A sleeping dragon awakes.

At our weekly health policy colloquium recently, the presenter described plans for our organization to form its own accountable care organization, or ACO.

The idea behind an ACO is to find patients who get the majority of their primary care within our system, and then “attribute” their health care and all of its attendant costs to that system, making the providers ultimately responsible for providing both high-quality and cost-efficient health care.

Inherent in this system is the expectation that savings get passed on to the providers in some fashion at the end of the year, and, ultimately, if the care they provide is inefficient, redundant, or overly expensive, then the excess may become a cost to the health system.

As you can imagine, many of the underlying pieces that have to exist in an ACO mirror those of the patient-centered medical home: Access to care when needed. Safe transitions of care. Robust IT tools to monitor health trends. Evidence-based care. Care coordination.

By using a pre-existing patient-centered medical home model, building an ACO requires the addition of even more extensive infrastructure support and even more rigorous efforts to coordinate care and prevent excessive spending.

When you build an ACO at an institution that is already providing patient-centered medical care, the pieces are already in place to create high-quality care, to get patients access to care so they do not need to seek redundant care elsewhere, and to make sure the necessary transitions of care are kept within the system if it all possible, and done better.

The resident-based practices within our institution care for a large majority of the highest-risk, most complex patients, those that utilize the most resources, and also as a byproduct sometimes have the most inefficient care (therefore leading to those increased costs).

In our patient-centered medical home model, we have started building care coordination into our practice, with incredible benefit to our patients and our providers. Care coordinators in our practice help ensure that patients’ care is delivered as planned, that ancillary services are supplied to them in their homes and communities, and help our busy providers coordinate care with external physicians, inpatient teams, and other caregivers.

Under an ACO model, the world of care coordination would of necessity increase massively, becoming one of the main foci of the care team. The whole point of this model is to identify those highest risk patients throughout the ACO that need reductions in duplicate care, prevention of defensive medicine, and implementation of high-quality interventions.

Those of us who have been doing this for a long time worry, however, that this is going to become just another version of some monitor looking over our shoulders at what we are spending while we care for patients, and telling us what we can and cannot do to take care of them.

Already the system is overwhelmed by prior authorizations for CT scans, limits on who providers are able to send their patients to see, and endless bureaucratic nonsense piled on top of our efforts to care for patients.

The ACO model will benefit our patients if it helps ensure evidence-based care, prevents unnecessary emergency room visits, keeps patients from doctor-shopping, and keeps them within our system where we can better take care of them.

What we do not want is to just have someone looking at our spending habits, peering into our patient interactions, and telling us what we can and cannot do.

While we recognize that ultimately there is a business side to health care, that someone needs to look at the bottom line, many of us fear that linking our practice of medicine to the sometimes unavoidable and messy nature of health care delivery, with the ultimate goal of saving money, creates a paradigm in which the practitioner may be pressured to avoid providing care they think is necessary and appropriate.

Keep building the support structures, keep giving us care coordinators, keep piling on the resources our patients need to achieve an optimal state of health. If at the edges of our care we can find ways to improve efficiencies and pare down costs, we will happily participate in this. But we are scared of having Big Brother look at everything we spend on our patients, because someone is always going to be worried that this is going to make us lose money.

Many of the medical systems that have tried ACOs have already abandoned their efforts: too hard, too costly, too risky, too little buy-in.

We want to be accountable to our patients, to ourselves, and to the best practices we believe will help our patients get healthy. But when money enters the picture and looms too large, it has the potential to take us away from our primary goal of caring for patients.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.