Accountable Care Organizations (ACOs) that participate in Medicare contracts in Texas vary greatly in size, geography, levels of physician engagement, and more. Innovista’s Texas ACOs cover substantial rural areas as well as more urban locations. Each of these ACOs experience geography-specific challenges that include social determinants of health, total cost of care, quality improvement, and technology adoption. Innovista’s approach begins with the primary care physician, where its population health strategies are centered. When strong physician leadership collaborates with a management partner that brings effective technology, proven programs, and experienced industry leaders, ACOs can continue to move the needle in population health and value-based care. Innovista has multiple years of experience partnering with Texas ACOs in MSSP and together achieved remarkable success in performance year 2018. This study highlights the factors that supported and drove this success and explores the challenges that may be faced by other ACOs as well.