Its basically now. 

Let's start with the timeline for implementation of the Patient Protection and Affordable Care Act. Despite the legal action which resulted in the Act being reviewed (and upheld) by the Supreme Court, and the uncertainty of the recent election, implementation has been marching forward.  

January first of this 2012, the first Pioneer Pilot ACOs were launched.   These organizations applied to participate in the pilot  program with CMS the national medicare administrator.  It just so happens that 5 of the 33 centers are large hospital systems in Eastern Massachusetts.  When they launched, more Medicare patients than not in the region were all of a sudden placed into ACO structures.  So in some parts of the country, we’ re here.

At this stage, the ACO pilots are sharing cost savings with the government.   The first bundled payment pilots launch January 1st, of 2013. 

The next important change occurs 1/1/14, with the launch of the exchanges and expansion of Medicaid. 

Private insurance companies are following suit. 

Private insurers are rapidly moving toward ACO structures and global payments, in some cases more quickly that the public sector insurances. This is occurring across the country.  In Massachusetts BCBS has instituted an "Alternative Quality Contract" (AQC).  This is an ACO structure with global payments.  BCBS is the largest insurer in MA.  At this point, 75% of BCBS MA HMO patients are covered under an ACQ contract.