Patient Success Stories
Behind every data point is a patient whose care was better, more proactive, and more personal. These stories show what accountable care looks like in real life and why it matters to patients and families.
That changed for practices like Patrick County Family Practice in rural Virginia after joining an Aledade ACO. Through data tools that combine information from EHRs, labs, pharmacies, and hospital systems, the clinic can now see when their patients are admitted to or discharged from the hospital, spot who is overdue for a check-up or chronic care follow-ups and reach out before small problems turn into big ones.
Before joining accountable care, patient information was scattered across different systems. ACO participation equips rural practices with the data and tools to support better care, helping small care teams manage complex patients more proactively. In communities with limited resources and where access to specialty care may be miles away, that analytical approach can make all the difference.
When Rex, a 70-year-old retired construction worker in Utah, lost his kidney transplant after 24 years, he faced a familiar and daunting reality: a return to in-center dialysis. In the past, clinic-based treatment had dominated his life – long, exhausting sessions several days a week that left little room for family or daily routines.
Rex’s experience changed after working with a care coordinator from Interwell Health, a participant in Medicare’s Comprehensive Kidney Care Contracting (CKCC) model. Under CKCC, Interwell embeds care coordinators in nephrology practices to support value-based care interventions, support patient education, and personalized care delivery. Rex’s coordinator spent hours helping him navigate better treatment options like home dialysis, becoming “like my second daughter almost” in the process.
Instead of defaulting to in-center dialysis, Rex received:
- One-on-one education on all treatment options, including home dialysis
- Hands-on support to select and prepare for home treatment
- Ongoing care coordination to monitor his condition and prevent complications
With that support, Rex transitioned to home dialysis. The change was immediate. Dialyzing at home reduced the physical toll of treatment, restored flexibility, and allowed him to safely integrate care into everyday life—spending time with his 18 grandkids.
By emphasizing early education, coordinated care, and prevention, the CKCC model helps patients like Rex avoid hospitalizations and unnecessary institutional care. His story shows how accountable care can turn complex chronic treatment into something more manageable, sustainable, and aligned with patients’ lives.
In rural southeastern Ohio, socioeconomic need is high and access challenges are persistent. Accountable care enabled a fundamental shift in how care is delivered. The agilon health Ohio ACO, launched in 2021, helped transform a fragmented network of practices into one that delivers stronger outcomes for patients.
Before forming an ACO, care delivery was disjointed. Practices operated on multiple electronic health records—or none at all—and coordination across sites was limited. Participation in accountable care provided the financial stability and flexibility to invest in infrastructure that rural practices often lack. The ACO:
- Built a centralized care management platform
- Unified practices under a single EMR
- Deployed real-time data feeds and tools to proactively manage high-risk patients
The results are measurable:
- 32% reduction in high-risk inpatient visits
- 54% reduction in high-risk readmissions
- 19% increase in timely seven-day follow-ups
- 12x improvement in cost efficiency
In 2023 alone, the ACO generated $21.6 million in gross savings while earning a perfect quality score.
Targeted programs – including a virtual heart health clinic, expanded palliative care, and proactive complex care management – demonstrate how accountable care can improve outcomes, reduce unnecessary utilization, and strengthen care delivery in rural communities where the need is greatest.
To change that, Bloom built an in-house behavioral health program grounded in Medicare’s Collaborative Care Model—an evidence-based approach that integrates behavioral health into primary care. Licensed clinical social workers, psychiatric nurse practitioners, and a geriatric psychiatrist work alongside Bloom’s primary care clinicians, meeting weekly to review cases and coordinate care.
The results have been significant. After an average of six months in the program, patients experienced a 34% reduction in depression scores and a 39% reduction in anxiety scores.
Participation in an ACO has been central to this work. Shared savings enable Bloom to reinvest in services that directly improve patients’ quality of life. The behavioral health program reflects the organization’s broader commitment to delivering comprehensive, coordinated care wherever patients call home.
Independent Research Confirms ACOs Deliver Savings
A 2026 study published in JAMA Health Forum found the Medicare Shared Savings Program generated between $4.3 billion and $13.4 billion in net savings to traditional Medicare over the program’s first decade — positive returns in 10 of 11 years studied. The study uses a longer time horizon and more recent data compared to other research.
The findings also show savings grew over time as ACOs matured. Per-beneficiary net savings rose from roughly $20–$33 in 2014 to over $100 in most subsequent years. Accountable care is a mechanism to control spending when so few exist.
ACO Patients Are 18% Less Costly
The gap between what Medicare spends on ACO patients versus everyone else keeps growing. By 2024, that difference had reached 18.5 percent — translating into $63.7 billion less in cumulative Medicare spending, and $18 billion in savings in 2024 alone.
Those numbers reflect a program that is widening its impact over time. Importantly, ACOs are improving the quality of care, like improved blood pressure control. As more beneficiaries are brought into accountable care, the savings and quality potential grows.
More Primary Care. More Prevention. Better Outcomes.
Patients in Medicare ACOs – especially those in two-sided risk models – are significantly more likely to receive primary care and preventive services like Annual Wellness Visits. These visits help clinicians find and treat chronic conditions earlier, deliver proactive preventive services, and prevent avoidable complications before they escalate.
The difference is even more pronounced for dually eligible beneficiaries, one of Medicare’s highest-need populations, where better care coordination can mean fewer crises and better quality of life.
Accountability Delivers Savings for Medicare – and Taxpayers
The Medicare Shared Savings Program generated $2.48 billion in net savings for Medicare in 2024 alone and more than $13.6 billion in net savings since 2012. These savings come from better coordination, smarter spending, and stronger incentives to manage total cost of care.
Two-sided risk is the engine of MSSP performance, delivering more than two-thirds of all gross savings in 2024 – $5.4 billion of the $6.6 billion total. These ACOs also delivered higher per-beneficiary savings and were much more likely to earn shared savings.
Preventing Hospitalizations Through Better Care
Accountable care helps save money by preventing unnecessary hospitalizations. By investing in primary care, care coordination, and early intervention, ACOs reduce avoidable admissions that are costly for Medicare and disruptive for patients.
The Medicare Shared Savings Program has prevented hundreds of thousands of hospitalizations, preventing more than 400,000 each in 2022 and 2023, the most recent two years of data. This translates into better patient experiences and lower system-wide costs.
The Evidence Is Clear: Accountability Works
Across access, prevention, cost, and outcomes, the evidence points in the same direction: accountable care delivers better results for patients and better value for Medicare.