What the Latest ACO Numbers Mean for the Future of the MSSP

Last week, CMS Administrator Seema Verma reported that CMS approved the applications for 53 new accountable care organizations (ACOs) to join the Medicare Shared Savings Program (MSSP) starting on Jan. 1, 2020. But an industry expert is saying that number is actually much lower.

“In the CMS blog they cited 53 new ACOs in 2020 and we cite 35,” Allison Brennan, senior vice president of government affairs at the National Association of ACOs (NAACOS), recently told RevCycleIntelligence in an interview.

The 18 remaining ACO applications are not truly “new” to the program, Brennan continued. These ACOs were in the MSSP before and are now reentering the program despite their new start date of Jan. 1, 2020. Some of these organizations have even participated in two performance periods in the past.

According to the federal regulation, re-entering ACOs have either participated in the MSSP before but their participation agreement expired or was terminated or have never participated in the MSSP but more than half of its ACO participants have been part of the program in any of the five most recent performance years prior to the agreement start date.

Administrator Verma included the 18 ACO applications that fit this definition in her tally of organizations entering the program. But NAACOS doesn’t consider the organizations new, and the group expressed concerns over the declining number of new ACOs entering the program since CMS overhauled it.

“We were disappointed with the numbers in terms of the new ACOs entering into the program, which is a much lower number than we used to see in previous years,” Brennan stated. On average, the MSSP has seen approximately 100 new ACOS a year.

“That may be challenging to maintain 100 new ACOS a year, but we’re seeing that number dramatically fall in 2019 and in 2020,” Brennan explained.

Last year, roughly 40 new ACOs entered the MSSP, according to a NAACOS analysis of 2019 program data.

“We had some initial concerns when we saw the 2019 participation numbers which were lower than usual, but we also recognize that it was an unusual year with an off cycle start time in July,” she said. “But seeing these numbers in 2020 being equally as low, that reinforces the need to take a closer look at this program so that providers know what to participate and continue on this path to value, which is a priority of the administration and for Congress.”

New ACOs may be hesitant to join the recently overhauled MSSP. Starting last year, ACOs in the program were put on a faster path to downside financial risk, with the general amount of time an organization can stay in an upside-only track decreasing from six to two years. The overhauled program also has a lower shared savings rate for upside-only ACOs compared to similar tracks in the MSSP.

“CMS officials have noted that ACOs that are forced into risk will generate greater savings for the program. I question that logic because in a voluntary program if an ACO is not ready to take on risk, then it will not stay in the program and generate greater savings. It will quit the program and not generate any savings,” Brennan asserted.

To counter lower participation rates, Brennan advised CMS to address these challenges.

“We have a number of policy recommendations we would like to see to the MSSP,” she said. “Some of those start with addressing challenges with the Pathway to Success final rule, so increasing the shared savings rate and allowing ACOs more time in the program before they assume risk. Additionally, change the risk adjustment methodologies to allow risk scores to increase over time to ensure benchmarks are accurate and fair and reinstate CMS funding to help ACOs start. Those funding opportunities provide an upfront funding which would later recoup from shared savings generated.”

These changes will hopefully boost participation in one of value-based care’s most influential programs and bring more providers and patients under the value-based umbrella. But without the right balance of rewards and requirements, then ACOs are going to pass by or exist the MSSP, returning to the fragmented care system of fee-for-service, Brennan stated.

“We just have so much room to grow,” she concluded. “We have seen positive results from ACO programs. The programs cover around 12 million Medicare beneficiaries. So, that’s a little over 11 million in MSSP for this year, and then a little over a million in the Next Gen program. That leaves 27 million traditional Medicare beneficiaries who aren’t in ACOs. There isn’t a saturation of ACOs right now, and there is room where we can continue to grow.”