["The Journal of Rural Health, Volume 42, Issue 2, Spring 2026. ", "\nABSTRACT\n\nPurpose\nLittle is known about factors driving rural providers—who face unique challenges—to participate and remain in accountable care organization models. The purpose of this study was to investigate the specific factors that rural hospitals evaluate when weighing both initial and continued participation in Medicare as well as commercial ACO models. Furthermore, we explored policy implications to improve ACO models’ capacity to attract, retain, and promote success of rural providers.\n\n\nMethods\nSemistructured, in‐depth interviews were conducted with rural hospital executives with direct knowledge of ACO agreement terms and factors driving ACO participation. The interview guide contained seventeen open‐ended questions. Interviews were recorded, transcribed, coded using codebooks informed by the interview guide, and analyzed using a thematic analysis approach.\n\n\nFindings\nInterviewees identified five primary multi‐faceted motivations for participation: (1) financial incentives—shared savings, upside‐only risk initially, and upfront funding for some providers, (2) getting ahead of the curve of the move to value‐based reimbursement, (3) importance placed on capacity to push toward improving population health or quality, (4) additional forms of resource gain, and (5) key outside factors. The specific ACO design affects rural providers’ decision‐making on timing and selection of particular models. Importantly for future policy development, multiple respondents raised concerns about moving to risk in ACO models, leading them to consider dropping out.\n\n\nConclusions\nFindings from this qualitative study provide an in‐depth understanding that is vital to achieving CMS's goal of increasing participation in value‐based care. In turn, this could further improve health care quality for countless lives.\n\n"]