IDEAS home Printed from https://ideas.repec.org/p/nbr/nberwo/20034.html

Structuring Incentives Within Organizations: The Case of Accountable Care Organizations

Author

Listed:
  • Brigham Frandsen
  • James B. Rebitzer

Abstract

Accountable Care Organizations (ACOs) are new organizations created by the Affordable Care Act to encourage more efficient, integrated care delivery. To promote efficiency, ACOs sign contracts under which they keep a fraction of the savings from keeping costs below target provided they also maintain quality levels. To promote integration and facilitate measurement, ACOs are required to have at least 5,000 enrollees and so must coordinate across many providers. We calibrate a model of optimal ACO incentives using proprietary performance measures from a large insurer. Our key finding is that free-riding is a severe problem and causes optimal incentive payments to exceed cost savings unless ACOs simultaneously achieve extremely large efficiency gains. This implies that successful ACOs will likely rely on motivational strategies that amplify the effects of under-powered incentives. These motivational strategies raise important questions about the limits of ACOs as a policy for promoting more efficient, integrated care.

Suggested Citation

  • Brigham Frandsen & James B. Rebitzer, 2014. "Structuring Incentives Within Organizations: The Case of Accountable Care Organizations," NBER Working Papers 20034, National Bureau of Economic Research, Inc.
    • Handle: RePEc:nbr:nberwo:20034
    Note: EH IO LS
    as

    Download full text from publisher

    File URL: http://www.nber.org/papers/w20034.pdf
    Download Restriction: no
    ---><---

    References listed on IDEAS

    as
    1. James B. Rebitzer & Mark E. Votruba, 2011. "Organizational Economics and Physician Practices," NBER Working Papers 17535, National Bureau of Economic Research, Inc.
    2. Robert Gibbons, 2010. "Transaction‐Cost Economics: Past, Present, and Future?," Scandinavian Journal of Economics, Wiley Blackwell, vol. 112(2), pages 263-288, June.
    3. Gary S. Becker & Kevin M. Murphy, 1994. "The Division of Labor, Coordination Costs, and Knowledge," NBER Chapters, in: Human Capital: A Theoretical and Empirical Analysis with Special Reference to Education, Third Edition, pages 299-322, National Bureau of Economic Research, Inc.
    4. Randall P. Ellis, 2012. "risk adjustment," The New Palgrave Dictionary of Economics,, Palgrave Macmillan.
    5. Kandel, Eugene & Lazear, Edward P, 1992. "Peer Pressure and Partnerships," Journal of Political Economy, University of Chicago Press, vol. 100(4), pages 801-817, August.
    6. Masten, Scott E & Meehan, James W, Jr & Snyder, Edward A, 1991. "The Costs of Organization," The Journal of Law, Economics, and Organization, Oxford University Press, vol. 7(1), pages 1-25, Spring.
    7. Randall D. Cebul & James B. Rebitzer & Lowell J. Taylor & Mark E. Votruba, 2008. "Organizational Fragmentation and Care Quality in the U.S. Healthcare System," Journal of Economic Perspectives, American Economic Association, vol. 22(4), pages 93-113, Fall.
    8. Rebitzer, James B. & Taylor, Lowell J., 2011. "Extrinsic Rewards and Intrinsic Motives: Standard and Behavioral Approaches to Agency and Labor Markets," Handbook of Labor Economics, in: O. Ashenfelter & D. Card (ed.), Handbook of Labor Economics, edition 1, volume 4, chapter 8, pages 701-772, Elsevier.
    9. Holmstrom, Bengt & Milgrom, Paul, 1991. "Multitask Principal-Agent Analyses: Incentive Contracts, Asset Ownership, and Job Design," The Journal of Law, Economics, and Organization, Oxford University Press, vol. 7(0), pages 24-52, Special I.
    10. Luis Garicano & Tano Santos, 2004. "Referrals," American Economic Review, American Economic Association, vol. 94(3), pages 499-525, June.
    Full references (including those not matched with items on IDEAS)

    Citations

    Citations are extracted by the CitEc Project, subscribe to its RSS feed for this item.
    as


    Cited by:

    1. Leila Agha & Keith Marzilli Ericson & Kimberley H. Geissler & James B. Rebitzer, 2022. "Team Relationships and Performance: Evidence from Healthcare Referral Networks," Management Science, INFORMS, vol. 68(5), pages 3735-3754, May.
    2. David G. Lugo‐Palacios & Jonathan M. Clarke & Søren Rud Kristensen, 2023. "Back to basics: A mediation analysis approach to addressing the fundamental questions of integrated care evaluations," Health Economics, John Wiley & Sons, Ltd., vol. 32(9), pages 2080-2097, September.
    3. Liang, Li-Lin & Tussing, A Dale & Huang, Nicole & Tsai, Shu-Ling, 2021. "Incentives for physician teams: Effectiveness of performance feedback and payment distribution methods," Health Policy, Elsevier, vol. 125(10), pages 1377-1384.
    4. Agha, Leila & Frandsen, Brigham & Rebitzer, James B., 2019. "Fragmented division of labor and healthcare costs: Evidence from moves across regions," Journal of Public Economics, Elsevier, vol. 169(C), pages 144-159.
    5. Leila Agha & Keith Marzilli Ericson & Kimberley H. Geissler & James B. Rebitzer, 2018. "Team Formation and Performance: Evidence from Healthcare Referral Networks," NBER Working Papers 24338, National Bureau of Economic Research, Inc.

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. James B. Rebitzer & Mark E. Votruba, 2011. "Organizational Economics and Physician Practices," NBER Working Papers 17535, National Bureau of Economic Research, Inc.
    2. Simona Grassi & Ching-to Albert Ma, 2016. "Information acquisition, referral, and organization," RAND Journal of Economics, RAND Corporation, vol. 47(4), pages 935-960, November.
    3. Larry G. Epstein & Hiroaki Kaido & Kyoungwon Seo, 2016. "Robust Confidence Regions for Incomplete Models," Econometrica, Econometric Society, vol. 84, pages 1799-1838, September.
    4. Aidan R. Vining, 2003. "Internal Market Failure: A Framework for Diagnosing Firm Inefficiency," Journal of Management Studies, Wiley Blackwell, vol. 40(2), pages 431-457, March.
    5. Bercovitz, Janet & Feldman, Maryann, 2011. "The mechanisms of collaboration in inventive teams: Composition, social networks, and geography," Research Policy, Elsevier, vol. 40(1), pages 81-93, February.
    6. Leila Agha & Keith Marzilli Ericson & Kimberley H. Geissler & James B. Rebitzer, 2022. "Team Relationships and Performance: Evidence from Healthcare Referral Networks," Management Science, INFORMS, vol. 68(5), pages 3735-3754, May.
    7. Dirk Sliwka, 2007. "Trust as a Signal of a Social Norm and the Hidden Costs of Incentive Schemes," American Economic Review, American Economic Association, vol. 97(3), pages 999-1012, June.
    8. Banerjee, Swapnendu & Chakraborty, Somenath, 2025. "Individual versus Team Production with Social Preferences," MPRA Paper 125933, University Library of Munich, Germany.
    9. Lee, Frances (Zhiyun Xu), 2013. "Trading between agents for a better match," International Journal of Industrial Organization, Elsevier, vol. 31(5), pages 501-515.
    10. Dr Alex Bryson & John Forth, 2012. "CEO Bonding: Who Posts Performance Bonds and Why?," National Institute of Economic and Social Research (NIESR) Discussion Papers 389, National Institute of Economic and Social Research.
    11. Lindbeck, A & Snower, D-J, 1996. "Centralized Bargaining, Multi-Tasking, and Work Incentives," Papers 620, Stockholm - International Economic Studies.
    12. Agha, Leila & Frandsen, Brigham & Rebitzer, James B., 2019. "Fragmented division of labor and healthcare costs: Evidence from moves across regions," Journal of Public Economics, Elsevier, vol. 169(C), pages 144-159.
    13. Uwe Jirjahn & Jens Mohrenweiser, 2019. "Performance Pay and Applicant Screening," British Journal of Industrial Relations, London School of Economics, vol. 57(3), pages 540-575, September.
    14. Wang, Peng, 2026. "Complementary and substitution cooperation in joint projects: Sabotage by the weak in mixed contests," Economic Modelling, Elsevier, vol. 154(C).
    15. Paul Walker, 2010. "The (Non)Theory Of The Knowledge Firm," Scottish Journal of Political Economy, Scottish Economic Society, vol. 57(1), pages 1-32, February.
    16. repec:eee:labchp:v:3:y:1999:i:pb:p:2373-2437 is not listed on IDEAS
    17. Brandts, Jordi & Corgnet, Brice & Hernán-González, Roberto & Ortiz, José Mª & Solà, Carles, 2021. "Watching or not watching? Access to information and the incentive effects of firing threats," Journal of Economic Behavior & Organization, Elsevier, vol. 189(C), pages 672-685.
    18. Jerker Denrell, 2000. "Radical Organization Theory," Rationality and Society, , vol. 12(1), pages 39-66, February.
    19. Uwe Jirjahn & Jens Mohrenweiser, 2025. "Variable Payment Schemes and Productivity: Do Individual‐Based Schemes Really Have a Stronger Influence Than Collective Ones?," Kyklos, Wiley Blackwell, vol. 78(4), pages 1316-1332, November.
    20. Fan, C. Simon & Wei, Xiangdong & Wu, Jia & Zhang, Junsen, 2022. "Observability and peer effects: Theory and evidence from a field experiment," Journal of Economic Behavior & Organization, Elsevier, vol. 200(C), pages 847-867.
    21. David Marsden & Richard Belfield, 2010. "Institutions and the Management of Human Resources: Incentive Pay Systems in France and Great Britain," British Journal of Industrial Relations, London School of Economics, vol. 48(2), pages 235-283, June.

    More about this item

    JEL classification:

    • D23 - Microeconomics - - Production and Organizations - - - Organizational Behavior; Transaction Costs; Property Rights
    • D86 - Microeconomics - - Information, Knowledge, and Uncertainty - - - Economics of Contract Law
    • I12 - Health, Education, and Welfare - - Health - - - Health Behavior
    • L14 - Industrial Organization - - Market Structure, Firm Strategy, and Market Performance - - - Transactional Relationships; Contracts and Reputation
    • L24 - Industrial Organization - - Firm Objectives, Organization, and Behavior - - - Contracting Out; Joint Ventures
    • M5 - Business Administration and Business Economics; Marketing; Accounting; Personnel Economics - - Personnel Economics

    NEP fields

    This paper has been announced in the following NEP Reports:

    Statistics

    Access and download statistics

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:nbr:nberwo:20034. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: the person in charge (email available below). General contact details of provider: https://edirc.repec.org/data/nberrus.html .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.