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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.
CMS should find ways to accommodate legitimate risk score increases and adjustment to the benchmark while protecting against excesses. The current CMS policy is in reaction to what was perceived as excessive risk coding in the Medicare Physician Group Practice Demonstration.17 However, the policy pendulum has swung too far in the other direction in the current ACO rules by not allowing modifications to the benchmark except in 1 direction unfavorable to ACOs.
Medicare Program Integrity and Recovery Audit Program organizations should collaborate more closely with ACOs on identifying and responding rapidly to emerging patterns and outliers in Medicare billing that may reflect overuse or misuse of Medicare resources. The combination of claims analytics and clinical insights into individual patients by ACO providers can be a powerful and untapped resource to reduce fraud, waste, and abuse in the Medicare Program.
State and federal regulators can encourage and enforce expectations that hospitals share ADT event notifications with patients’ primary care providers via health information exchanges where operational. For example, Florida’s 1115 Managed Medical Assistance Waiver Demonstration Program requires hospitals receiving “Low Income Pool” funds to participate in the Florida Event Notification program.18
Finally, current site-based reimbursement policies create artificial arbitrage opportunities and encourage hospital consolidation and lower market competition. Site-neutral payments, as advocated by the Medicare Payment Advisory Commission,19 should be expanded to existing arrangements, as well as the prospective limitations introduced by MACRA.
We have learned that, given the right support and incentives, independent primary care practices can embrace population health and practice redesign. These efforts can begin to bear fruit in improved patient access, quality of care, and appropriate utilization in the short term. We strongly believe that the benefits of the program to patients and the taxpayer are not limited to those ACOs that received shared savings distributions. However, lack of recognition of these contributions may stifle continued innovation and physician engagement with alternative payment models. Aledade is committed to navigating these challenges and we are committed to sharing our learning so that more independent physician-led ACOs can succeed in their mission to profitably deliver better care at lower cost. We also hope that policy makers and commercial payers continue to work to remove the unintended policy headwinds ACOs must presently overcome.
The authors first acknowledge the 84 independent PCPs who led the ACO efforts. They also acknowledge Dr Mark McClellan, Dr Bob Kocher, Edwin Miller, Mat Kendall, Laura Chmar, Dr Emily Maxson, Dan Bowles (executive director, Aledade Primary Care ACO), Ahmed Haque (executive director, Aledade Delaware ACO), and Alexander Wess for their editorial inputs and their contributions in guiding the ACOs.

Author Affiliations: Aledade, Inc (FM, TB), Bethesda, MD.

Source of Funding: None.

Author Disclosures: Mr Broome and Dr Mostashari are employees of Aledade, Inc, as the policy lead and CEO, respectively. Over the last 12 months, Dr. Mostashari has received honoraria or lecture fees for speeches/conference attendance at events organized by: Maine Medical Center, Indiana Primary Care Association, TriZetto Corporation, National Association of Children's Hospitals and Related Institutions, American College of Chest Physicians, Accountable Care Learning Collaborative, and Medhost.

Authorship Information: Concept and design (FM); acquisition of data (TB); analysis and interpretation of data (TB, FM); drafting of the manuscript (FM); critical revision of the manuscript for important intellectual content (TB, FM); statistical analysis (TB, FM); and supervision (FM).

Address Correspondence to: Farzad Mostashari, MD, ScM, Aledade, Inc, 7315 Wisconsin Blvd, Suite 1000E, Bethesda, MD 20814. E-mail:

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