Accountable care organizations (ACOs) are willing to leave the Medicare Shared Savings Program (MSSP) unless CMS changes course and allows them to be eligible for MARCA’s advanced alternative payment models (APMs) system.

The survey from the National Association of ACOs (NAACOS) collected responses from 144 ACOs about their MACRA concerns, operational costs and willingness to take on downside risk.

On MACRA implementation, the survey asked ACOs the likelihood of them leaving MSSP Track 1 if the proposed rule isn’t changed to allow organizations in the track to receive the 5 percent APM bonus. More than half (56 percent) said they would, while 32 percent said they would stay. There was a noticeable difference in responses between single ACOs (61 percent said they’d leave, 23 percent said they’d stay) and multi-ACOs (42 percent said they’d leave, 56 percent said they’d stay).

“We continue to invest significant resources and were very disappointed in CMS's recent decision not to allow Track 1 ACOs for the 5 percent APM bonus,” said one respondent to the survey.

On costs, the survey found the average cost of running an ACO to be $1.6 million, with the majority of respondents calling those ongoing operational expenses to be “very significant” (51 percent) or “significant” (36 percent). Broken down by category, the biggest average expense was clinical and care management, at more than $640,000 per year.

Again, there was a big difference between estimated costs for single and multi-ACOs, with the latter’s average annual costs ($974,000) being less than half the former’s ($1.9 million).

This split between types of ACOs was also present when respondents were asked what they would do if CMS required them to take on downside risk. Overall, 43 percent of ACOs said they would leave MSSP under those circumstances, with 33 percent saying they’d continue to participate. Single ACOs were more likely to say they’ll exit the program (47 percent versus 20 percent who would stay) than multi-ACOs (32 percent said they’ll leave versus 66 percent who would stay).

Without any CMS requirements, most respondents (84 percent) said they’d be prepared to take on downside risk or share losses within the next six years.

The overall conclusion of the survey was ACOs want more “supportive policies” than what CMS is currently offering.

“Although the ACO model holds great promise, recent policy decisions could significantly undercut the ability of ACOs to flourish individually and collectively,” said NAACOS CEO Clif Gaus. “Sadly, the survey findings in this report indicate that many ACOs are under enormous pressure from the significant operational investments combined with unfavorable policies. Should policies remain on the current trajectory, this model may decline over time leading to the end of ACOs as we see them today.”