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ACOs increasing their participation in downside risk contracts, study says

Study suggests that while ACOs are willing to accept increased financial risk, they are still learning how to manage populations.

Susan Morse, Managing Editor

Despite uncertainty over the direction of federal healthcare policy, a new study has found that a large number of accountable care organizations are participating, or are considering taking part in risk-based contracts.

An estimated 47 percent of ACOs are planning for shared savings or shared risk, and 38 percent for capitation, according to the first Annual ACO Survey by the National Association of ACOs and Leavitt Partners, published in Health Affairs.

[Also: Medicare Shared Savings ACOs saved $1 billion over 3 years, report says]

The study also found that care management strategies remain largely unchanged.

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This suggests that while ACOs are willing to accept increased financial risk, they are still learning how to manage populations.

[Also: ACO tools have lukewarm effect on cost savings, improvement in care quality, Health Affairs study says]

Nearly 90 percent of survey respondents had at least one upside-only shared savings contract. But half were in contracts that included downside risk.  Shared savings or losses represented 38 percent of contracts in downside risk, while 12 percent were in capitation.

While the number of capitated agreements remain low, the adopted of other risk contracts has increased in recent years, according to the study.

[Also: MACRA is pushing ACO growth, says new Health Affairs study]

The adopted of risk varied by type of ACO ownership. Physician-led ACOs were less likely to take part in downside risk than hospital-led and integrated ACOs.

But physician-led ACOs said they were planning to adopt two-sided shared savings contracts.

The survey did not give a reason for physician willingness, or whether it could be related to the challenges of the merit-based incentive payment system, MIPS and advanced alternative payment model payments under the Medicare Access and CHIP Reauthorization Act.

But ACOs of all types said they were considering or had firm plans to participate in at-risk arrangements, which could be influenced by the Medicare Shared Savings Program participation requirements for downside risk, the new risk options under ACO Track 1+, bonuses under MACRA for MSSP Tracks 1, 2 and 3, and Next Generation ACOs. The survey was sent to all known ACOs nationwide, including participants in Medicare, commercial and Medicaid programs from January to April.

About a quarter, 240 ACOs responded, with Medicare ACOs representing more than three-quarters of respondents.

The Medicare ACO contracts had about the same levels of risk as commercial and Medicaid arrangements, but fewer lives, about 30,000 compared to 60,000.

A little more than half of ACOs, 53 percent, reported bearing the same levels of financial risk in their commercial and Medicaid contracts as their accountable care contracts with Medicare, the study said. One-quarter, 26 percent, reported less commercial and Medicaid risk, suggesting that commercial and Medicaid plans are not pushing provider-born risk faster than the Centers for Medicare and Medicaid Services.

"This is likely a function of the flexibility and variability of commercial and Medicaid contracts. When programs are optional, and often subject to negotiation, risk levels may remain low," the study said.

Twitter: @SusanJMorse
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