Several years ago in the early days of Accountable Care Organizations (ACOs), we worried and warned about the importance of how each organization should divide up potential savings. In a white paper published in Physician Leadership Journal and on the Salient Web site, co-author Stephen Sheiko and I called it an “Elephant in the ACO Waiting Room.” In fact, today a new elephant is in the waiting room, and he is trumpeting a different warning message. The message is still about money; however, the elephant is warning about how much money is saved for the payer rather than how it is divided in the ACO. In 2018 ACOs generated net savings of $739.4 million during the year. In the most recently measured year, 2019, ACOs generated $1.2 billion net savings.While this is an improvement, it still begs the same question–is it enough?