- Pride. Being joined by new physicians or another group may be experienced as an affirmation that the practice is respected, admired, and an excellent place to be.
- Security. The external environment is full of threats. Members of the group may feel that there is greater strength and security in greater numbers. More leverage in dealing with insurers drives up overall costs and contributes to the national cost spiral, but from within the group it looks like a good thing.
- Alienation. Many physicians join group practices hoping to be able to practice medicine without having to fret over the business elements of the profession. What interests them is seeing patients. What turns them off is their leaders' preoccupation with growth and excitement about it. They may feel like the older sibling when a new baby comes along - "have you stopped caring about me?"
- Fear. Especially when a small group becomes larger, it may feel like the loss of a golden age. This is a common phenomenon in organizational development and not distinctive to medicine. The feeling is - "why can't we stay as we are - things are great right now?"
- Opportunity. Sometimes growth creates new professional opportunities for members of the group. I experienced this in 1975. I was practicing contentedly at Harvard Community Health Plan when the group developed a new practice site in the town where I lived. I was asked if I was interested in leading the new site. My first answer was "no." But when I thought about the challenge of building a practice that would directly serve my own community I changed my mind.
- Learning. Growth is a significant change for organizations, and change creates the potential for learning. In the 1970s at Harvard Community Health Plan we argued about whether we needed to grow. For many of us, myself included, these discussions increased our "economic literacy" about what the U.S. commitment to a "competitive medical marketplace" meant. And developing a new practice site led us to make visits to each other to refine our understanding of local "best practices."
In ethical medicine, the guiding principle is to learn from each other and disseminate best practices. In competitive capitalism, the guiding principle is to hoard our good ideas to gain market strength. In the era of insurance company-led managed care, insurers followed the second path. Criteria for defining "medical necessity" were treated as proprietary business secrets. This was standard business practice, but a gross violation of health care ethics. It contributed to the backlash against managed care.
If ACOs take that route they won't deliver on their promise and the public won't - and shouldn't - trust them. The right ethical configuration for healthcare is as a "learning healthcare system," with free and open communication among clinicians and between clinicians and patients. It would be a tragedy for the ACO movement not to reach its potential.