What is an ACO? That's the question so many of us keep asking, and we are waiting for CMS to propose regulations to give us some guidance. What's the structure? How do we form one?

Well, those are the wrong questions. Leave it to governance guru Jamie Orlikoff to put it into larger perspective. The question we should be asking is: Why an ACO?

"The ACO is the unicorn of health care. Everyone knows what a unicorn is, but have you ever seen one?" He said during his keynote address this morning. The issue isn't how an ACO—or whatever you want to call it—is structured, no; the issue is why your organization must transform into one.

It's all about value. The current health care system of rewarding inefficiency, he said, is unsustainable and will change regardless of what happens politically to the health reform law. It is important to keep in mind that the health reform law isn't driving the change. The economic factors that spurred health reform in the first place are driving change: growing national debt, slow economic growth, the need to cut costs anywhere and everywhere. Value is the new reality and the sooner organizations can adapt to that mindset, the better they'll be positioned to survive.

Trustees, Orlikoff said, are integral to pushing hospitals out of their current comfort zone. Most trustees come from industries that have already been through some sort of evolution/revolution/transformation. The mantra that "health care is different" no longer holds water and trustees need to be more forceful in getting their hospitals to truly transform.

There are three critical questions a board needs to think about during this time of change: 1) What do we believe? 2) Whom do we serve? 3) What do we do? Unfortunately, he suggested, many organizations start at question three, when they should first be answering questions one and two.