Presentation (CTI)

OBJECTIVES: Accountable Care Organizations (ACOs) are key to U.S. value-based care. However, the evidence is limited on how domain-specific performance, especially preventive and primary care, can be translated into a longitudinal return on investment (ROI) or influence provider incentives. As ACOs transition to the ACO REACH framework, understanding the cost-quality dynamics is essential. This study developed a composite ROI index to evaluate how preventive health, care coordination, and patient experience jointly contribute to financial performance over time.
METHODS: We analyzed 2012-2016 data from the Centers for Medicare & Medicaid Services (CMS) ACO Public Use Files for Pioneer and Medicare Shared Savings Program ACOs. A composite financial outcome (“ROI_index”) was derived from "benchmark-minus-actual expenditure percent" and "shared savings or losses", weighted in order to reflect variation in financial returns. Quality performance included 20 standardized measures across three domains: patient experience, care coordination/patient safety, and preventive health. Associations between domain scores and ROI_index were estimated using linear mixed-effects models with ACO-level random intercepts and year-by-domain interaction terms.
RESULTS: Preventive health and care coordination scores improved over time, while patient experience remained more heterogeneous. Preventive health showed the largest improvement by Year 5 (+22.7 points) but also displayed substantial baseline variability. ROI_index changed at Years 2, 4, and 5 (all p < 0.001). At baseline, ROI_index was positively associated with preventive health (β = 0.162, p < 0.001) and negatively associated with care coordination/patient safety (β = -0.171, p < 0.001), but these associations reversed along with time.
CONCLUSIONS: The positive increasing association between care coordination/patient safety and ROI suggests the success dose-response effectiveness between quality improvement and financial incentives. However, the improved preventive health services with diminishing financial returns suggest weaker incentives for long-term investment. Highly variable patient experience outcomes highlight the need for locally tailored quality strategies in future ACO models.