Lessons from the Field: Making Accountable Care Organizations Real
Originally published by the Center for Studying Health System Change
Published: January 2011
Updated: April 4, 2026
NIHCR Research Brief No. 2, January 2011
By Timothy K. Lake, Kate A. Stewart, and Paul B. Ginsburg
Overview
Accountable care organizations, broadly defined as organized groups of providers that accept shared responsibility for the cost and quality of care delivered to a defined patient population, gained substantial policy attention following the passage of the Affordable Care Act. The Medicare shared savings program established under the ACA created a formal pathway for fee-for-service Medicare beneficiaries to receive care through ACO arrangements. Yet the practical realities of building such organizations from the ground up remained poorly understood at the time of this research. This study, conducted by the National Institute for Health Care Reform, set out to document how seven provider organizations across the United States were approaching ACO-like delivery system reforms well before federal regulations took final shape.
Drawing on 34 semi-structured interviews conducted between March and May 2010 with organizational leaders, physicians, and administrative staff, the researchers identified recurring themes around investment demands, physician engagement, care delivery innovation, and the barriers that threatened to slow progress. The findings offered an early window into the operational complexities that would continue to shape ACO policy debates for years afterward.
Financial and Organizational Investment
A central theme that emerged from the field research was the magnitude of upfront investment required to pursue accountable care. Even organizations with preexisting physician affiliations and established governance structures found that the transition toward population-based accountability demanded significant capital outlays and sustained management attention. Several organizations reported drawing on financial reserves accumulated over prior years, while others secured philanthropic grants or demonstration project funding to underwrite early-stage development activities.
These investments spanned a wide range of needs. Infrastructure for health information technology, including electronic medical record systems and centralized data warehouses capable of tracking utilization patterns and quality metrics across provider networks, represented some of the largest expenditures. Organizations also invested heavily in staffing, bringing on care coordinators, data analysts, and project management personnel whose roles did not fit neatly within existing fee-for-service revenue streams. The absence of a clear short-term business case for these expenditures created tension with boards of directors and physician partners who questioned the return on investment timeline.
Physician Leadership and Engagement
The study identified physician leadership as a critical determinant of organizational progress. Organizations where respected clinicians championed delivery reform initiatives reported greater success in gaining buy-in from rank-and-file physicians. This leadership operated through both formal channels, such as medical director positions and quality committee chairmanships, and informal channels where influential physicians modeled new practice behaviors and encouraged their peers to follow suit.
Transparency around performance data proved equally important. Several organizations began sharing practice-level and, in some cases, individual physician-level data on cost and quality measures. While this transparency initially generated discomfort among some clinicians, organizational leaders noted that it ultimately fostered productive conversations about variation in care patterns and opportunities for improvement. The willingness to present data openly, rather than using it solely for punitive purposes, helped establish a culture of collective accountability.
Financial incentive structures also played a role. Some organizations redesigned physician compensation arrangements to incorporate quality metrics alongside productivity measures. Others created bonus pools tied to shared savings targets. The common thread was an effort to align individual physician incentives with the broader organizational goal of delivering higher-value care, though the specific mechanisms varied considerably across settings.
Care Delivery Innovations
The provider organizations studied had launched a variety of care delivery improvement initiatives targeting conditions and transition points where better coordination could yield measurable benefits. Congestive heart failure management programs were among the most common, typically involving dedicated case managers who followed patients across inpatient and outpatient settings, monitored symptoms through regular check-ins, and worked to prevent avoidable hospital readmissions.
Care transitions programs, focused on the period immediately following hospital discharge, represented another frequent area of investment. These programs aimed to ensure that patients received timely follow-up appointments, understood their medication regimens, and had access to community-based support services that could prevent deterioration and return visits to the emergency department.
Diabetes management and cancer patient navigation programs rounded out the most frequently cited initiatives. Diabetes programs typically emphasized proactive outreach to patients with poorly controlled blood glucose levels, offering education, self-management support, and closer monitoring by care teams. Cancer navigation programs assigned staff to guide patients through the often-fragmented sequence of diagnostic workups, treatment decisions, and follow-up care, reducing delays and improving the overall patient experience.
Implementation Challenges
Despite genuine enthusiasm for delivery reform, all seven organizations confronted significant obstacles. The most persistent challenge involved implementing changes with minimal disruption to day-to-day clinical productivity. Physicians and staff were being asked to adopt new workflows, participate in team-based care models, and engage with unfamiliar information systems, all while maintaining patient volumes sufficient to sustain revenue under existing fee-for-service payment arrangements. Organizations that tried to move too quickly risked backlash from clinicians who felt overwhelmed by the pace of change.
Resistance to change, while not universal, surfaced in predictable patterns. Physicians who had practiced independently for decades were understandably cautious about ceding autonomy to team-based approaches or accepting external review of their practice patterns. Organizations that acknowledged this resistance openly and built in sufficient time for adaptation tended to fare better than those that attempted top-down mandates.
Infrastructure limitations, particularly in health information technology, posed another barrier. While electronic medical records were spreading rapidly during this period, many organizations lacked the integrated data platforms necessary to track patients across multiple care settings, generate timely performance reports, or identify high-risk patients for proactive intervention. Building these capabilities required not only technology procurement but also substantial investments in data governance, staff training, and workflow redesign.
Flexibility as a Success Factor
A recurring observation across the study sites was the importance of organizational flexibility. Provider groups that succeeded in advancing delivery reforms did not follow rigid implementation blueprints. Instead, they adopted iterative approaches, piloting new care models in selected practice sites, gathering data on outcomes and implementation barriers, and refining their strategies before expanding more broadly. This willingness to experiment, learn from setbacks, and adapt was cited by multiple interviewees as essential for maintaining momentum in an uncertain policy environment.
Flexibility extended to governance structures as well. Several organizations modified their decision-making processes to give physician leaders greater voice in strategic choices about care redesign priorities. Others created new committees or working groups that brought together administrators, clinicians, and information technology specialists to collaborate on implementation planning. The organizations that treated delivery reform as an adaptive process rather than a fixed project tended to sustain engagement over time.
Policy Implications
The experiences documented in this study carried several implications for policymakers shaping the ACO regulatory framework. First, the researchers emphasized the need for flexibility in ACO participation requirements. Prescriptive rules about organizational structure, governance composition, or required technology platforms risked excluding provider groups that were making genuine progress toward accountable care through alternative pathways.
Second, the study highlighted the importance of supporting physician leadership development. The organizations that had made the most progress consistently pointed to strong clinical champions as a key ingredient in their success. Federal and state policies that invested in leadership training programs for physicians, or that created financial incentives for physician participation in organizational governance, could accelerate readiness across a broader range of provider groups.
Third, infrastructure investment emerged as a prerequisite that could not be taken for granted. The data systems, care coordination staffing, and quality measurement capabilities that ACOs needed did not materialize overnight, and the upfront costs were substantial. Policies that provided seed funding, technical assistance, or transitional financial support could lower the barriers to entry for organizations willing to pursue accountable care but lacking the resources to do so independently.
Conclusion
The seven organizations profiled in this research brief demonstrated that meaningful progress toward accountable care was achievable, but far from straightforward. The transition required sustained financial commitment, strong physician engagement, investments in care coordination and information technology, and a willingness to tolerate uncertainty and adapt strategies over time. Their experiences underscored that building an ACO was not primarily a regulatory compliance exercise but a fundamental transformation in how care was organized, delivered, and measured. For policymakers and health system leaders alike, these early adopters provided valuable evidence about the real-world demands of turning the ACO concept into operational reality.