Profiling ACO Success: At a Glance
Leveraging CareJourney’s 100% Medicare Fee-for-Service claims dataset, we analyzed available MSSP performance results from the last three years (2017 – 2019). We evaluated over 200+ cost, utilization and quality metrics paired with total and per capita generated savings from over 450+ ACO participants. In order to sift through all of this data, we created a quintile of savings for ACOs with full year participation in 2019.
Figure 2: CareJourney 2019 MSSP Performance Results Analysis: ACOs Quintiled by Total Savings per Beneficiary
Note that this analysis is based on total savings per capita (benchmark minus expenditures) versus shared savings earned by the ACO. In 2019 74% of ACOs generated savings for Medicare FFS, but only 55% earned savings back as part of their unique risk sharing formula. By using total savings instead of earned savings as our “KPI”, we were able to control for outside factors that impact an ACO’s “take home” value; such as quality score, risk model, savings rate etc. This allowed us to profile ACOs based solely on their savings performance in the program, and seek to understand “All Stars” through claims behavior.
- Experience in MSSP: ACOs with higher savings per capita participated longer in MSSP
- High vs Low Revenue: 73% of ACOs in the top quintile of savings per capita are low revenue organizations
- Risk Type: The top tiers of ACOs based on savings per capita had a higher prevalence of taking on downside risk, relative to the lower tier ACOs that were almost exclusively upside only
Figure 3: CareJourney 2019 MSSP Performance Results Analysis: ACOs Quintiled by Total Savings per Beneficiary
As you can see in Figure 3 above, on average top performing ACOs have participated in the program 29% longer than their peers with the lowest savings. This is consistent with what’s observed in the industry as it can take time to navigate, implement and realize the return on various care reform initiatives.
In addition, 73% of top performing ACOs are low revenue, which is consistent with CMS findings, and noted as their reason to create the high and low revenue designations for Pathways to Success: ‘Further, we have observed that low revenue ACOs (which are typically composed of physician practices and rural hospitals) outperform high revenue ACOs (typically ACOs that include hospitals). However, participation in performance-based risk Tracks remains modest, and some low revenue ACOs lack a pathway to transition from a one-sided model to more modest levels of performance-based risk.’3 Conversely, we found higher rates of both low revenue ACOs and two-sided risk models in top quintile ACOs.
Finally, within ACOs that had lower savings, we identified fewer with downside risk models. This could be correlated to an ACOs maturity in the program: ACOs that continue to participate year over year may gradually take on more risk as they refine their strategy. This is important in context of the new Pathways to Success program, as it shortens the length of time required for ACOs taking on risk from six years to two (high revenue) and three (low revenue) year.3
In our initial analysis, we were not able to identify associated trends by track type, quality score, patient Medicare cohorts or avg HCC risk score. However, this led us to dig a bit deeper into other areas that may influence success in MSSP, specifically cost and utilization of services.
Profiling ACO Success: Which expenditure categories contribute to high or low spend?
At a high level, we see that top performing ACOs on average spend 10% less per beneficiary than those who lost savings – this accounts for over $1,200 in spend per member per year (PMPY) in PY 2019. This trend remains consistent over the last three years of performance, 2017 – 2019. The top performing quintile not only continues to spend less overall, but we see similar trends in how spend is distributed across the Medicare expenditure categories: Part B, and Part A (inpatient, outpatient, home health, skilled nursing and hospice facilities).
Within Part A, it’s no surprise we observe ACOs with the most savings are spending less across facility services as seen in the table below. ACOs can play an important role when coordinating the right care in facility settings, and have shown to reduce overall facility expenditures in a given population.4 The greatest difference in spending from ACOs in the top quintile compared to their peers was at the SNF and outpatient setting; boasting an average of over 30% lower cost than those that did not make savings.
Within the SNF setting, ACOs set a precedent for their focus on coordinating high quality and low cost care, and is highlighted by CMS as a key strategy for success in value based care programs.5 As shown in the table below, ACOs in top quintiles have significantly lower SNF PMPY than those who did not make savings. This could be indicative of some active care coordination in transitions to post acute care. Additionally, we see a slight increase in Home Health utilization among the top cohorts, which could signal re-routing patients, where appropriate, to the home setting. Not only is home health usually less expensive, but it is often just as effective as caring for a patient in a hospital or SNF.6 This CareJourney analysis expands on trends in home health utilization, and what the future of home health may look like in a post-pandemic world.