One of the more surprising moments during last week's Health Forum-AHA Leadership Summit came when attendees were polled as to whether their hospitals would be participating in the CMS Accountable Care Organization program when it launches at the start of next year. The reaction since the proposed ACO regulations were released in April has been decidedly mixed, with providers concerned about two major problems; the difficulty of meeting the program's quality standards, and the prospect that the resulting financial incentives wouldn't be enough to justify the risk of missing out on them.

Since April, in conversations I've had with hospital executives and thought leaders, almost everyone I've spoken to embraces the broader concept of accountable care, but I've been hard-pressed to find anyone who's ready to join the CMS pilot as it currently stands. For instance, when I interviewed leaders at Chicago-based Advocate Health Care, they spoke highly of an ACO pilot they're entering into with Blue Cross Blue Shield of Illinois, but said they have not yet decided whether to participate in the federal program.

Back at the Summit, though, 45.5 percent of respondents to the poll — to be sure, an instant, unscientific poll conducted via mobile applications — said their hospitals would definitely or probably participate in the program when it starts in a little over five months. That suggests to me that there is a high level of interest from hospitals in the ACO concept, even as part of the federal effort, but hospitals and other providers simply want a program they feel ensures them of receiving fair value from before they sign on.

A little while after I saw the results of the poll, I sat in on an ACO-themed session that featured several CEOs of leading hospital systems, including Nancy Schlichting, CEO of Henry Ford Health System in Michigan, and Chris Van Gorder, CEO of Scripps Health in San Diego. Henry Ford has been developing an ACO with its physicians since last year, while Scripps recently formed an integrated delivery network with North American Medical Management that includes many of the same principles as an ACO. But to date, neither system has decided to join the CMS initiative.

"It's too much stick, not enough carrot," Van Gorder said. "It's pretty much a non-starter for us."

Schlichting, meanwhile, said the program needed to create more flexibility in both the structure of participating ACOs and the design of incentive payments.

Van Gorder did have some positive things to say about the Pioneer ACO model — a sort of advanced program for early adopters of accountable care that CMS proposed in May after the negative reaction to the proposed regulations. For instance, Van Gorder noted, the Pioneer program allows for the prospective attribution of patients, which means participating ACOs would be aware of patients who are assigned to them. The proposal for the regular ACO program includes only retrospective attribution, which means ACOs would not know in advance which Medicare patients were assigned to them.

"The dialogue around the Pioneer model has been much more constructive," Van Gorder said.

Still, with five months to go until the CMS ACO program starts in earnest, it's difficult to find a hospital CEO, even from the most leading-edge organizations, who will commit to the federal program. But if you ask a roomful of hospital leaders if they think their organization will participate in theory, you'll get plenty of affirmative answers.  That suggests that CMS is on the right general track with the broad outlines of its initiative, but needs to pay much closer attention to providers' concerns about the nitty-gritty details if it hopes to receive actual commitments this summer and fall.