Accountable Care In 2023: Evolving Terminology, Current State, And Priorities

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Journal Article

Accountable Care In 2023: Evolving Terminology, Current State, And Priorities

Published date

February 24, 2023

Accountable care has been at the center of the evolution—and debate—around health care payment and delivery moving from “fee-for-service” (FFS) care to “value-based” care. The Centers for Medicare and Medicaid Services (CMS) recently reaffirmed a goal of speeding the uptake of accountable care: they aim to give all Medicare beneficiaries and half of Medicaid beneficiaries access to coordinated, longitudinal care through advanced accountable care relationships by 2030. This would represent a substantial acceleration in the pace of accountable care growth in the US over the past two decades: accountable care contracts currently amount to around 40 percent of US health insurance payments, with most in “shared savings” arrangements that still largely involve FFS. 

This is also a challenging time for accountable care. There is some evidence that health care organizations in more advanced accountable care arrangements did better in terms of financial stability and longitudinal care delivery during the pandemic. But progress in accountable care adoption over the past three years has been modest, with some shift in contracts from FFS to greater “shared risk” but slow overall growth. Health care organizations used Medicare and private FFS payment flexibility in such areas as telehealth substitution for in-person care and site-of-service. But many have argued that FFS payment flexibility and parity should remain after the COVID-19 public health emergency ends—essentially continuing FFS in more sites rather than encouraging more accountable care models to reduce complications and spending. Moreover, facing the combination of supply chain disruptions, labor shortages, high inflation, and the end of COVID-19 relief payments, many organizations are dealing with staffing and financial challenges that complicate investments in care reforms in the short term. 

Consequently, this is an important time for new perspectives on the current status and future outlook of accountable care. In this article, we start with a review of what “accountable care” means, and how its evolving definition provides insights into its opportunities and challenges. We then give an overview of where accountable care models are across payers in 2023. Finally, we turn to some of the key issues facing policymakers and the health care industry for translating the promise of accountable care into greater realized success in improving health care experiences, affordability, and outcomes for all.

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Duke-Margolis Authors

William K. Bleser - Margolis headhot

William K. Bleser, PhD, MSPH

Research Director, Health Care Transformation for Social Needs and Health Equity
Senior Team Member
Anti-Racism and Equity Committee Member

Frank McStay Photo

Frank McStay, MPA

Assistant Research Director


David Muhlestein, PhD, JD

Chief Research & Innovation Officer, HMA

Mark McClellan

Mark McClellan, MD, PhD

Director of the Duke-Margolis Institute for Health Policy
Robert J. Margolis, MD, Professor of Business, Medicine and Policy
Margolis Executive Core Faculty