MIDWAY, UTAH—During last week's CMS announcement of the proposed rules for accountable care organizations, or ACOs, I was, appropriately enough, in Utah's Rocky Mountains at the Intermountain Healthcare Clinical Quality and Accountable Care Seminar. Intermountain, with its own insurance plan and medical group, is designed to deliver clinical best practices in every patient encounter and is often held up as one of the models for ACOs. The seminar was billed as a chance for other hospitals to learn how all the pieces fit together.

But while Intermountain leaders were happy to discuss their efforts to root out variation, partner with physicians and manage population health initiatives, they were generally cautious about the comparisons between the ACO program and their system, which has evolved gradually since it was created in 1975 as a non-for-profit organization inheriting 15 hospitals previously run by the Church of Jesus Christ of Latter-day Saints.

When I talked to Intermountain CEO Charles Sorenson, M.D, he took pains to point out that many of Intermountain's key assets—an EMR that gives doctors best-practice information at the point of care; its in-house insurance plan, Select Health; and its close relationships with doctors—took years of fine-tuning and negotiations to get right. And Linda Leckman, M.D. CEO of Intermountain's Medical Group, had words of caution about the ACO model's emphasis on clinical integration, during a session on alignment between the medical group and individual physicians. Sometimes, hospitals simply don't have the capacity to hire or affiliate with every physician who would like to join, Leckman pointed out.

"Nationally, speakers are telling physicians that in the next three years, you need to be tied to an ACO," Leckman said. "In our community, there are physicians who want to be a part of us, but it doesn't always work for us. The more clinicians you have, the more your infrastructure gets stretched."

On the final day of the seminar, Greg Poulsen, senior vice president of strategy for Intermountain, drove home the importance of the work that ACOs and independent care coordination efforts, like those at Intermountain, will have to deliver in the years to come. Poulsen briefly surveyed the current political machinations around the ACA, and then argued that regardless of how national reform plays out, the challenge of bending the ever-rising health care cost curve will remain. Poulsen noted that future, unfunded obligations to Medicare are estimated by the GAO at roughly $37.9 trillion—dwarfing unfunded obligations to the national debt and Social Security.

"This is a big problem if the growth rate continues," Poulsen said.

Despite that grim forecast—backed up by a flurry of statistics on variations in health care outcomes and utilization—Poulsen sounded a somewhat upbeat call to the hospital leaders and doctors who trekked out to Utah to look for solutions.

"Can we change the health care cost structure to make things better?" Poulsen asked the audience.