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Factors Influencing Rural Hospitals to Participate and Remain in Accountable Care Organizations
Journal article   Open access   Peer reviewed

Factors Influencing Rural Hospitals to Participate and Remain in Accountable Care Organizations

Emily J. Lawton, Jenah McCarty, Thomas E. Vaughn, Fred Ullrich and Keith J. Mueller
The Journal of rural health, Vol.42(2), e70179
03/2026
DOI: 10.1111/jrh.70179
PMCID: PMC13251898
PMID: 42268668
url
https://doi.org/10.1111/jrh.70179View
Published (Version of record) Open Access

Abstract

Purpose Little is known about factors driving rural providers—who face unique challenges—to participate and remain in accountable care organization models. The purpose of this study was to investigate the specific factors that rural hospitals evaluate when weighing both initial and continued participation in Medicare as well as commercial ACO models. Furthermore, we explored policy implications to improve ACO models’ capacity to attract, retain, and promote success of rural providers. Methods Semistructured, in-depth interviews were conducted with rural hospital executives with direct knowledge of ACO agreement terms and factors driving ACO participation. The interview guide contained seventeen open-ended questions. Interviews were recorded, transcribed, coded using codebooks informed by the interview guide, and analyzed using a thematic analysis approach. Findings Interviewees identified five primary multi-faceted motivations for participation: (1) financial incentives—shared savings, upside-only risk initially, and upfront funding for some providers, (2) getting ahead of the curve of the move to value-based reimbursement, (3) importance placed on capacity to push toward improving population health or quality, (4) additional forms of resource gain, and (5) key outside factors. The specific ACO design affects rural providers’ decision-making on timing and selection of particular models. Importantly for future policy development, multiple respondents raised concerns about moving to risk in ACO models, leading them to consider dropping out. Conclusions Findings from this qualitative study provide an in-depth understanding that is vital to achieving CMS's goal of increasing participation in value-based care. In turn, this could further improve health care quality for countless lives.
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