Medicare Accountable Care Organizations (ACOs) continued to spread in non-urban counties. This policy brief provides an analysis of the differences in ACO performance on the quality measures among the Medicare Shared Saving Program (MSSP) ACOs with varying levels of rural presence. We classified ACO geographic categories as urban, mostly urban, mixed, and rural based on county location of ACO providers and county Urban Influence Codes.

Analyzing performance data released by the Center for Medicare and Medicaid Services, we find that ACOs located in rural counties performed better than urban ACOs on three quality domain scores (Care Coordination/Patient Safety, Preventive Health, and At-Risk Population) and the overall quality score in Performance Year 2014. ACOs in mixed and mostly urban categories performed as well as urban ACOs on these three domain scores and the overall quality score. Urban ACOs performed better than ACOs in other geographic categories on Patient/Caregiver Experience score. ACOs in all geographic categories improved their quality performance between 2014 and 2015.