Research Alert: February 20, 2026

Rural-based Accountable Care Organizations Agreement Renewal

This policy brief describes characteristics of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) and compares trends in exits and entries into MSSP between nonmetropolitan (rural) and metropolitan (urban) geographies from 2013 through 2022.

Key Findings:

• In 2013, only 10.9 percent of new ACOs were rural. The rate of growth has been somewhat uneven over the years, but in 2022, 34.8 percent of new ACOs were rural – down from a peak of 48.0 percent in 2016.
• Between 2013 and 2016, the average program tenure (years an ACO remains in the MSSP) was slightly longer in urban ACOs. From 2017 to 2022, the tenure in rural ACOs was slightly longer compared to urban ACOs.
• Two-sided risk adoption was almost nonexistent through 2016. Starting in 2017, the proportion of ACOs assuming two-sided risk has grown unevenly but substantially as a result of Centers for Medicare & Medicaid Services' (CMS) modifications to the MSSP in 2016 that encouraged ACOs to choose two-sided performance-based risk arrangements. Agreement renewals among ACOs with two-sided risk have been high, with up to 94.1 percent of urban ACOs (2019) and up to 100 percent of rural ACOs (2017-2019) with two-sided risk renewing their agreements. A relatively small proportion of rural ACOs initiate with two-sided risk.
• The CMS Innovation Center ACO Investment Model (AIM) was designed to encourage new rural ACOs, as well as existing ACOs, to transition to arrangements with more financial risk when renewing participation in MSSP. Starting in 2016, more than half (60.4 percent) of rural ACOs participated in AIM, but only 17.2 percent of them renewed their MSSP agreement after the initial three-year term.

Additional Resources of Interest:

• More FORHP-funded research on Healthcare financing, Medicare
• More information about the RUPRI Center for Rural Health Policy Analysis