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The Opportunities and Challenges of the MSSP ACO Program: A Report From the Field
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The Opportunities and Challenges of the MSSP ACO Program: A Report From the Field

Farzad Mostashari, MD, ScM, and Travis Broome, MPH
This article provides a detailed description of a Medicare Shared Savings Program accountable care organization (ACO)'s actions and results, to increase understanding of the challenges and opportunities facing ACOs-particularly those comprised of independent practices.
ABSTRACT

In this article, we seek to provide the first detailed description of a Medicare Shared Savings Program (MSSP) accountable care organization (ACO)’s actions and results to help increase understanding of the challenges and opportunities facing ACOs, and in particular, those comprised of a network of independent practices. Whether ACOs have been successful in delivering value has been the subject of much debate and speculation. What has been missing from this discussion is a look at the program from the frontlines and those who are launching and running MSSP ACOs. We hope to fill that gap.
 
Am J Manag Care. 2016;22(9):564-568
Take-Away Points
  • Implementation of accountable care organization (ACO) strategies, such as quality improvement, care management, and management of care transitions, depend on different capabilities in health information technology and process improvement. 
  • The strategies of our physician-led ACOs successfully increase primary care utilization (and revenue), decrease lab and imaging costs, and decrease emergency department and hospital utilization and readmission. 
  • Achieving savings on the total cost of care takes time, but the benefits of the program to patients and taxpayers are not limited to those ACOs that received shared savings distributions.
The Medicare Shared Savings Program (MSSP) was founded in 2010 to create a vehicle through which doctors in the Medicare program could be paid more for delivering better outcomes at a lower cost, commonly called accountable care organizations (ACOs). The MSSP was established as part of a larger bipartisan movement to shift the delivery of healthcare in the United States from a fee-for-service to a value-based system—a movement that was reaffirmed most recently with the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
 
Whether ACOs have been successful in delivering value has been the subject of much debate and speculation.1,2 Missing from this discussion, however, is a look at the program from the frontlines and the voices of those running MSSP ACOs. We aim to fill that gap.
 
In June 2014, we launched Aledade, a company with the mission to help independent primary care physicians (PCPs) form and operate physician-led ACOs. We offer providers data analytics and user-friendly technology to promote seamless care, regulatory expertise, best practices shared by a national network of hundreds of doctors, and face-to-face practice transformation support. Since our start, Aledade has formed ACOs in New York, Delaware, Maryland, Arkansas, West Virginia, Tennessee, Mississippi, Florida, Louisiana, Virginia, and Kansas, which collectively care for more than 100,000 Medicare patients.
 
The official results from CMS on the 2015 performance year were recently released,3 and CMS reported $429 million in total program savings. An increasing proportion of ACOs have generated savings above their minimum savings rate each year, and success appears to increase with the number of years in the program: increasing from 21% of first year ACOs to 42% of ACOs that were in their fourth year.3
 
There were 2 Aledade-initiated ACOs in the 2015 class. Based on CMS public data,4 the “Aledade Primary Care ACO” (APC) (with practices in Maryland, New York, and Arkansas) was in the 98th percentile of quality scores across all 327 ACOs that began in 2012 to 2014,5 but essentially broke even, with 0% savings and 0% cost increase. The “Delaware ACO” quality scores were in the 88th percentile, with a calculated cost increase of 2.5%. 
 
In this article, we seek to provide the first detailed description of an MSSP ACO’s actions and results to help increase understanding of the challenges and opportunities facing ACOs, particularly those comprised of a network of independent practices. We will first provide the context of what the ACO implemented, alongside the impact reflected in the CMS final reconciliation reports for 2015. Use of the monthly claims and claims line feeds for more detailed investigation of our results will be the subject of a future article. We will conclude with lessons learned for ACO implementers and policy makers.
 
Strategies
Patient engagement. Attribution is the CMS designation of which patients “belong” to each ACO. In the MSSP track 1 program, attribution is retrospective and is based on which PCP delivered more primary care services for a patient than any other PCP. We worked with practices to increase their availability and access to patients and to actively reach out to patients who had not been seen recently for annual wellness visits. Our hypothesis is that more intensive primary care should reduce more expensive specialty care and hospitalizations. Total primary care services received by our patients increased slightly in the APC and Delaware ACOs compared with national fee-for-service trends (by 2% and 5%, respectively).
 
As we had hoped, our ACOs were able to increase the number of patients attributed to the ACO. Our ACOs were also able to minimize the rate of patient “churn,” where accountability for a patient’s care shifts between primary care practices. The APC and Delaware ACOs saw increases of 5% and 15%, respectively, in the number of patients attributed to the ACO over the course of the year (vs 2% for the average MSSP ACO). Additionally, retention was high, with 87% and 88%, respectively, of patients who were preliminarily attributed to the ACO, based on last year’s data, being continuously enrolled by the end of 2015.
 


 
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