Table 2. Themes and Representative Quotations.

Theme	Representative quotation
Key programmatic initiative
ACO leaders reported several key initiatives, including increasing provision of annual wellness visits; ensuring that patients’ medical complexity was captured by rigorous coding efforts; and improving transitions of care, with a focus on postacute care.	“Our focus has been on annual wellness visits. We feel they help drive down ER visits, catch cancers, all that good stuff…We started embedding nurses in offices to do the heavy lifting.”
	“We’ve come to realize that Medicare wellness visits drive almost everything in terms of quality and cost.”
	“Accurately capturing the disease burden in our patient population is critical for success. It’s also become a bit of an arms race across the industry.”
Clinician engagement
ACO leaders used both relationship-based and metrics-based strategies to promote clinician alignment with ACO goals.	“We generate very detailed reports that provide peer comparisons and actionable data. Everyone can see how they’re doing in general and how they compare to the doc down the hall.”
	“As a leader, I never tell clinicians, “Here’s what thou shalt do!”…It’s our role to understand the clinicians’ wish list and see how we can meet it.”
	“I personally visit every practice. I’m not some faceless bureaucrat.”
Shared savings distribution
ACOs generally distribute half or more of shared savings to participating clinicians, usually at the practice or organization level, based on a combination of attribution, engagement, and quality performance.	“Distribution of savings depends on how badly you need to attract people. We have traditionally been able to keep 30% and distribute 70%. But in markets where there’s not much competition to get [practices] to join, it might be 50-50.”
	“Distributions are based primarily on number of attributed beneficiaries, but we’re developing systems to incentivize quality based on annual wellness visits, diabetes screening, appropriate coding, that sort of thing.”
	“We distribute based on quality metrics at the clinic level. We don’t want to do it at the physician-level or they’ll start playing “not it” with challenging patients.”
Recruitment and retention
ACOs’ recruitment and retention efforts of practices and patients were increasingly influenced by market competition resulting from health system consolidation and large medical groups, as well as the growth of the Medicare Advantage program.	“We are being attacked by private equity, other health systems, other medical groups. We are desperate to stay alive, so we will take anyone who is willing to be engaged.”
	“Our problem is that Medicare Advantage has whittled away our numbers tremendously…I’m starting to feel that smaller ACOs just can’t compete with Medicare Advantage.”
	“In exchange for listening to our ACO spiel, we tell the [physicians] we’re giving them a ‘get-out-of-MIPS-free card.’”
Hospital-associated ACOs
Leaders of hospital-associated ACOs held mixed views of whether hospitals help or hinder the ACO’s objectives, but many reported misaligned incentives.	“We’ve created a system of hospital-based systems whose goal is to fill hospital beds. They speak the right words…but all the actions are about putting resources into profitable cardiac and spine procedures.”
	“The hospitals are happy when Medicare patients are kept out of the hospital because they can fill their beds with commercial patients that generate more revenue.”
	“Compared to ACOs that don’t have hospitals, I think we’re at an advantage. We get timely data from our hospitals and it helps that we can talk to the people who run the inpatient case management teams.”
	“Nobody fights you on improving quality, but it’s hard to get alignment on reducing utilization…There might be an opportunity to reduce costs, but it’s not worth banging your head against the wall.”

Abbreviations: ACO, accountable care organization; ER, emergency room; MIPS, Merit-based Incentive Payment System.