Home-Based Primary Care Reach vs. Hospitalizations in High-Needs Patients

X = share of an ACO's high-needs patients receiving home-based primary care (n_bene_hnp_hbpc / n_bene_hnp). Y = average acute hospital stays per high-needs patient per year (avg_acute_stays_hnp); axis reversed so better performance is higher. MSSP tracks assigned by joining ACO IDs to the CMS PY2025 Shared Savings Program organizations file (246 Enhanced, 211 Basic plotted; 1 ACO not in the PY2025 list excluded). REACH types inferred from ID prefix (D) with High Needs Population ACOs identified as those whose high-needs share of beneficiaries exceeds 50% (13 ACOs, matching the CMS PY2025 participant list; the remaining 87 match the Standard/New Entrant count). 14 ACOs with suppressed HBPC counts (n<11) are excluded. Sources: HCCI 2025 claims extract; CMS PY2025 MSSP organizations file (data.cms.gov); CMS ACO REACH PY2025 participant list.