Public health agency participation in accountable care organizations: Opportunities and obstacles

Both accountable care organizations (ACOs) and public health agencies (PHAs) address the health of defined populations, but do PHAs have a role in ACO activity?  We examined facilitating factors and obstacles to PHA roles in ACOs in a literature review and key informant interviews, then identified nine organizations representing the range of ACO payer types, and interviewed individuals with comprehensive information regarding their ACOs’ interactions with PHAs. We found that PHAs are most likely to be active participants in the ACO-like initiatives that partner with state Medicaid agencies, typically as State Innovation Models.  Interviewees identified barriers to ACO-PHA collaboration in Medicare and commercial ACOs, including Medicare participation and service activity requirements, cost of full ACO membership, restrictions on government agencies’ risk-bearing financial arrangements, data sharing issues, the medicine-public health divide, and ACOs’ need for near-term return on investment.  Factors that supported PHA participation included development of shared activities and objectives, ACO sponsors with substantial market shares, PHA service on ACO advisory boards, and contractual relationships. Full PHA participation in Medicare and commercial ACOs will require creativity and persistence to overcome the numerous barriers identified by our respondents.  PHAs interested in ACO participation need expertise in identifying returns on ACOs’ investments within time constraints that are much shorter than for most PHA functions.  To avoid conflicts with core public health activities, PHAs could begin to explore ACO partnerships by assessing their existing scope of services to identify areas of mutual potential advantage.