MSSP accountable care organizations share key priorities and challenges

In the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) prioritize annual wellness visits, care transitions, and clinician engagement, as Medicare Advantage growth causes recruitment challenges.

MSSP is the largest ACO model and has been operating for over ten years. Past data has suggested that the program leads to modest improvements in care quality and healthcare spending for Medicare beneficiaries. However, some stakeholders have raised concerns about adverse patient selection, inadequate risk adjustment, and unreasonable benchmarking incentives.

Researchers conducted interviews with 49 ACO leaders between September 29 and December 29, 2022, to understand their priorities, strategies, and challenges they faced. Among the 49 ACOs, 34 were hospital-associated, 35 were medium or large, and 17 were rural.

The interviews revealed that ACO leaders focused on three key initiatives: annual wellness visits, coding practices, and care transitions. Increasing annual wellness visits was a common priority, with leaders describing the visits as an opportunity to engage patients, identify their needs, and provide evidence-based preventive care.

Enhancing coding practices can help capture the clinical complexity of patients. This focus may be tied to changes in MSSP financial benchmarking in which an ACO’s per-beneficiary costs are compared with costs for other Medicare beneficiaries in the area.

ACO leaders reported investing in care management programs that improve the flow of patients across care settings. These programs facilitate care transitions through medication reconciliation efforts, post-hospitalization phone calls, and early post-hospitalization primary care visits.

Another theme highlighted in the interviews was how ACOs engage clinicians through relationship-based and metrics-based strategies. Many ACOs implemented dashboards for clinicians to view their performance on quality and cost measures. ACO leaders also emphasized the importance of personal relationships when engaging clinicians in programmatic efforts. Some leaders at smaller ACOs regularly visited practices and met with clinicians to discuss new initiatives and strategies.

When distributing savings to their organizations, most ACO leaders reported distributing at least 50 percent of savings to participating practices. Many respondents said payments were based on the number of attributed patients, while others reported trying to link payments to quality performance and clinician engagement.

Most ACOs distributed savings to practices rather than individual clinicians. Practices were generally allowed to use the savings as they saw fit, with ACOs offering examples of where to invest them.

Market competition influenced recruitment and retention strategies, the ACO leaders shared. Some leaders cited health system consolidation and Medicare Advantage growth as barriers to MSSP participation. One respondent said retaining sufficient numbers of Medicare fee-for-service patients in their ACO was difficult because beneficiaries were increasingly moving to Medicare Advantage plans.

ACO leaders said they sometimes tried to increase ACO participation by mentioning that practices could avoid the Merit-based Incentive Payment System (MIPS)—which comes with high administrative burdens—by joining an ACO.

Hospital-associated ACOs reported misaligned incentives, including one leader who noted that improving care quality is usually universally agreed on but reducing utilization is not. Another leader said aligning incentives was possible but primarily as a way to change the hospital’s payer mix and reduce the number of Medicare patients.

Other hospital-associated ACOs said including a hospital in an ACO could boost investments in quality improvement processes. In addition, hospitals can facilitate care transitions before and after hospitalizations and improve ACOs’ ability to communicate with inpatient care management teams.

The findings suggest that researchers should study the benefits and outcomes of the common practices and initiatives that MSSP ACOs are focused on.

“As CMS continues to refine the ACO program and introduce new opportunities for clinicians and healthcare organizations to engage in value-based payment, it may benefit from an understanding of the priorities, strategies, and challenges of ACO leaders, as well as how the incentives embedded in national policy manifest on the front lines of care delivery,” the study concluded.