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The Problem with ACOs & Vulnerable Patients

Fewer physicians serving vulnerable patient populations join ACOs—this is a problem. (Volume 9, Issue 8)

Growing evidence suggests that (ACOs), which are networks of health care providers (including both physicians and hospitals) with shared financial and medical responsibility for coordinated patient care, are improving health outcomes. For this reason, along with strong financial incentives, are becoming more common across the United States and more patients are being served by these models.

Ilmicrofono Oggiono (Flickr/CC)

Ilmicrofono Oggiono (Flickr/CC)

Despite the rapid expansion of ACOs, a recent Health Affairs article highlighted the unintended consequence of greater ACO uptake by providers serving affluent patients and less participation by providers serving communities with more black residents, higher poverty, and more uninsured or disabled residents. The largest differences in ACO participation were in communities with high and low percentages of black residents, with 31.8% ACO participation in communities with the fewest black residents and only 22.9% in communities with the most black residents.

The authors cite a number of potential reasons for this disparity. First, ACOs may be less likely to locate in areas with potentially sicker, hard-to-treat, and vulnerable patients due to the requirements for meeting quality and cost benchmarks. Second, even where ACOs have been adopted, physicians serving the most vulnerable patients may be excluded from joining the ACOs due to the risk their patients bring. Third, physicians serving these populations may choose not to join ACOs due to lack of resources needed to start-up and succeed in the model and concern about achieving the requisite quality and cost benchmarks.

Most concerning are the potential consequences of this disparity. Because ACOs are achieving higher quality outcomes, the shortage of ACOs in communities with more blacks, higher poverty, and more uninsured and disabled residents may exacerbate the already higher burden of health disparities within these communities. In addition, providers serving these communities are missing out on much-needed financial resources.

Policymakers have many options to reverse this trend: providing physicians that serve vulnerable populations with the capital needed to form an ACO; risk-adjusting for patient demographic factors; and rewarding for quality improvements over time rather than requiring them to meet rigid benchmark standards.

commentary by Megan Douglas


Early evidence suggested that accountable care organizations (ACOs) could improve health care quality while constraining costs, and ACOs are expanding throughout the United States. However, if disadvantaged patients have unequal access to physicians who participate in ACOs, that expansion may exacerbate health care disparities. We examined the relationship between physicians’ participation in both Medicare and commercial ACOs across the country and the sociodemographic characteristics of their likely patient populations. Physicians’ participation in ACOs varied widely across hospital referral regions, from nearly 0 percent to over 85 percent. After we adjusted for individual physician and practice characteristics, we found that physicians who practiced in ZIP Code Tabulation Areas where a higher percentage of the population was black, living in poverty, uninsured, or disabled or had less than a high school education—compared to other areas—had significantly lower rates of ACO participation than other physicians. Our findings suggest that vulnerable populations’ access to physicians participating in ACOs may not be as great as access for other groups, which could exacerbate existing disparities in health care quality. PMID: 27503961

Yasaitis, LC, et al. (2016) Health Affairs.  35 (8): 1382-1390.

Megan Douglas, JD
About Megan Douglas, JD

Megan Douglas is the Associate Director of Health Information Technology Policy in the National Center for Primary Care at Morehouse School of Medicine in Atlanta, GA. She is a licensed attorney and focuses on health policy and its impact on individuals from underserved communities. She was a 2012-13 Health Policy Leadership Fellow under Dr. David Satcher, 16th Surgeon General of the United States. Megan has worked on health policy issues related to neurodevelopmental disabilities, HIV and AIDS discrimination, racial and ethnic health disparities, and individuals identifying as LGBTQ. In her current role, she is looking at the impact of Health Information Technology (HIT) policies on healthcare providers who serve underserved communities and is identifying ways to leverage HIT to improve health outcomes for the underserved. Contact: Website | Facebook | Twitter | Google+ | More Posts

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