Analysis: ACO survey identifies top barriers to bearing risk

NAACOs recently released the results of its second annual survey of ACOs. A total of 201 respondents from a database of 1,011 ACOs responded making the findings instructive. 

The survey found that most respondents, 90%, were involved in a Medicare ACO with slightly over half in a commercial ACO. Less than 30% of respondents were in either Medicare Advantage or Medicaid ACOs. Not surprisingly, one-sided shared savings models remain the dominate risk arrangement. 

The survey also asked MSSP Track 1 participants to identify the three most significant barriers to bearing risk. The Health Affairs blog reporting the results states, “Respondents that reported being likely to stay in MSSP even if required to take downside risk selected ‘unpredictable changes to the ACO model’ as the top challenge. ACOs that were likely to exit the MSSP if required to take downside risk identified ‘too much risk is required’ as the top challenge. The more risk-averse respondents also reported a higher rate of concerns about their own past performance (40 percent) than the other ACOs (17 percent).”

Takeaway

A few thoughts about the results of the survey of ACOs:

1. Given that 32% of MSSP participants responding to the survey stated they will leave the program if they are forced to take risk, it will be interesting to see what happens to ACO participation numbers as organizations have to renew into risk-bearing models when their current MSSP contract expires.
2. Unpredictable changes in the model was the second-most frequently selected barrier chosen by those who were likely to exit the model and the most frequently cited barrier for those in the model. Given these models are still more or less policy experiments, any organization needs to enter into participation with the awareness that the contract they sign will likely change. While most of the time those changes are favorable to efficient providers (e.g. recent changes to the benchmarks), there’s a risk they won’t always be.
3. What this survey doesn’t pick up is why more organizations aren’t participating in these models. As policymakers wring their hands about why more organizations aren’t participating in downside-risk, they need to realize the financial terms of these models must reward participants for their significant investments in care management infrastructure. They also should know for healthcare organizations to make these investments in disrupting their existing business model, there needs to be a certain degree of program stability to instill confidence that these investments will have an opportunity to generate the necessary return.