As Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation (RWJF), noted earlier this year, Accountable Care Organizations (ACOs) are no longer the “mythical unicorn creatures” they once were. In just six short years following the enactment of the Affordable Care Act (ACA), ACOs have moved from a small market experiment to now being responsible for the health care—and the health care costs—of nearly 30 million Americans.

While ACO performance continues to evolve, one thing is clear: ACOs were early trend-setters in the movement toward advancing population health.

But when it comes to actual operations, what does “population health” look like in an ACO, particularly in ACOs led by community hospitals? Do ACOs see their role in population health management as caring for their patient populations as a whole? Patients in their catchment areas? In their communities? And how do those views “sync” with the care delivery and partnership approaches that hospital-based ACOs are actually using?

The Robert Wood Johnson Foundation and Premier Inc. (in conjunction with Greenwald & Associates, LLC, National Research, LLC, and KNG Health Consulting, LLC,  set out to answer these and other questions in a comprehensive study of ACO activities and performance. The study spanned from September 2015 through May 2016 and explored population health services offered and ACO operations at nineteen hospital-based, fully integrated ACOs using surveys and telephone-based interviews of ACO leaders. The results highlight many of the tensions that ACOs are currently facing.


First, the ACOs define “population health” as attributable patient population health—meaning the population health of those who belong to the ACO and for whom ACOs are striving to provide high-quality care at lower cost. These ACOs’ focus is on patients with high, unnecessary health care spending, such as people with complex needs or expensive conditions. This is not a surprising early area of focus, as these patients tend to be the “heavy users” of high-cost medical services, such as the emergency department, even though, with proper care coordination and management, much of this use could be avoided and/or directed to a more appropriate ambulatory setting. Typically, population health work is seen as the purview of a particular department or program within a hospital that targets these specific types of patients for enhanced care coordination or management.

What makes this narrow focus especially interesting is that the majority of the ACO leaders queried described their hospitals as in a good or very good position to provide resources that could improve overall community health—yet, that wasn’t reflected in their priority activities. Encouragingly, however, several ACO leaders described their emphasis on heavy users as being initial “low-hanging fruit” or a type of test case for change that could be expanded to include other populations in the future.

A second interesting finding was the degree to which ACO activities matched up, or did not match up, against what were identified as the largest impediments to overall community health. For example, every ACO in the sample said that better behavioral health services are needed to improve community health. The next most common responses were the need for substance abuse services, more affordable prescription medications, and transportation services.

But when ACO leaders were asked what sorts of community health programs and services they were either employing or planning to employ within six months, the top three answers were, instead, related to care coordination, chronic disease management, and health education.

Similar to the aforementioned reasoning, this suggests that many ACOs may be taking a “walk before they run” approach, establishing basic ACO infrastructure first before tackling more targeted community needs. It also implies that an additional focus may be needed on helping ACOs to expand their view—and services—beyond their current patient population.

Likewise, while 71 percent of ACO leaders are either offering, or plan to offer, integrated physical and behavioral health services (a helpful response to the unmet behavioral health services need), fewer than 25 percent believe their ACOs will have adequate numbers of behavioral health staff to meet their populations’ needs.

This is a substantial gap and highlights one of the major challenges faced by ACOs: insufficient resources to accomplish one of their primary goals. It also offers some insight into why ACOs are investing first in infrastructure before they integrate more specialized community services for overall health. They are attempting to invest in broad-brush measures, with costs that can be spread over the entire beneficiary community before they focus in on subsets of needs.

Connections To Social Services

Additionally, while nearly every ACO reported working partnerships with social service organizations, only one in five ACO leaders said partnering with others to address social service needs was a major priority for their institutions. This disconnect may be attributed to the lack of funding associated with these social service programs, cited as a barrier by 89 percent of all the studied ACOs. In other words, they are working with these social service groups, but at a more superficial level than they would if funding were no obstacle. Other cited barriers to working partnerships included poor access to services and the uneven geographic distribution of community services. However, despite these limitations, many ACOs are finding ways to bridge the divide between ACO health care providers and social services organizations.

For example, where community services are offered and care coordination has been poor, some ACOs are moving to serve as the central hub to enable community organizations to be more effective in meeting the needs of mentally ill and chemically addicted residents.

Expanding ACO Reach

Also, despite insufficient funding, some ACOs are expanding their catchment areas to include other populations not included in Medicare and private-payer contracts. Activities extended to these catchment areas include smoking cessation programs for patients as well as caregivers; health education; assessing the need for, and providing, required equipment for patients to be monitored at home in their communities; providing care managers to help patients and their families navigate the health system; and working as a team with local community organizations to provide a coordinated response to patients’ needs.

Several ACO leaders identified new or expanded programs focusing on community wellness, including partnering with employers to improve nutrition, frequency of exercise, and health literacy. One ACO is partnering with faith communities and other organizations to offer training in palliative and end-of-life care.

Concluding Thoughts

In general, ACO leaders acknowledged that the answer to expanding population health services lies in larger public policy changes—that is, providing the resources and funding to address the basic clinical, social, and psychological needs of the population in the United States.

One path forward to enabling more effective population health management is in helping regulators, funders, and patient advocacy groups to understand the current limitations and pressures facing ACOs. This includes suggesting ways to restructure current policies that keep ACOs tethered to the perverse incentives inherent in fee-for-service care delivery, even as ACOs work to transition to a care model better suited for shared savings and global payments.

In addition to macro changes, there are also opportunities to better enable ACOs to seek out and identify high-value health care and community partnerships to achieve health improvement goals and spending targets.

As payment reform continues to evolve, ACOs could and should be better positioned to improve the quality of care, costs of care, and many unmet community health needs.