- Accountable care organizations are less likely to leave the Medicare Shared Savings Program after their third year in the program, according to a new study published in the May issue of Health Affairs.
- Some 30% of all MSSP ACOs exited within the first five years of the program, mostly midcontract, the study found. Of that, 4% exited in their first year, 9.5% in their second year, 20.7% in their third year, 10.6% in their fourth year and 11.2% in their fifth.
- Factors contributing to longer ACO survival in MSSP included shared-savings bonus payment achievement, higher financial performance benchmarks, more care coordination, lower-risk patients and contracts with upside-only risk where the ACO's don't have financial skin in the game, in line with previous research finding the move to downside risk drives ACOs from the program. Quality measures did not correlate with ACO longevity.
ACOs are key agents of the shift to value-based care and are associated with a suite of positive results, including lower costs, lower hospital readmissions and higher patient satisfaction scores. According to some estimates, there are roughly 1,000 in the United States, covering over 32 million lives.
CMS credited MSSP with saving $314 million overall to the Medicare Trust Fund in 2017.
One issue that's holding back ACO success, however, is the switch from upside to downside risk, according to experts. A National Association of ACOs study last year found nearly three-forths of ACOs would leave MSSP in 2019 if forced to assume financial risk.
In December, CMS finalized a rule that cut the time ACOs had to avoid risk in half: from six years to two years for new ACOs and three years for new low-revenue ACOs. The rule also injected increased flexibility into the program, including new beneficiary incentives and telehealth services.
"These policies may present challenges to providers who want to participate in this important, yet voluntary, Medicare program," National Association of Accountable Care Organizations CEO Clif Gaus said in a statement about the change. "There needs to be a movement toward greater risk, and that movement requires an appropriate and reasonable glide path to encourage participation and success."
The Health Affairs study, which looked at MSSP enrollment for 624 ACOs between 2013 and 2017, seemed to agree, finding that "while new flexibilities for low-revenue ACOs likely reduce uncertainty for some, MSSP ACOs may need more than the new period of one to three years to prepare for downside risk" — bolstering previous studies finding experience is a key factor in ACO success.
Researchers also found ACOs with "little fat to trim" were more likely to exit. This includes high-performing organizations with low benchmarks and existing ACOs that improved and dropped their benchmarks. Additionally, ACOs with sicker patients were also more likely to leave MSSP, prompting a need for further research, the authors of the study concluded.