Serious Illness and Accountable Care Organizations


The Duke-Margolis Center for Health Policy, funded by the Gordon and Betty Moore Foundation, is investigating how accountable care approaches can improve care for people with serious illness, which is a next step in the Center’s work on accountable care. In partnership with Leavitt Partners, the project identifies promising practices and practical operational guidance that organizations could implement.  Accountable Care Organizations (ACOs) offer an important strategy for improving care for serious illness populations. ACOs are by far the largest alternative payment model sponsored by Medicare, and the number of commercial ACO contracts is growing rapidly. ACOs are powerful vehicles for improving serious illness care given the incentives ACOs have to deliver effective, efficient, and coordinated care that improves outcomes and quality of life without increasing costs. Further, the ACO model offers numerous improvements in serious illness care over traditional fee-for-service reimbursement. Notably, for example, fee-for-service does not reimburse for key infrastructure and services, such as 24/7 access outside of emergency departments, patient and caregiver education, care coordination, and shared decision making, whereas the ACO model provides financial flexibility to invest in these areas and provide crucial services, and typically brings new data on patients’ healthcare use across the spectrum.  While ACOs have great potential in improving serious illness care, there remains substantial opportunities for improvement due to a lack of evidence on what works, a need for practical guidance, and challenges in implementing new initiatives.

“Providing healthcare for people with serious illnesses is incredibly complex and involves medical and social services from a variety of providers and caregivers,” said Duke-Margolis Director Mark McClellan, MD, PhD, “ACOs are a potentially powerful way to improving serious illness care in an effective, efficient, and coordinated way.”

“The challenge is that we do not have a broad evidence base on what works and could serve as a best practice for accountable care in cases of serious illness across the spectrum of providers and settings,” said Robert Saunders, PhD, who leads the project.

“To realize the potential of the ACO model, organizations have to redesign their care models. For ACOs to be successful, they need operational guidance on how to identify patients with serious illness and how to improve care for this population of patients,” said David Muhlestein, PhD, JD, chief research officer for Leavitt Partners.

The Moore Foundation grant, part of its Patient Care Program which is focused on improving the experience and outcomes of patient care, enables the team to complete a comprehensive review of the available research, convene stakeholders who have expertise in the area of serious illness and accountable care, develop a series of case studies outlining best practices and lessons learned from ACOs succeeding in serious illness care, and analyze quality and claims data to identify factors affecting serious illness care and to help build the business case for why more ACOs should develop serious illness programs. The Duke-Margolis Center and Leavitt Partners are working with partners (such as the Accountable Care Learning Collaborative) to disseminate these findings so that healthcare providers and systems implementing accountable care can learn from successful organizations.

The project builds on previous work by the Center defining strategies for ACO success, as well as prior collaborative work by the Center and Leavitt Partners tracking ACO growth  and analyzing ACO performance over time. This portfolio of projects, including accountable care in the United States and globally, demonstrates how organizations can succeed under new delivery arrangements to provide integrated, comprehensive care at lower cost to patients.


Duke Research Team

Robert Saunders, PhD
Research Director, Payment and Delivery Reform, Duke-Margolis Center for Health Policy

Research Associate, Payment and Delivery System Reform, Duke-Margolis Center for Health Policy

Jeff Clough, MD
Assistant Professor of Medicine, Duke University School of Medicine

Mark Japinga, MPAff
Senior Research Assistant, Payment and Delivery System Reform, Duke-Margolis Center for Health Policy

Brystana Kaufman, PhD, MSPH
Post-Doctoral Research Fellow, Duke-Margolis Center for Health Policy

Mark McClellan, MD, PhD 
Director, Duke-Margolis Center for Health Policy, and Robert J. Margolis, MD, Professor of Business, Medicine and Policy

Leavitt Partners Research Team

David Muhlestein, PhD, JD
Chief Research Office, Leavitt Partners

Nathan Smith, PhD
Research Manager, Leavitt Partners
Lia Winfield, PhD
Manager, Leavitt Partners 


Funding for this project is provided by the Gordon and Betty Moore Foundation