Regardless of one’s loyalties, anyone who has attended or seen professional football games played in the last decade knows the image of Peyton Manning breaking a huddle, surveying the field in front of him and pointing vigorously, while calling out signals to the other players on his team.

It is the image of a coach on the field. It is the image of a leader.

Who will be the leaders in the new, emerging landscape of our healthcare system? Rodak quotes Dave MacDonald, who says, “Healthcare organizations can have very complex political environments that demand comprehensive, deliberate and sound decision making. Any ‘team’ needs to have at least one person who can step in and make the tough calls.” In the evolving era of Accountable Care Organizations (ACOs), bundled payments, collaboration, physician alignment, and integration, who will become the leaders, where will they come from and what decisions will they execute?

What are the issues and where are we headed? No one can really outline the future with great clarity. However, the Supreme Court’s decision on June 28, 2012 means PPACA will go forward. The key indices and industry parameters currently developing all seem to be principally focused on value-based purchasing, ACOs, quality of care, and evidenced based care.

On the issue of evidenced based care it will presumably support and substantiate physician participation in the ACO environment. Robert Galvin, MD defines value as being quality/cost, and adds a key statement to help evaluate the signals from the noise in the current environment: “Invest in strong and clinically savvy physician leadership.”

In the recent Forbes Insights report focused on senior hospital and healthcare executives (i.e. C-Suite), two key results stand out relative to this projected state. First, 39 percent of respondents believe that at least a quarter of their revenues will be derived from value based purchasing in the next five years. Second, fully engaging their doctors was seen by C-Suite executives as the key to value based purchasing participation, as selected by one half of the respondents. In perhaps the most outspoken statement in this report, Peter J. Holden, CEO of Jordan Hospital states: “I told the doctors front and center that if you don’t learn and you don’t embrace and you don’t exert influence on what’s coming, you could be one class away from building houses.”

Regarding the evolving ACO networks, Fuchs and Schaeffer conclude health plans are the “most feasible candidate to get ACOs rolling.” This can be an ominous forecast, particularly for physicians. There are certainly similarities between the various ACO models and the original managed care model which saw such physician-unfriendly concepts as capitation, but this new, evolving era seems destined for growth. Indeed, the evolving ACO environment has grown dramatically within the last several months. Muhlestein, Croshaw, Merrill and Pena report that “the last eight months have seen considerable growth in the number of health care entities commencing Accountable Care Payment arrangements. Despite large variation in models used, this growth is evidence of the increasingly common belief that health care should be more than simply providing and billing for services. Leavitt Partners has utilized both public and private sources to track the activity of 221 Accountable Care Organizations through the end of May 2012. Although growth is concentrated in larger population centers, it has expanded to 45 different states.”