More ACOs Than Ever: Medicare Shared Savings Program Swells in 2018

Though the program and its savings have steadily climbed, CMS released participant data without fanfare.

There are more accountable care organizations (ACOs) participating in the Medicare Shared Savings Program this year than ever before.

The Centers for Medicare and Medicaid Services released data online this month, listing 561 ACOs and 10.5 million assigned beneficiaries for performance year 2018—up from 480 ACOs and 9 million beneficiaries in 2017.

Despite MSSP’s sustained growth in both size and performance payments earned, this year’s participant numbers were released quietly, and a spokesperson for CMS declined to arrange an interview to discuss the program’s apparent success.

But representatives from many of the ACOs taking advantage of the program this year were eager to tell HealthLeaders Media about their efforts to improve quality and cut costs.

“From our perspective, we are looking to help hospitals and clinicians improve the quality of care they provide and do it in a sustainable way that supports their business needs,” says Tim Gronniger, MHSA, MPP, a former CMS official in the Obama administration and current senior vice president of development and strategy for Caravan Health, based in Kansas City, Mo.

Caravan Health, which has worked with hospitals to build MSSP ACOs across the country, added 15 ACOs this year to the 23 it already had. The expansion reflects Gronniger’s confidence in MSSP’s utility and durability moving forward.

That confidence endures despite uncertainty last year over how the Trump administration might seek to change the Medicare Access and CHIP Reauthorization Act (MACRA) and Merit-based Incentive Payment System (MIPS).

“You know, Tom Price has come and left, and MACRA is still standing, and the Innovation Center is still churning out models, and we still see a pretty strong push for value from the government but also an organic desire from the health industry to continue finding ways to improve,” Gronniger says.

“So I think that some of the uncertainty that was there in 2017 with the new administration, I think a lot of that has disappeared, and there’s a clear direction that MACRA is staying and that there’s still really strong financial reasons to be in an ACO, even apart from all of the clinical and patient experience sides of things.”

Assisting, protecting physicians

One of the financial reasons to consider joining an ACO is that CMS gives them preferential treatment under MIPS, Gronniger says.

“We see a lot of hospitals that are using this program to protect their physicians in their clinical networks from penalties under the MIPS program, using it as an opportunity to embrace their physician networks,” Gronniger says. “There’s certainly also revenue-generating opportunities and shared savings, but that’s usually like a secondary issue for a lot of the providers we work with.”

Gronniger served as CMS deputy chief of staff until the end of the Obama administration, but that hasn’t stopped him from criticizing some of his own team’s work product.

“I am no fan of the MIPS program, even though I helped to write the rules for it,” he says. “I think there are a lot of problems with the MIPS program. One of the benefits of an ACO is that it takes you out of the worst elements of the MIPS program, honestly. I think that the MIPS program, as it’s currently constituted, is burdensome for clinicians and that it can’t really be easily repaired.”

Gregory M. Whisman, MD, serves as chief medical officer for OhioHealth Venture LLC, a new MSSP ACO that serves OhioHealth’s employed physicians group and independent practices that are part of the system’s clinically integrated network.

Before OhioHealth Venture was formed, many of OhioHealth’s employed practices were part of Comprehensive Primary Care Plus (CPC+), meaning they were already part of an advanced alternative payment model (Advanced APM) that kept them prepared, Whisman says. Small practices, however, were feeling the strain.

“On behalf of the independents,” Whisman says, “there was a lot of angst because there was a lot of reporting that had to go into MIPS if they were doing it on their own: how they were going to get their data out of their systems or out of their patient charts, certainly the risk of losing money and losing payments if they weren’t on an electronic record already, and then also being compared across practices to large groups, such as employed groups that had the economies of scale that smaller practices didn’t have.”

With the MSSP ACO model, physician offices are empowered to learn from each other, says Shannon L. Ginther, JD, OhioHealth Venture’s chief operating officer.

“These doctors are every day seeing patients, seeing patients, trying to keep the doors open. So the idea of participating with another group they can learn from and access some resources, I think, is part of it as well,” Ginther says.

Incentivizing risk with bonus payments

Avalere Health, based in Washington, D.C., released updated research on the financial benefits of a new hybrid risk model made available to MSSP ACOs this year: Track 1+.

By analyzing data from performance year 2016, Avalere reached the conclusion that participants would benefit from taking on a limited amount of financial risk under the model, which would make them eligible to qualify for 5% bonus payments currently offered under the Quality Payment Program (QPP) to Advanced APMs.

“As they take on more risk, Medicare beneficiaries should see their providers doing more to keep their patients healthy,” said Avalere Senior Vice President Josh Seidman, in a statement.

Regardless of its potential benefits, only 10% of MSSP ACOs are taking part in the Track 1+ model this year. The non-risk based Track 1 model remains the most popular, with 82% of ACOs participating.

Yvonne Ketchum-Ward, CEO of Boise-based Community Health Center Network of Idaho, oversees one of those non-risk based Track 1 ACOs.

Her program serves federally qualified health centers that treat populations with a high rate of uninsured patients—all of whom receive care, regardless of their ability to pay. The real benefit of MSSP is in its reliable data, informational websites, and personnel who walk participants through their expectations, she says.

“There’s a lot of infrastructure that you have to have in place to go into these arrangements, and the payment doesn’t come until a year-and-a-half after you do the lift. So you do the work with the potential that a payment will come a year-and-a-half from now,” Ketchum-Ward says. “If the motivation is purely financial, you’re not going to be successful.”

Participant data for the much-smaller Next Generation ACO Model, which builds upon MSSP, were released Thursday. It, too, showed an increase in participants, moving from 45 ACOs in 2017 to 58 this year.