Adherence to Positive Airway Pressure Therapy in a Cohort of Colombian Patients with Obstructive Sleep Apnea Syndrome.

Objective To describe the adherence to the use of positive air pressure (PAP) devices in a cohort of patients with sleep apnea syndrome in Colombia. Material and Methods Descriptive cross-sectional study of adult patients treated between January 2018 and December 2019 in the sleep clinic of a private insurer in Colombia. Results The analysis included 12,538 patients (51.3% women) with a mean age of 61.3 years; 10,220 patients (81.5%) use CPAP and 1,550 (12.4%) BIPAP. Only 37% are adherent (> 70% of use for 4 hours or more), adherence rates were highest in the >65 years age groups. 2,305 patients (18.5%) were hospitalized, on average 3.2 times; 515 of these (21.3%) had one or more cardiovascular comorbidities. Conclusion Adherence rates in this sample are lower than those reported elsewhere. They are similar in males and females and tend to improve with age.

Accountable Care Organizations and Health Disparities of Rural Latinos: A Longitudinal Analysis.

The purpose of this study was 2-fold: (1) to analyze the change in diabetes-related hospitalization rates of rural Latino older adult patients as compared with their White counterparts and (2) to determine what factors, including rural health clinic (RHC) participation in accountable care organizations (ACOs), are related to reduced disparities in diabetes-related hospitalization rates. Data for Latino Medicare beneficiaries who were served by RHCs over an 8-year period were analyzed. First, a difference-of-means test was conducted to determine whether there was a change in disparity from the pre-ACO period (2008-2011) to the post-ACO period (2012-2015). A statistically significant decrease in disparity over time was found (t = -7.6899, df = 115, P < 0.001.) Second, multiple regression analyses of 3 separate models were conducted to determine whether ACO participation contributed to reducing disparities in diabetes-related hospitalization rates between Latinos and Whites. The analyses indicated moderate evidence that consistent ACO participation is associated with lower health disparities (t = -1.947, P = 0.0525). However, this association is not significant after balancing covariates, and no causal relationship can be established. Latinos compose one of the fastest growing groups in rural as well as urban areas of the United States. It is critical that ACOs, with their emphasis on care coordination, health care quality, and value, monitor their provision of services to Latinos, rural, and other vulnerable populations.

Trends in Health Disparities of Rural Latinos Pre- and Post-Accountable Care Organization Implementation.

Purpose: We present findings from a longitudinal investigation, the purpose of which was to compare health disparities of rural Latino older adult patients diagnosed with diabetes to their non-Latino White counterparts. Methodology/Approach: A pre-post design was implemented treating Medicare Accountable Care Organization (ACO) participation by Rural Health Clinics (RHCs) as an intervention, and using diabetes-related hospitalizations to measure disparities. Data for a nationwide panel of 2,683 RHCs were analyzed for a study period of eight years: 2008 - 2015. In addition, data were analyzed for a subset of 116 RHCs located in Florida, Texas, and California that participated in a Medicare ACO in one or more years of the study period. Findings: Two broad findings resulted from this investigation. First, for both the nationwide panel of RHCs and the three-state sample of "ACO RHCs," there was a decrease in the mean disparities in diabetes-related hospitalization rates over the eight-year study period. Second, in comparing a three-year time period after Medicare ACO implementation in 2012 to a four-year period before the implementation, a statistically significant difference in mean disparities was found for the nationwide panel. Research limitations/implications: There are a number of factors that may contribute to the decrease in diabetes-related hospitalization rates for Latinos in more recent years. Future research will identify specific contributors to reducing diabetes-related hospitalization disparities between Latinos and the general population, including the possible influence of ACO participation by RHCs. Originality/Value of Paper: This paper presents original research conducted using data related to rural Latino older adults. The data represent multiple states and an eight-year time period. The U.S. Latino population is growing at a rapid pace. As a group, they are at a high risk for developing diabetes, the complications of which are serious and costly to the patient and the U.S. healthcare system. With the continued growth of the Latino population, it is critical that their health disparities be monitored, and that factors that contribute to their health and well-being be identified and promoted.

Healthcare Needs of U.S. Rural Latinos: A Growing, Multicultural Population.

PURPOSE: From 2000 to 2050, the Latino population in the United States (U.S.) is expected to grow by 273%. Health outcomes vary widely among Latino subgroups and health disparities more adversely affect rural residents. The commonly used "one-size-fits-all" approach assumes that the U.S. Latino population is homogeneous. SAMPLE METHOD: Rural Latinos in four study states: Arizona (AZ), California (CA), Florida (FL) and Texas (TX) were the focus of this study. This research describes changes in the Latino population in rural counties of the U.S. in two dimensions: 1) change in population by number, and 2) change in population by country of origin using data from 2000-2017. FINDINGS: The following themes emerged: 1) the overall Latino population grew in each state; 2) rural Latino populations in each state also increased but at a higher rate; 3) there is a variety of diversity in the countries of origin of rural Latinos based in each state; and 4) a considerable proportion of Latinos living in rural areas are of unknown Latino origins. CONCLUSIONS: As the largest racial or ethnic minority in rural populations and as the second largest group in the nation, Latino health has a significant influence on the U.S. healthcare system. For nurses, evidence-based strategies can be tailored to address diverse Latino subpopulations to reduce specific disparities for various ethnic populations.

ACOs' Impact on Hospitalization Rates of Rural Older Adults With Diabetes: Early Indications.

The purpose of this study was to examine the impact of Medicare Shared Savings Program Accountable Care Organizations (SSP ACOs), along with other factors, on diabetes-related hospitalization rates for rural older adults. Using an early year of the SSP ACO program, we conducted multiple linear regressions to examine the effect of ACO participation on African American and white older adults. In neither model was ACO affiliation found to have a statistically significant impact on diabetes-related hospitalization rates. This study provides baseline measures for patient outcomes during the initial years of ACO formation.

Impact of Nurse Practitioner Practice Regulations on Rural Population Health Outcomes.

Background: For decades, U.S. rural areas have experienced shortages of primary care providers. Nurse practitioners (NPs) are helping to reduce that shortage. However, NP scope of practice regulations vary from state-to-state ranging from autonomous practice to direct physician oversight. The purpose of this study was to determine if clinical outcomes of older rural adult patients vary by the level of practice autonomy that states grant to NPs. Methods: This cross-sectional study analyzed data from a sample of Rural Health Clinics (RHCs) (n = 503) located in eight Southeastern states. Independent t-tests were performed for each of five variables to compare patient outcomes of the experimental RHCs (those in “reduced practice” states) to those of the control RHCs (in “restricted practice” states). Results: After matching, no statistically significant difference was found in patient outcomes for RHCs in reduced practice states compared to those in restricted practice states. Yet, expanded scope of practice may improve provider supply, healthcare access and utilization, and quality of care (Martsolf et al., 2016). Conclusions: Although this study found no significant relationship between Advanced Registered Nurse Practitioner (ARNP) scope of practice and select patient outcome variables, there are strong indications that the quality of patient outcomes is not reduced when the scope of practice is expanded.

Does Patient-Centered Medical Home Recognition Relate to Accountable Care Organization Participation?

As of April 2015, less than 10% of Medicare Shared Savings Program Accountable Care Organizations (MSSP ACOs) included Rural Health Clinics (RHCs). In order to understand why RHCs are not participating in this ACO model in greater numbers, this study examined the influence of several factors on ACO participation. Data for this study were collected via a survey distributed during the summers of 2012, 2013, and 2014 to all RHCs in 9 states. This study had a cross-sectional design using survey research. The unit of analysis was the RHC; the total sample size was 178. This study found that those respondents who reported knowing very little about ACOs had the lowest "willingness to join an ACO" score and that the passage of time increased RHC willingness to join an ACO. Also, patient-centered medical home (PCMH) recognition was the most influential factor related to an RHC's adopting the ACO model. If ACO model adoption is to increase in rural areas, this study suggests that strategies would need to include methods for (1) targeting RHCs that have PCMH recognition; (2) increasing PCMH recognition in rural areas; and (3) increasing RHC knowledge about what an ACO is, how the model works, and why this model may benefit RHCs and other rural primary care providers.

Cost of Practice Transformation in Primary Care: Joining an Accountable Care Organization.

The purpose of this study is to examine the costs related to practice transformation from the perspective of primary care organizations transitioning to become participants in Accountable Care Organizations (ACOs). We pose two research questions: 1) Will a Rural Health Clinic that participates in an Accountable Care Organization see higher or lower cost per visit, and 2) If the cost per visit is higher or lower, how large will that difference be? We analyze administrative data from a panel of over 800 Rural Health Clinics for the period 2007 - 2013 using a treatment effects approach, where a clinic's participation in an ACO is viewed as a "treatment." Since the first year that an RHC could join an ACO was 2012 and our most recent year of complete data is 2013, we restricted our analysis of the impact of participation in an ACO to include only 2012 and 2013 data. The estimates of the average treatment effect on the treated (ATET) pertain to only those RHCs that joined ACOs. The results show that those 20 sample ACO RHCs experienced an average from $15.00 to $18.61 higher cost per visit than the matching non-ACO RHCs. At this very early stage of ACO development, our results must be considered very preliminary at best. Whatever conclusions we draw from these results are intended to merely suggest what might be found once many more RHCs join ACOs. The conclusions we draw from this early analysis can lay a foundation for more analysis after data are available when more RHCs join ACOs.

Variations in Influenza and Pneumonia Immunizations for Medicare Beneficiaries Served by Rural Health Clinics.

The availability of a rural health clinic (RHC) database over the period of 6 years (2008-2013) offers a unique opportunity to examine the trends and patterns of disparities in immunization for influenza and pneumonia among Medicare beneficiaries in the southeastern states. The purpose of this exploratory study was twofold. First, it examined the rural trends and patterns of immunization rates before (2008-2009) and after (2010-2013) the Affordable Care Act (ACA) enactment by state and year. Second, it investigated how contextual, organizational, and aggregate patient characteristics may influence the variations in immunization for influenza and pneumonia of Medicare beneficiaries served by RHCs. Four data sources from federal agencies were merged to perform a longitudinal analysis of the influences of contextual, organizational, and aggregate patient characteristics on the disparities in immunization rates of rural Medicare beneficiaries for influenza and pneumonia. We included both time-varying and time-constant predictors in a multivariate analysis using Generalized Estimating Equation. This study revealed the increased immunization rates for both influenza and pneumonia over a period of 6 years. The ACA had a positive effect on increased immunization rates for pneumonia, but not for influenza, in rural Medicare beneficiaries in the eight states. The RHCs that served more dually-eligible patients had higher immunization rates. For influenza immunization, provider-based RHCs had a higher rate than the independent RHCs. For pneumonia immunization, no organizational variables were relevant in the explanation of the variability. The results also showed that no single dominant factor influenced health care disparities. This investigation suggested further improvements in preventive care are needed to target poor and isolated rural beneficiaries. Furthermore, the integration of immunization data from multiple sources is critically needed for understanding health disparities.

Contextual, organizational and ecological effects on the variations in hospital readmissions of rural Medicare beneficiaries in eight southeastern states.

The enactment of the Patient Protection and Affordable Care Act (ACA) has been expected to improve the coverage of health insurance, particularly as related to the coordination of seamless care and the continuity of elder care among Medicare beneficiaries. The analysis of longitudinal data (2007 through 2013) in rural areas offers a unique opportunity to examine trends and patterns of rural disparities in hospital readmissions within 30 days of discharge among Medicare beneficiaries served by rural health clinics (RHCs) in the eight southeastern states of the Department of Health & Human Services (DHHS) Region 4. The purpose of this study is twofold: first, to examine rural trends and patterns of hospital readmission rates by state and year (before and after the ACA enactment); and second, to investigate how contextual (county characteristic), organizational (clinic characteristic) and ecological (aggregate patient characteristic) factors may influence the variations in repeat hospitalizations. The unit of analysis is the RHC. We used administrative data compiled from multiple sources for the Centers of Medicare and Medicaid Services for a period of seven years. From 2007 to 2008, risk-adjusted readmission rates increased slightly among Medicare beneficiaries served by RHCs. However, the rate declined in 2009 through 2013. A generalized estimating equation of sixteen predictors was analyzed for the variability in risk-adjusted readmission rates. Nine predictors were statistically associated with the variability in risk-adjusted readmission rates of the RHCs pooled from 2007 through 2013 together. The declined rates were associated with by the ACA effect, Georgia, North Carolina, South Carolina, and the percentage of elderly population in a county where RHC is located. However, the increase of risk-adjusted rates was associated with the percentage of African Americans in a county, the percentage of dually eligible patients, the average age of patients, and the average clinical visits by African American patients. The sixteen predictors accounted for 21.52 % of the total variability in readmissions. This study contributes to the literature in health disparities research from the contextual, organizational and ecological perspectives in the analysis of longitudinal data. The synergism of multiple contextual, organizational and ecological factors, as shown in this study, should be considered in the design and implementation of intervention studies to address the problem of hospital readmissions through prevention and enhancement of disease management of rural Medicare beneficiaries.

Accountable Care Organization Implementation Experiences and Rural Participation: Considerations for Nurses.

BACKGROUND: Little is known about how accountable care organizations (ACOs) participate with rural health providers. This pilot study examines ACO participation with rural health clinics (RHCs). METHODS: Telephone interviews with 8 ACO administrators were conducted to determine the early implementation experiences of these organizations, and their participation with rural health providers, such as RHCs, using qualitative content analysis, ACO characteristics, and emerging themes from the ACO executive responses was identified. RESULTS: Three predominant themes emerged: 1) ACOs are growing in size and number and have various organizational structures; 2) there is an expanding emphasis on preventive primary care and chronic disease management for patients; and 3) there is a need for improved information technology integration with clinical services and financial systems. CONCLUSION: Of 8 participants, 7 reported that their ACO was planning to expand into rural areas and partner with rural providers.

Contextual, Ecological and Organizational Variations in Risk-Adjusted COPD and Asthma Hospitalization Rates of Rural Medicare Beneficiaries.

The purpose of this study is to examine what factors contributing to the variability in chronic obstructive pulmonary disorder (COPD) and asthma hospitalization rates when the influence of patient characteristics is being simultaneously considered by applying a risk adjustment method. A longitudinal analysis of COPD and asthma hospitalization of rural Medicare beneficiaries in 427 rural health clinics (RHCs) was conducted utilizing administrative data and inpatient and outpatient claims from Region 4. The repeated measures of risk-adjusted COPD and asthma admission rate were analyzed by growth curve modeling. A generalized estimating equation (GEE) method was used to identify the relevance of selected predictors in accounting for the variability in risk-adjusted admission rates for COPD and asthma. Both adjusted and unadjusted rates of COPD admission showed a slight decline from 2010 to 2013. The growth curve modeling showed the annual rates of change were gradually accentuated through time. GEE revealed that a moderate amount of variance (marginal R2 = 0.66) in the risk-adjusted hospital admission rates for COPD and asthma was accounted for by contextual, ecological, and organizational variables. The contextual, ecological, and organizational factors are those associated with RHCs, not hospitals. We cannot infer how the variability in hospital practices in RHC service areas may have contributed to the disparities in admissions. Identification of RHCs with substantially higher rates than an average rate can portray the need for further enhancement of needed ambulatory or primary care services for the specific groups of RHCs. Because the risk-adjusted rates of hospitalization do not very by classification of rural area, future research should address the variation in a specific COPD and asthma condition of RHC patients. Risk-adjusted admission rates for COPD and asthma are influenced by the synergism of multiple contextual, ecological, and organizational factors instead of a single factor.

Costs of accountable care organization participation for primary care providers: early stage results.

BACKGROUND: Little is known about the impact of joining an Accountable Care Organization (ACO) on primary care provider organization's costs. The purpose of this study was to determine whether joining an ACO is associated with an increase in a Rural Health Clinic's (RHC's) cost per visit. METHODS: The analyses focused on cost per visit in 2012 and 2013 for RHCs that joined an ACO in 2012 and cost per visit in 2013 for RHCs that joined an ACO in 2013. The RHCs were located in nine states. Data were obtained from Medicare Cost Reports. The analysis was conducted taking a treatment effects approach where the treatment is joining an ACO. Propensity-score matching was employed to provide multiple single and pooled estimates of the average treatment effect on the treated. RESULTS: Four-hundred thirty four to 544 RHCs (depending on the type of analysis and the variables used) were used in the several analyses. Seven of the RHCs joined an ACO in 2012 and 14 joined an ACO in 2013. The mean cost per visit for RHCs that did not join an ACO rose 4.40 % from 2011 to 2012 whereas the mean cost per visit for RHCs that joined an ACO rose by triple: 13.5 %. All of the pooled estimates of the average treatment effect on the treated from the propensity-score matching showed that joining an ACO was associated with higher mean cost per visit. The range of the estimated mean cost per visit differences was $17.19 (p value = 0.00) to $25.19 (p value = 0.00). CONCLUSIONS: This study is one of the first to describe the cost of ACO participation from the perspective of primary care provider organizations. It appears that for at least one type of primary care provider - the RHC - there are substantial costs associated with ACO participation during the first two years.

Racial Disparities in Diabetes Hospitalization of Rural Medicare Beneficiaries in 8 Southeastern States.

This study examined racial variability in diabetes hospitalizations attributable to contextual, organizational, and ecological factors controlling for patient variabilities treated at rural health clinics (RHCs). The pooled cross-sectional data for 2007 through 2013 for RHCs were aggregated from Medicare claim files of patients served by RHCs. Descriptive statistics were presented to illustrate the general characteristics of the RHCs in 8 southeastern states. Regression of the dependent variable on selected predictors was conducted using a generalized estimating equation method. The risk-adjusted diabetes mellitus (DM) hospitalization rates slightly declined in 7 years from 3.55% to 2.40%. The gap between the crude and adjusted rates became wider in the African American patient group but not in the non-Hispanic white patient group. The average DM disparity ratio increased 17.7% from the pre-Affordable Care Act (ACA; 1.47) to the post-ACA period (1.73) for the African American patient group. The results showed that DM disparity ratios did not vary significantly by contextual, organizational, and individual factors for African Americans. Non-Hispanic white patients residing in large and small rural areas had higher DM disparity ratios than other rural areas. The results of this study confirm racial disparities in DM hospitalizations. Future research is needed to identify the underlying reasons for such racial disparities to guide the formulation of effective and efficient changes in DM care management practices coupled with the emphasis of culturally competent, primary and preventive care.

Participation of Rural Health Care Providers in Accountable Care Organizations: Early Indications.

Recently, some rural health clinics (RHCs) throughout the country have chosen to join groups of health care providers in accountable care organizations (ACOs). Examined are characteristics of Southeastern RHCs and the counties they serve; it is shown how those characteristics compare with other regions across the country and suggested what role those differences might play in an RHC's decision to participate in an ACO. Rural health clinic-related data were collected and summarized for 2 time periods: 2007 and 2011: for 2007, data from RHCs throughout the United States; for 2011, summarized demographic data related to region 4 RHCs specifically. Several characteristics about region 4 RHCs indicate that they may be slow to participate in ACOs. However, other characteristics, including their perception that ACOs may improve the quality of care and health outcomes of their patients and communities, may facilitate the process of RHCs joining ACOs, should they choose to do so. Addressing the health care needs and health care quality of rural populations must be part of the design, development, and performance monitoring of ACOs of the future.

Variations in Colorectal Cancer Screening of Medicare Beneficiaries Served by Rural Health Clinics.

This study aims (1) to examine the trends and patterns of colorectal cancer screening (CCS) of Medicare beneficiaries in rural areas by state and year (before and after Affordable Care Act [ACA] enactment) and (2) to investigate the contextual, organizational, and aggregated patient characteristics influencing variations in care received by patients of rural health clinics (RHCs). The following 2 hypotheses were formulated: (1) CCS rates are higher in the post-ACA period than in the pre-ACA period, irrespective of the factors rurality, poverty, dually eligible status, and the organizational characteristics of RHCs and (2) the contextual and organizational factors of RHCs exert more influence on the variation in CCS rates of RHC patients than do aggregated personal factors. We used administrative data on CCS rates (2007 through 2012) for rural Medicare beneficiaries. Autoregressive growth curve modeling of the CCS rates was performed. A generalized estimating equation of selected predictors was analyzed. Of the 9 predictors, 5 were statistically significant: The ACA and the percentage of female patients had a positive effect on the CCS rate, whereas regional location, years of RHC certification, and average age of patients had a negative effect on the CCS rate. The predictors accounted for 40.2% of the total variance in CCS. Results show that in rural areas of 9 states, the enactment of ACA improved CCS rates, contextual, organizational, and patient characteristics being considered. Improvement in preventive care will be expected, as the ACA is implemented in the United States.

Primary Care Clinics and Accountable Care Organizations.

BACKGROUND: The Accountable Care Organization (ACO) is one of the new models of health care delivery in the U.S. To date, little is known about the characteristics of health care organizations that have joined ACOs. We report on the findings of a survey of primary care clinics, the objective of which was to investigate the opinions of clinic management about participation in ACOs, and the characteristics of clinic organizational structure that may contribute to joining ACOs or be willing to do so. METHODS: A 27-item survey questionnaire was developed and distributed by mail in 3 annual waves to all Rural Health Clinics (RHCs) in 9 states. Two dependent variables - participation in ACOs and willingness to join ACOs - were created and analyzed using a generalized estimating equation (GEE) approach. RESULTS: 257 RHCs responded to the survey. A small percentage (5.2%) of the respondent clinics reported that they were participating in ACOs. RHCs in isolated areas were 78% less likely to be in ACOs (odds= 0.22, p= 0.059). Non-profit RHCs indicated a higher willingness to join an ACO than for-profit RHCs (B= 1.271, p= 0.054). There is a positive relationship between RHC size and willingness to join an ACO (B= 0.402, p=0.010). CONCLUSIONS: At this early stage of ACO development, many RHC personnel are unfamiliar with the ACO model. Rural providers' limited technological and human resources, and the lack of ACO development in rural areas, may delay or prevent their participation in ACOs.

Predictors of Rural Health Clinics Managers' Willingness to Join Accountable Care Organizations.

PURPOSE: The implementation of the Patient Protection and Affordable Care Act has facilitated the development of an innovative and integrated delivery care system, Accountable Care Organizations (ACOs). It is timely, to identify how health care managers in rural health clinics are responding to the ACO model. This research examines RHC managers' perceived benefits and barriers for implementing ACOs from an organizational ecology perspective. METHODOLOGY/APPROACH: A survey was conducted in Spring of 2012 covering the present RHC network working infrastructures - 1) Organizational social network; 2) organizational care delivery structure; 3) ACO knowledge, perceived benefits, and perceived barriers; 4) quality and disease management programs; and 5) health information technology (HIT) infrastructure. One thousand one hundred sixty clinics were surveyed in the United States. They cover eight southeastern states (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) and California. A total of ninety-one responses were received. FINDINGS: RHC managers' personal perceptions on ACO's benefits and knowledge level explained the most variance in their willingness to join ACOs. Individual perceptions appear to be more influential than organizational and context factors in the predictive analysis. RESEARCH LIMITATIONS/IMPLICATIONS: The study is primarily focused in the Southeastern region of the U.S. The generalizability is limited to this region. The predictors of rural health clinics' participation in ACOs are germane to guide the development of organizational strategies for enhancing the general knowledge about the innovativeness of delivering coordinated care and containing health care costs inspired by the Affordable Care Act. ORIGINALITY/VALUE OF PAPER: Rural health clinics are lagged behind the growth curve of ACO adoption. The diffusion of new knowledge about pros and cons of ACO is essential to reinforce the health care reform in the United States.

INFRASTRUCTURAL MECHANISMS LEADING TOWARD PRO-ACCOUNTABLE CARE ORGANISATION ORIENTATION: A SURVEY OF HOSPITAL MANAGERS.

Organisations across the country are transforming the way they deliver care, in ways similar to the accountable care organisation (ACO) model supported by Medicare. ACOs modalities are varying in size, type, and financing structure. Little is known about how specific infrastructural mechanisms influence hospital managers' pro-ACO orientation. Using an electronic-survey of hospital managers, this study explores how pro-ACO orientation, as a latent construct, is captured from the perceptions of hospital managers; and identify infrastructural mechanisms leading to the formation of pro-ACO orientation. Of the total hospital respondents, 58% are moving toward the establishment of ACOs; 56% are planning to join in the next two years; 48% are considering joining ACOs; while 25% had already participated in ACOs during 2012. Urban hospitals are more likely than rural hospitals to be engaged in ACO development. The health provider network size is one of the strongest indicators in predicting pro-ACO orientation.

Willingness to participate in accountable care organizations: health care managers' perspective.

This study examines how health care managers responded to the accountable care organization (ACO). The effect of perceived benefits and barriers of the commitment to develop a strategic plan for ACOs and willingness to participate in ACOs is analyzed, using organizational social capital, health information technology uses, health systems integration and size of the health networks, geographic factors, and knowledge about ACOs as predictors. Propensity score matching and analysis are used to adjust the state and regional variations. When the number of perceived benefits is greater than the number of perceived barriers, health care managers are more likely to reveal a stronger commitment to develop a strategic plan for ACO adoption. Health care managers who perceived their organizations as lacking leadership support or commitment, financial incentives, and legal and regulatory support to ACO adoption were less willing to participate in ACOs in the future. Future research should gather more diverse views from a larger sample size of health professionals regarding ACO participation. The perspective of health care managers should be seriously considered in the adoption of an innovative health care delivery system. The transparency on policy formulation should consider multiple views of health care managers.