Upside-only ACOs will leave if forced to take on downside risk
If participants in the Medicare Shared Savings Program (MSSP) are required to move into a track which involves downside risk for their organization, they’re likely to leave the program altogether, according to the results of a survey from the National Association of Accountable Care Organizations (NAACOS).
The responses came from 82 ACOs that joined MSSP in 2012 and 2013 and have remained in the upside-only Track 1, which has far more participants than the program’s two-sided tracks. Under the rules of the program, they’ll be required to move into a two-sided risk ACO model for their third agreement period in 2019.
Some 71.4 percent of the responding ACOs said they would likely leave the program if forced to take on risk. 22.9 percent said they’re “not at all likely” to leave because of those requirements, will another 5.7 percent were unsure.
“These results paint a bleak future of what will happen if the government keeps its mandate to push ACOs into risk,” said NAACOS president and CEO Clif Gaus, ScD, MHA. “It’s naïve to think ACOs that aren’t ready will be forced into risk in what is ultimately a voluntary program. The more likely outcome will be that many ACOs quit the program, divest their care coordination resources and return to payment models that emphasize volume over value. This would be a real setback for Medicare payment reform efforts.”
When asked what barriers remain to assuming downside risk, respondents focused on three challenges: 1) The amount of risk is too great; 2) They’re concerned about “unpredictable changes” to CMS rules on ACOs; and 3) They want more reliable financial projections.
If they’re allowed by CMS to remain in Track 1 for another agreement period, 76 percent of responding ACOs said they would be “completely likely” or “very likely” to stay in the program. NAACOS, along with other groups like the American Medical Association and the Medical Group Management Association, advocated for just that change in a Feb. 22 letter to CMS.
The stakeholders argued these “dedicated” ACOs should be allowed to stay in Track 1 if they meet certain criteria, such as generating net savings for four performance years, scoring at above the 50th percentile in quality for two of three pay-for-performance years or improving their overall quality score by at least 10 percentage points.
“These ACOs need more time to prepare for two-sided risk. While six years may sound sufficient, given the programmatic changes and considerable learning curve for these ACOs, this is not enough time,” the letter said.
Some organizations have been able to move to two-sided risk. 18 percent of all MSSP ACOs are assuming some risk in 2018—the highest level ever—thanks to the introduction of the new Track 1+ model. Other healthcare groups and consultants have said the move to downside risk is happening, though more slowly than expected, with providers advised that they can’t stay in upside-only models forever, especially when those models have been shown to increase Medicare spending.
NAACOS has argued against some of those criticisms of upside-only models, while pointing out the “significant hurdles” in two-sided risk models like Next Generation ACO, which lost seven participants earlier this year.
“Transforming care delivery and achieving successful payment reform is a long road. Let’s keep ACOs on the right path by allowing those that demonstrate results in cost and/or quality to remain in a one-sided model for at least one more contract term,” Gaus said. “At the same time, we need to fix program rules to enable ACO success and provide new opportunities to attract ACOs into two-sided models.”
John joined TriMed in 2016, focusing on healthcare policy and regulation. After graduating from Columbia College Chicago, he worked at FM News Chicago and Rivet News Radio, and worked on the state government and politics beat for the Illinois Radio Network. Outside of work, you may find him adding to his never-ending graphic novel collection.