MSSP ACO Participation Remains Flat in 2020

Stakeholders say 'Pathways to Success' mandates have dampened ACO enthusiasm for the program.

Participation in the Medicare Shared Savings Program held steady for 2020, with 517 accountable care organizations participating in the value-based payment program, the Centers for Medicare & Medicaid Services reported. 

The 2020 participation level is one fewer than the 518 ACOs that participated in 2019, and down from the high of 561 ACOs that participated in 2018.

Only 35 Shared Savings Program ACOs are entering their first contract with CMS, compared with an average of 107 new ACOs annually between 2012 and 2018. Last year, overall participation fell to 41 new ACOs.

However, 192 ACOs are taking on downside risk in 2020, more than double the 93 ACOs taking risk at the start of 2019.

In addition, CMS said 11.2 million Medicare beneficiaries–the largest number ever, and representing nearly 30% of Medicare fee-for-service beneficiaries–are being cared for by ACOs.

In an essay Friday in Health Affairs, CMS Administrator Seema Verma wrote that she was "excited to report continued strong interest and robust participation in the redesigned program."

"It’s been rewarding to see that low-revenue (physician-led) ACOs have found the new participation options appealing. As of January 1, there are 270 low-revenue ACOs participating in the program, up 27% from a year ago," she said.

Verma said the number of ACOs participating in MSSP in 2020 validated CMS's Pathways to Success overhaul in 2018. Ignoring the protestst of stakeholders, CMS mandated forcing ACOs to accept risk sooner, while also reducing the share of the savings that ACOs could keep.

Verma said the mandated downside risk is needed because ACOs aren't generating enough savings.

"Given all the best practices and learnings that emerged from over half a decade of experience, it was time to strengthen the incentives in the program and ensure real accountability while also providing more flexibility for ACOs to innovate," she wrote.

CMS reported in October that MSSP generated $1.7 billion in total savings in 2018. Of that, Medicare netted $739 million, after paying out shared savings bonuses, and collecting shared savings loss payments from ACOs.

However, ACOs that took on downside risk generated more savings than ACOs that did not, with an average $96 reduction in spending per enrollee, compared with $68 per enrollee in ACOs that did not take on risk.

ACO stakeholders had a decidedly different interpretation of the figures put forward Friday by CMS.

Clif Gaus, president and CEO of National Association of ACOs, said his association has predicted in 2018 "that changes CMS made under Pathways would throw off the careful balance of risk and reward for too many ACOs."

"Sadly, those fears may be coming true," he said. “To date, there have been few attractive alternative payment models besides ACOs, so harming participation in the Medicare Shared Savings Program hurts Medicare’s priority of changing how it pays for care."

A 2018 study commissioned by NAACOS found that MSSP ACOs generated estimated gross savings of $1.84 billion during performance years 2013 through 2015; nearly double the $954 million in estimated gross savings CMS had reported.

Gaus urged Congress to review the program "to ensure more damage isn't done."

"If interest in ACOs dwindles, then doctors and hospitals will fall back into a fragmented, fee-for-service system, and any momentum to transform our health system will be lost," he said.

Last June, University of Michigan researchers issued a study which found that high-cost patients and high-cost doctors were much more likely to exit ACOs than low-cost patients and doctors, and that ACOs did not demonstrate improvement in spending or quality after selective dropping of clinicians and their patients from the program.