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Health Aff (Millwood). 2017 Jan 1;36(1):57-66. doi: 10.1377/hlthaff.2016.0626.

ACOs Serving High Proportions Of Racial And Ethnic Minorities Lag In Quality Performance.

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Valerie A. Lewis ( is an assistant professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, in Lebanon, New Hampshire.
Taressa Fraze is a research scientist at the Dartmouth Institute for Health Policy and Clinical Practice.
Elliott S. Fisher is director of the Dartmouth Institute for Health Policy and Clinical Practice and the John E. Wennberg Distinguished Professor of Health Policy, Medicine, and Community and Family Medicine, Geisel School of Medicine at Dartmouth.
Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management, a professor of organization behavior, director of the Center for Healthcare Organizational and Innovation Research, and dean emeritus, all at the School of Public Health, University of California, Berkeley.
Carrie H. Colla is an associate professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice.


Accountable care organizations (ACOs) are intended, in part, to improve health care quality. However, little is known about how ACOs may affect disparities or how providers serving disadvantaged patients perform under Medicare ACO contracts. We analyzed racial and ethnic disparities in health care outcomes among ACOs to investigate the association between the share of an ACO's patients who are members of racial or ethnic minority groups and the ACO's performance on quality measures. Using data from Medicare and a national survey of ACOs, we found that having a higher proportion of minority patients was associated with worse scores on twenty-five of thirty-three Medicare quality performance measures, two disease composite measures, and an overall quality composite measure. However, ACOs serving a high share of minority patients were similar to other ACOs in most observable characteristics and capabilities, including provider composition, services, and clinical capabilities. Our findings suggest that ACOs with a high share of minority patients may struggle with quality performance under ACO contracts, especially during their early years of participation-maintaining or potentially exacerbating current inequities. Policy makers must consider how to refine ACO programs to encourage the participation of providers that serve minority patients and to reward performance appropriately.


Disparities; Health Reform; Medicare; Organization and Delivery of Care; Quality Of Care

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