Medicare Accountable Care Organizations: Clinical Performance for Patients With Heart Failure

Objective: To understand factors that distinguish higher-performing accountable care organizations (ACOs) in the Medicare Shared Savings Program from those with average levels of clinical performance for patients with heart failure (HF), a common and complex condition.

We used a 2-step design. First, we measured ACOs' clinical performance using Medicare data to calculate risk-standardized admission rates over time (2014-2017) for patients with HF. Next, we conducted 16 videoconference interviews with key informants in 2 ACOs that were average performers on this measure and 2 that were higher performers. At each ACO, we interviewed at least 1 of 4 key informant types: top leader, manager or director, clinical-level staff, and HF clinician or cardiologist.

We developed semistructured interview guides that included questions about ACO history and geographic context, organization and governance, management and leadership, and care management practices.

A combination of factors distinguishes higher-performing ACOs from average performers: fewer ACO staff and offices, majority-White beneficiary populations, and primary care physician leaders. In addition, higher-performing ACOs were characterized by close communication, real-time information sharing, regular feedback, physician buy-in, and strong care management programs.

The results suggest a challenge in scaling up the best practices of small, primary care-centered ACOs to improve the performance of larger, complex hospital-dominated health systems. The results also suggest prioritizing the development of data and information systems that track patients in real time and provide clinicians with regular feedback on the quality of their work.