The Jefferson School of Population Health just finished hosting a special two day invitation only advisory board on the current status of Health Reform. We had one dozen experts from all around the nation convene on our campus for a two day discussion of the details and an update on implementation challenges. It was sobering indeed!! At this juncture, I believe that most organizations are NOT culturally ready for the hard work of true accountability.The heart of a real ACO, whether with Medicare or commercial patients, is the realization that clinicians will have to self evaluate, measure what they do everyday, and be willing to engage in the gut bustingly difficult work of improvement. The "shared savings" may in fact be minimal, especially in the early stages. It will take a commitment to practicing based on the evidence and a willingness to benchmark performance against regional and national leaders. A tall order for any organization and in my view, most are not at all ready for this cultural paradigm shift. Who will make it---organizations with a hierarchical doctor culure, accustomed to profiling and willing to police members within their own ranks. The Ochsners, Geisingers and Mayos of the world will be able to make it work, very few others have the skill sets necessary at this juncture. Stay tuned for more posts from our amazing advisory board and for publications that will come from our deliberations together. DAVID NASH