In federal ACO programs, advocates see signs of slow but steady progress

Growth in accountable care organization (ACO) programs has been inconsistent since the Affordable Care Act made accountable care part of the healthcare lexicon in 2010.

Nonetheless, proponents are optimistic about the state of ACOs and their potential in upcoming years, even if there’s uncertainty about CMS’s ability to achieve its stated goal of ensuring every Medicare fee-for-service beneficiary is in an accountable care relationship by 2030.

Reaching that milestone is “probably going to require additional changes from Congress to make sure there are strong enough incentives [for providers] to be in those risk programs,” said Tim Gronniger, executive vice president for accountable care with Signify Health. “I think we’re headed in the right direction. One hundred percent is a big number.”

Anticipating bigger steps forward

CMS’s latest metrics on its ACO programs don’t shed much light on the feasibility of attaining the 100% goal.

Progress in the core federal ACO model, the Medicare Shared Savings Program (MSSP), stalled between 2022 and 2023. The number of participating ACOs fell from 483 to 456, while the number of assigned beneficiaries slipped from 11 million to 10.9 million.

The peak for MSSP participation was 2018, when there were 561 ACOs in the program. The National Association of ACOs (NAACOS) notes that an ensuing update required participants to take on downside risk more quickly, a change that tempered enthusiasm among providers. However, some of the more recent stagnation can be attributed to participation in the new ACO REACH (Realizing Equity, Access and Community Health) model, which includes 132 entities this year.

In addition, recent changes to the MSSP are expected to bolster the numbers in upcoming years.

“We expect 2023 to be a turning point for ACOs and growth in participation to really accelerate in 2024,” Clif Gaus, ScD, president and CEO of NAACOS, said in a written statement.

The changes, which were codified going into 2023, include a longer glide path to taking on downside risk. In addition, a modified benchmarking system hinges less on a provider’s own past performance, thus removing an obstacle to consistently earning shared savings.

Gronniger pointed to the steady increase in MSSP participation since the program launched in 2012 with 220 ACOs and 3.2 million assigned beneficiaries. Moreover, he said, there has been notable growth “in terms of the sophistication of the ACOs serving those patients and their ability to really track and manage their care over the course of a year or multiple years.”

Raising the stakes

Gronniger also is keeping an eye on ACO REACH, a first-year model with heightened risk and reward from a contracting standpoint. It’s a modified version of the Global and Professional Direct Contracting (GPDC) Model, which was terminated in 2022 amid various stakeholder and policymaker complaints, including about the potential for conveners such as private-equity entities to excessively profit from the model’s risk adjustment mechanism.

ACO REACH resembles more of a traditional ACO model while retaining components of the GPDC program. A distinctive aspect is its focus on health equity, including a push to bring accountable care to underserved areas. Among the equity-oriented features are requirements for participants to produce a health equity plan and to collect pertinent beneficiary data. The model also includes a health equity benchmark adjustment.

Looking forward, REACH creates opportunities for policymakers to derive and disseminate lessons on accountable care best practices, Gronniger said.

Whereas the MSSP is a core Medicare program, REACH is a pilot of the Center for Medicare & Medicaid Innovation (CMMI). One purpose of CMMI models is to “test out different approaches to financing, to regulatory requirements, to care models,” Gronniger said.

REACH is “definitely important in serving that point,” he added. “Just by virtue of existing and testing out a number of potentially useful new cash-flow mechanisms like capitated structures, network discounts — I think that’s all to the good.”

The MSSP similarly has benefited from lessons gleaned from CMMI’s ACO Investment Model, which closed in 2018 and was designed to support low-revenue or rural MSSP participants via upfront payments. As part of this year’s changes to the MSSP, such payments are available for addressing social needs in an ACO’s patient population (among other expenditures).

Secrets to success

Gronniger was president and CEO of Caravan Health before moving to Signify in early 2022 following the latter company’s purchase of Caravan, which supports providers in population health initiatives such as ACOs. (Signify’s acquisition by CVS Health for $8 billion in September 2022 is awaiting regulatory approval.) He also has a stint as CMS’s director of delivery system reform on his résumé.

With that background, Gronniger has garnered key insights into what separates successful ACOs from those that struggle.  

“The first thing is really being intentional about tracking your patients and their needs,” he said. “You don’t know their full set of issues until you get them in and assess them and do an annual wellness visit — identify the problems they’re having, document them, document quality-measure gaps and close them out, refer [patients] for tests that they need.”

From there, providers need to take on the responsibility of “more intensively managing” patients. Patient engagement is vital, even for as basic a reason as increasing the likelihood that patients answer calls from their physicians because they recognize the caller ID.

As an example of taking engagement to another tier, Gronniger said, “We’ve had some success with an SMS texting pilot [that uses] a semi-automated approach where, every day, we will send patients with pulmonary disease a text just basically asking how you’re feeling.”

Patients can text back “1”to indicate they’re well and “2” to signal that they’re struggling with their breathing or other symptoms. In the latter scenario, a set of response protocols is activated.

“There’s a variety of ways to [operate an ACO], all organized around different patient needs,” Gronniger said, “but it also evolves over time as new technologies emerge and we get better at organizing our products and services in terms of what we can help patients with.”