ACOs Edging Toward Downside Risk

The Trump administration’s push to get more Medicare Shared Savings Program (MSSP) ACOs to take on downside risk is having an effect, but there are still many nontakers.

According to tallies in an analysis published on the Health Affairs blog last month, 53% of the 139 MSSP ACOs that migrated out of the regular MSSP program last year into the administration’s Pathways to Success program took on downside risk. That makes sense because the Pathways program is designed to encourage ACOs to take on downside risk. But a greater proportion (309 out of 514, or 60%) of the MSSP ACOs stayed in the legacy program and only 17% of those ACOs took on downside risk.

Trump administration health officials — and a number of experts outside the administration — have argued that the ACOs will realize their value-base care potential only if they take on downside risk, the shorthand way of saying that penalties would be assessed if the ACO exceeds financial benchmarks.

The analysis was conducted by Mark McClellan, M.D., Ph.D., director the Duke-Margolis Center for Health Policy at Duke University, and his colleagues.

McClellan, who was FDA commissioner and CMS administrator during the George W. Bush administration, and his co-authors say cost and quality metrics for ACOs this year will be “muddled” because of the COVID-19 pandemic and uncertainty about the effects of the adjustments CMS has made in the program. They note, though, that the dire scenario of an exodus of ACOs because of the Pathway of Success rules didn’t happen last year