ACOs Could do More to Care for Seriously Ill Patients

Salt Lake City, June 3, 2019— Accountable care organizations (ACOs) have potential to care for the nation’s seriously ill patients at lower costs and improved quality, but few are taking steps to do so, according to new research  conducted by the Duke-Margolis Center for Health Policy and Leavitt Partners.

The research appears today in June issue of Health Affairs and is based on a national survey and interviews with 53 leaders at six diverse ACOs. It will be presented to an audience of agency officials, congressional staff, academics, other health care policy professionals, and members of the news media, along with several other papers from Duke University faculty and staff, at a June 4 Health Affairs briefing on Community Care for High-Need Patients in Washington, DC.

ACOs, which care for more than 32 million patients nationwide, are groups of doctors, hospitals, and other health care providers, who come together to give coordinated high-quality care to their patients. A leading alternative payment model to fee-for-service, these organizations are designed to improve value and quality of care through financial and other incentives. According to the researchers, ACOs are ripe to improve the care of people living with serious illness for two reasons. First, hospitalizations and emergency room visits at the end of life are often unnecessary or harmful, and the ACO model supports the care coordination necessary to prevent these inappropriate visits. Second, the ACO model offers flexible spending of Medicare dollars to pay for important serious illness services that fee-for-service does not cover.

The national survey found that 94 percent of ACOs worked to identify their seriously ill patients. Yet, only 8 to 21 percent widely implemented serious illness initiatives, such as advance care planning or home-based palliative care.

The interviews identified paths for success as well as challenges ACOs face in caring for patients confronting serious illness, defined as patients with high risk of mortality or multiple chronic diseases, heavy use of health care, and limited function.

Keys to successful programs included:

  • Upfront investment: ACO infrastructure can cost up to $1 million or more, and additional infrastructure for serious illness care requires additional capital. Data infrastructure and a workforce to identify and care for the serious ill were singled out as particular needs. A key element of success was building on prior infrastructure. Many ACOs were able to extend prior efforts in complex care management and value-base care redesign by developing care programs for seriously ill patients. Also important to success was the ability to connect patients to existing community resources that address social drivers of health (e.g., legal assistance, food insecurity, housing, and transportation), along with hiring social workers or community health workers.
  • Business plan and organizational buy-in: ACOs that focus on identifying seriously ill patients but have few dedicated care programs suggest that the business case for serious illness care is underdeveloped. Short-term data derived from serious illness care efforts, however, resonated with leaders and helped with organizational buy-in. Importantly, the mission to care for seriously ill patients is also a big motivator for providers, staff and many leaders: “We’re just doing it because it’s the right thing to do. Period. For the patient,” stated one interviewee.
  • Data and health information technology: Capturing actionable data to identify and track seriously ill populations is still a work in progress, most interviewees noted. However, ACOs found data dashboards helpful in tracking important serious illness care metrics and helping to schedule and coordinate patient care across different settings.
  • Context matters: ACOs in rural or urban safety-net areas had greater difficulty investing in new initiatives to care for seriously ill patients due to resource constraints.

“The untapped potential of ACOs to improve serious illness care underscores the need for a better understanding of organizations that do this well,” said lead author William Bleser, a research associate at Duke-Margolis. “We did observe that success in caring for thse populations can occur in diverse settings, regardless of geography, rurality, payer, organizational size or leadership structure.”

“High serious illness performance is affected by a range of policy and regulatory issues,” said David Muhlestein, chief research officer at Leavitt Partners. “These include calculating shared savings in ways that properly assess the health status among seriously ill patients, the need for better quality measures to evaluate care for this population, and the vital importance of accessing timely, actionable data about these patients.”

The national survey, the ACO interviews and the analysis of this research were supported by a grant from the Gordon and Betty Moore Foundation.

About Leavitt Partners:

Leavitt Partners is a health care intelligence business. The firm helps clients successfully navigate the evolving role of value in health care by informing, advising, and convening industry leaders on value market analytics, alternative payment models, federal strategies, insurance market insights, and alliances. Through its family of businesses, the firm provides investment support, data and analytics, member-based alliances, and direct services to clients to support decision-making strategies in the value economy. For more information please visit

About Duke-Margolis Center for Health Policy
The Robert J. Margolis, MD, Center for Health Policy at Duke University brings together expertise from the policy community in Washington, DC, Duke University, and Duke Health to address the most pressing issues in health policy. The mission of Duke-Margolis is to improve health and the value of health care through practical innovative, and evidence-based policy solutions. The Center’s DC offices are located at 1201 Pennsylvania Avenue, NW, Washington, DC 20004. For more information, please visit our web site:


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