Levers of Successful ACOs

The Health Care Transformation Task Force interviewed high-performing Accountable Care Organizations (ACOs) to assess structures and strategies that led to their success. Although each organization had differing approaches and experiences, common themes emerged in three major categories: 1) Achieving High-Value Culture, 2) Proactive Population Health Management, and 3) Structures for Continuous Improvement.


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Part 1: Identifying the Levers of Successful ACOs

The Health Care Transformation Task Force (HCTTF) designed and conducted a qualitative study analyzing the elements of ACO success. The reports below detail that work, describing key findings across a number of domains, while this introductory report provides background, detailed methodology, and ACO selection criteria. The findings represent the experiences of select high-performing ACOs, including HCTTF and non-HCTTF members. The objective of this resource is to move beyond high-level themes to provide a tactical guide for understanding, prioritizing, and implementing the levers of ACO success.  The HCTTF recommends that ACOs and other health care stakeholders leverage these resources to:

  • Evaluate proficiency across key activities;
  • Educate organizations about the importance of these key activities; and
  • Prioritize improvement efforts based on unique needs.

Part 2: Achieving a High-Value Culture

Perhaps the most elusive yet most important element for achieving long-term success is developing a culture conducive to value. Having a high-value culture means that all levels of the organization –particularly the leadership – demonstrate an internally-motivated commitment to excellent patient outcomes (quality) that are achieved at the lowest possible cost. This category represents the underlying current that drives all improvement efforts, by ensuring the ACO objectives are prioritized at every level of the organization.

As true with most other elements, approaches to developing and maintaining a strong culture will vary from organization to organization. Still, all studied ACOs have pursued similar channels for engaging individuals across the organization:

  • Involvement by senior decision-makers (i.e., governance bodies) in ACO operations
  • Physician and community practice engagement
  • Expanded clinical partnerships

Part 3: Proactive Population Health Management

Unsurprisingly, common to all studied ACOs is a dedication to proactive population health management. Managing the health of a defined population across the continuum of care requires a complete paradigm shift for most providers, as well as the development of new systems and processes. While challenging to learn and implement, population health management is the cornerstone of all accountable care success. In addition to its foundational importance for accountable care, population health management and its various components were mentioned most frequently in the interviews, and were said to have the greatest impact on practice transformation.

While population health approaches can take many forms, most ACOs studied had developed analogous operational elements. Those fundamentals – which are detailed in a separate report – include:

  • Systems for identifying high-risk patients
  • General care management functions
  • Specific disease management programs

Part 4: Structure for Continuous Improvement

To be successful under any value-based payment model requires a strong supporting infrastructure, but this is especially true of ACOs. The nature of this care model, combined with the added complexity of multiple providers with disparate systems and multiple payers with different requirements, makes careful investments in infrastructure a principal strategic decision for organizations participating in ACOs. In combination with workforce resources, this is the backbone of all performance improvement. A successful ACO leverages its supporting structure to learn about its organization, its people, its performance, and its patients, and then uses that information to create feedback loops for continuous learning and system improvement. ACOs identified essential elements that support continuous improvement:

  • Operational infrastructure for performance measurement
  • Tying performance to compensation and network contracts
  • Participation in shared learning opportunities

Project Background

Value-based payment models have proliferated over the past several years in an attempt to address the unsustainably high costs and variable outcomes of health care in the U.S., and to test innovative models to solve these particular challenges and promote high-quality, low-cost care. While there are several approaches to value-based payment, accountable care organizations (ACOs) have been the most popular vehicle for value-based payment model adoption to date, with over 923 ACOs covering approximately 32.4 million lives across the country in 2017. ACOs can take a variety of forms, differing by provider configuration, contracted payers, payment methods, and more. While approaches to ACO implementation vary, the principles of population health management remain the same. Now, several years into the accountable care movement, health care stakeholders are closely studying the structures and behaviors of existing ACOs to learn about the attributes of successful organizations.
Recognizing the importance of identifying and disseminating these success levers, the Health Care Transformation Task Force (HCTTF) designed and conducted a nearly 12-month qualitative study analyzing the elements of ACO success. This report details that work, outlining research methods and describing key findings across a number of domains. The information contained in this paper represents the experiences of select ACOs, including HCTTF and non-HCTTF members, and is supported by additional evidence found in the current literature.


The HCTTF’s Accountable Care Work Group conducted a multi-step project which included, among other things, a series of in-depth interviews with leaders of successful ACOs to investigate the common structures and strategies that enable success.
It was determined that all interviewed ACOs must meet the following criteria:

• Shared savings rate ≥2%
• Quality score ≥90%
• Below-average baseline
• ≥5,000 ACO-covered lives
• More than one year under accountable care contract
• At least one commercial ACO contract (in addition to a Medicare ACO contract)
• Diverse geographic representation (preferred)
Using the PY 2015 Medicare ACO performance results and the Leavitt Partners ACO database, 21 Medicare Shared Savings Program (MSSP) and Pioneer ACOs were identified as meeting the criteria. The Work Group conducted interviews with 11 of the 21 ACOs, corresponding to over 10 hours of interviews. Within each ACO, the HCTTF interviewed senior decision-makers involved in designing and implementing accountable care-related activities across the ACO. To standardize the areas investigated, all ACOs were interviewed using the same interview guide. Interview transcripts were then coded to enable a thorough qualitative analysis. All quotes in this report draw from these interviews and written transcripts.


This is a product of the Health Care Transformation Task Force under the leadership of the Accountable Care Work Group. The Accountable Care Work Group is comprised of Task Force members and other organizations dedicated to improving the design and implementation of the ACO model in public and private payer programs. The Work Group addresses both internal operational challenges as well as public policy issues that challenge transformation efforts for health care organizations.

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In case you missed it: Gain insights from organizations at the vanguard of value in our Transformation to Value leadership guide and strategy framework.