Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)



First Advisor

David B. Yerger

Second Advisor

John A. Anderson

Third Advisor

J. Beth Mabry


The passage of the Patient Protection and Affordable Care Act of 2010 authorized the Centers for Medicare and Medicaid Services (CMS) to create the Medicare Shared Savings Program (MSSP). This program aims to lower costs, improve access to care, and increase the quality of care provided to Medicare Beneficiaries (Berwick, 2011). Accountable Care Organizations (ACOs) are the mechanism for delivering this value based care within the MSSP and are a potential innovation at the forefront of healthcare redesign.

However, during the first three years of the MSSP less than one third of ACOs succeeded at reducing spending enough to qualify for a shared savings payment (Fact Sheet, 2014, 2015, 2016). Without qualifying for a savings payment, an ACO receives no direct funding from Medicare, essentially causing ACOs to operate at a loss. The low success rate experienced by the majority of ACOs jeopardizes the longevity of this program.

Acknowledging the challenges ACOs face in achieving success, this study examines ACOs within the MSSP to identify variables associated with success. The research uses a systems analysis methodology, which involved classifying ACOs into performance groups. These groups included financially successful ACOs, ACOs that lowered costs but did not achieve their minimal savings rate target, and ACOs that experienced higher costs.

This research set out to identify why some ACOs are successful and others are not by evaluating: financial performance, available resources, the utilization of resources, quality performance of health outcomes, and changes in performance over time. This quantitative study used secondary data sources to identify variables that serve as precursors for success. Key findings from this study found that financially successful ACOs experienced less skilled nursing facility use, an increase in the use of nurse practitioners and physician assistance, and no significant difference in quality outcomes despite financial performance. These findings have policy and practice implications for both program administrators and current and future ACO leadership.