The seems to be unfair both to the responsible ACO provider and to the patient, who will likely not receive optimal care in these transitions.

WSJ: Christensen, Flier and Vijayaraghavan:The Coming Failure of 'Accountable Care'

Transitions from one care setting to another in the last 90 days of life increased by 50 percent, from an average of two moves in 2000 to three in 2009.

FORBES: More People Are Dying At Home And In Hospice, But They Are Also Getting More Intense Hospital Care

Mercy Health, a not-for-profit health system in Cincinnati, Ohio that owns six hospitals, was able to reduce its 30-day readmission rate to 14.5% as of November, from 16.9% in 2011, with a Care Transitions program that assigns nurses to high-risk patients to keep them out of the hospital.

WSJ: Bringing the Hospital to Your Home