System Integration and Rural Provider Participation in Accountable Care Organizations (ACOs)

Research center:
Lead researcher:
Project funded:
September 2012
Project completed:
July 2013

The development of ACOs (Medicare-, Medicaid-, and third party payer driven) is a rapidly expanding health care delivery and financing option. More than 160 ACOs operate in the United States. Medicare has approved 32 Pioneer ACOs (sophisticated system based providers) and 27 Medicare Shared Savings Program ACOs (announcement made April 10, 2012) that include 2 Advanced Payment ACOs (small ACOs in rural areas). Little is known about rural provider characteristics that might make ACO participation more likely and the characteristics most likely to lead to performance success.

This project will develop a comprehensive national database of rural provider participation in Medicare ACOs. This activity will inform a policy discussion regarding the impact of the ACO movement on rural providers and potential consequences on rural people and places. Beginning with four ACO case studies (one in each Census Region), we will develop a descriptive database of geographic, demographic, organizational, governance, cost/revenue allocation, and other variables likely to impact ACO success and performance.

Hypotheses, Design, and Analysis:
Due to the descriptive and explorative nature of this research, we do not aim to test specific hypotheses. However, the guiding proposition of this research is that rural providers' decision to participate in ACOs and their strategies regarding the form of participation depend on the characteristics of the communities they serve, their own capacities, their relationships with other rural providers, and their relationships to surrounding ACO development activities (often the development of urban-based ACOs).

We will examine the following research questions to assess the guiding proposition:

  • 1. What is the current state of rural provider participation in ACOs?
  • 1.1 How many current ACOs involve rural service areas and/or providers?
  • 1.2 Where are these rural inclusive ACOs? What are their service areas?
  • 2. Why do rural providers participate in ACOs?
  • 2.1 Who participates?
  • 2.2 What community, provider, and relational characteristics are associated with rural providers' participation in ACOs?
  • 3. How do rural providers participate in ACOs?
  • 3.1 How are ACOs with rural participants structured?
  • 3.2 What community, provider, and relational characteristics are associated with rural providers' form of participation in ACOs?
  • 4. In rural communities with ACO participants, what are the plans for providers who do not currently participate in the ACO regarding future participation?
  • 4.1 Do they plan to participate?
  • 4.2 If not, what are their perceived barriers for participation?
  • 4.3 If so, what is their anticipated form of participation?
  • 4.4 What factors would cause them to decide to participate?
  • 4.5 What community, provider, and relational characteristics are associated with prospective rural providers' plan to participate in ACOs?


  • The Uninsured: An Analysis by Income and Geography
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2013
    This brief reports that a larger proportion of the rural versus urban population is uninsured and low income and will be eligible for subsidized Health Insurance Marketplace coverage due to income levels and current lack of insurance.