Analyzing the Variation in the Performance of Accountable Care Organizations Serving Rural Medicare Beneficiaries

Research center:
Lead researcher:
Project funded:
September 2015
Project completed:
November 2016

Problem statement: The Medicare Shared Savings Program (MSSP) continues to attract attention, now as a means of meeting goals to transition Medicare Fee-for-services (FFS) to alternative payment systems. Increased flexibility has been built into the program since its inception, such that Accountable Care Organizations (ACOs) now include even more that serve rural areas, more that are governed and owed by independent physician associations, more that are small (fewer than 10,000 attributed beneficiaries), and more that are part of national consortia.

As the program enters its fourth year, performance data are now available for over 200 ACOs. Research questions about the relationship between ACO characteristics and performance can now be addressed. We will test hypotheses that size, direct involvement of physicians through governance structure, and investment in data analytics predict higher performance.

The goals of this project are to characterize ACOs that operate in rural areas (defined by the locations of primary care providers to whom beneficiaries are attributed and organizations participating in the ACO), describe the models being used to organize those ACOs (e.g., arrangements among participating providers, engagement of other providers in the region, relationship to large health care systems, participation in regional or national consortia), and to test relationships of those characteristics to performance measures related to financial success (i.e., shared savings) and quality (the indicators used by CMS). We will identify potential changes in legislative and regulatory policies that could strengthen the utility of the ACO model to achieve high performing rural healthcare delivery organizations.


  • Financial Performance of Rural Medicare ACOs
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2016
    Assesses the financial performances of rural accountable care organizations (ACOs) based on different levels of rural presence.
  • Medicare Accountable Care Organizations: Beneficiary Assignment Update
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2016
    This brief updates Brief No. 2014-3 and explains changes in the Centers for Medicare & Medicaid Services Accountable Care Organization regulations issued in June 2015 pertaining to beneficiary assignment for Medicare Shared Savings Program ACOs. Understanding ACO beneficiary assignment policies is dire in managing ACO providers and beneficiaries.
  • Medicare Accountable Care Organizations: Quality Performance by Geographic Categories
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2016
    Provides an analysis of the differences in Accountable Care Organization (ACO) performance on the quality measures among the Medicare Shared Saving Program ACOs with varying levels of rural presence. Findings suggest that ACOs with significant rural presence have performed as well as, if not better than, urban ACOs in delivering quality care.
  • Organizational Attributes Associated with Medicare ACO Quality Performance
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2018
    Peer-reviewed paper evaluating associations between geographic, structural, and service-provision attributes of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) and the ACOs' quality performance.
  • Organizational Attributes with Medicare ACO Quality Performance
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2018
    Cross-sectional and longitudinal analyses of Medicare Shared Savings Program Accountable Care Organizations' (ACOs') quality performance found rural ACOs' score was comparable to those in other categories. ACOs with hospital-system sponsorship, larger beneciary panels, and higher post-hospitalization follow-up rates had better performance.