Date of Award

Fall 2018

Document Type


Degree Name

Master of Public Health (MPH)


Public Health

First Advisor

Andrew F. Coburn, Ph.D.


health, healthcare, value, data, management, quality, cost, accountability, transformation


Accountable Care Organizations (ACOs) have grown rapidly in recent years as an organizational vehicle to support high quality care at a sustainable cost. ACOs function by holding providers financially accountable on measures of quality and cost for respective patient populations. Patient populations are defined via attribution methods that identify patient-provider relationships via service encounter history or attestation. There are hundreds of variations to attribution methods documented in the literature, some resulting in up to fifty percent different patient populations (for the same providers over the same time period) depending on methods. As a result, the quality and cost measure performance can be meaningfully different depending on attribution methods. With more ACOs forming and existing ACOs assuming higher levels of financial risk, the need to understand performance quality and cost measures for the attributed patient population is increasing.

There are management challenges related to understanding the nuances of different attribution methods used in each ACO contract and monitoring performance over time. I identify a framework of four categories of management challenges: data accuracy and availability, team-based attribution, prospective and retrospective attribution, and method testing and evaluation. Leaders at the MaineHealth ACO have experienced challenges within each of these categories and provide use case examples to themes from the literature. For ACOs to succeed in advancing the transition from volume-based to value-based healthcare, there will need to be heightened attention to the management challenges related to complex attribution methods.



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