogue of athletes) to improve their underlying performance.

If an ACO were a bicycle, its wheels, spokes, and gears would be the criteria used by payers such as Medicare to determine providers’ eligibility, the methods used to assign patients to a given ACO, and the manner in which financial bonuses are calculated. These and other key operational issues are important and have accordingly attracted close scrutiny in the past year. Yet the success of ACOs — like the usefulness of bikes — depends on whether they can compel and equip the athletes riding them to improve their performance. It’s not merely about the bike.”

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