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WASHINGTON -- Are 66 new accountable care organizations (ACOs) in a year a sign of progress or a disappointing result? That depends on who you ask.

CMS that 66 additional ACOs joined the Medicare Shared Savings Program (MSSP) for ACOs in 2022, bringing the total up to 483 ACOs. However, that number is only six more than last year's total of 477 and 34 fewer than the 2020 total of 517.

The fact that 66 additional ACOs joined the program but the total number of ACOs only increased by six suggested that 60 ACOs left the program last year. Asked to clarify the issue, a CMS spokesperson confirmed in an email that "60 ACOs either terminated their agreement or completed their agreement and did not renew their participation in the Medicare Shared Savings Program." However, the spokesperson added, "while ACOs may have left the program, many practitioners treating patients have stayed with the program by joining a different ACO. Nearly two-thirds of the practitioners that made up the ACOs have moved into a different ACO, with 49% in Medicare Shared Savings Program ACOs and 16% in other ... ACO models."

"With one in every five healthcare dollars paid by Medicare, we can strengthen and transform our healthcare system," said CMS Administrator Chiquita Brooks-LaSure in a statement. "Accountable care organizations present an invaluable opportunity to move Medicare toward person-centered care." The agency noted that these ACOs will be serving approximately 11 million Medicare beneficiaries nationwide, up from 10.7 million in 2021.

ACOs are groups of doctors, hospitals, and/or other healthcare providers that work together with a goal of providing better care at a lower cost. Under the MSSP, ACOs share in the savings when the providers' cost of caring for the beneficiaries in the ACO falls below a prespecified benchmark. The MSSP offers several different options for ACOs in terms of financial risk; one option allows for only "upside risk" in which the plan shares in savings but not in any losses, while other options include a higher level of financial reward but also require ACOs to share in any losses that may occur.

The National Association of ACOs (NAACOS) was not impressed by the CMS announcement. "Following multiple years of flat or declining ACO growth, today's announcement is disappointing and should send a wake-up call to an administration whose goal is to have all traditional Medicare patients in an accountable care model by 2030," the organization . "There are still fewer patients in ACOs and ACOs in the program than there were in 2020." That year, according to a , there were 517 ACOs serving 11.2 million people through the program.

NAACOS has suggested several ways to improve the MSSP, including increasing ACO shared savings rates, fixing key benchmarking and risk adjustment issues, allowing more time before requiring risk, minimizing administrative burdens, and providing more timely and complete data.

A CMS spokesperson who was asked to comment further on the results said in an email that "[w]hile we recognize that there is still more work to do, CMS' commitment to increasing the number of health care providers in accountable care arrangements has never been stronger. CMS is listening to stakeholders to gather input on how to incentivize increased participation of ACOs in the Medicare Shared Savings Program and we look forward to the upcoming Shared Savings Program application cycle that will open this summer."

One possible reason that interest in the MSSP is flagging may be that ACOs and other entities are more interested in a new model called Direct Contracting, which is being introduced by the Center for Medicare & Medicaid Innovation at CMS. The Direct Contracting demonstration program offers three different types of direct contracting models, including "both capitated and partially capitated population-based payments that move away from traditional fee-for-service," according to a .

The program also tries to broaden participation to include "organizations new to Medicare fee-for-service, such as physician-managed organizations that currently operate exclusively in the Medicare Advantage program," according to CMS. These organizations, which could include physician-run ACOs, insurance companies, and health systems, would agree to provide care for a certain number of traditional Medicare beneficiaries in a geographic area for a set amount of money.

"Regardless of the growth in Direct Contracting, the lack of new participation in MSSP is gravely concerning," wrote David Pittman, senior policy advisor for NAACOS, in an email. "Yes, Direct Contracting will be growing Medicare's 'accountable care' footprint, but declining interest in MSSP -- the permanent, statutory ACO model -- needs to be addressed by CMS and Congress."

America's Physician Groups (APG), a lobbying organization for physician-run ACOs, also expressed concern about the MSSP enrollment. The results "were a mixed bag of promising trends and some areas of concern where things could potentially be improved," noted Valinda Rutledge, the group's executive vice-president of federal affairs, in an email.

"There are many APG members in MSSP, but many are considering making the jump to the Direct Contracting program due to these program elements that must be improved," she added. "Moving forward, it is important that the MSSP program not just seek to maintain stable growth but incentivize more participants into its risk-based tracks."

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