The Annual ACO Roster Building Checklist:
Top 10 Considerations to Drive Success

Spring marks the opening of the annual window for Accountable Care Organizations (ACOs) to curate their roster of provider participants for the upcoming performance year (PY). Medicare Shared Savings Program (MSSP) ACOs have from May 20, 2024 to June 17, 2024 to submit their roster of TINs for PY2025, while Realizing Equity, Access, and Community Health (REACH) ACOs have from June 3, 2024 to August 1, 2024 to submit their roster of Individual Practitioners, Facility or Institutional Providers, or Organizational providers for their PY2025 Provider List (according to program portal documentation). (Note: NPI, TIN or facility level providers are collectively referred to as ‘providers’ going forward.)

An ACO’s provider roster determines the patient population the ACO is accountable for, the financial budget the ACO is assigned, and ultimately the ACO’s ability to achieve savings. These are foundational details. Therefore, when evaluating providers to add to an ACO roster before these windows close, it’s critical to be informed with the most accurate assessments of performance.

Specifically, these key questions drive successful decision making:

1. What is the provider’s expected attributed volume?
ACOs need a reliable projection of attributed patient volume for planning purposes, and must understand how that volume is spread across providers or TINs to inform resource allocation and financial modeling. ACOs cannot rely on historical panel size to estimate volume; rather, plurality of Evaluation & Management services must be calculated for reliable volume estimations. For MSSP, ACOs should also compare attributed volume projections under prospective and retrospective alignment methodologies to inform their beneficiary assignment methodology.

2. What is the provider’s risk score?
Having a financial budget that accurately reflects the clinical complexity of a provider’s patient population is critical for sustainable success in value based care (VBC) models. An ACO should evaluate the provider’s average risk score and compare the prevalence of captured and recaptured HCCs among their population to peers – identifying whether there are opportunities to close gaps in coding and documentation. ACOs should also understand the provider’s growth in risk score year over year, and the impact the provider may have on the organization’s overall risk score and likelihood of hitting the risk score cap. Comparing rates of annual wellness visit (AWV) compliance and primary care visits help identify avenues to improve risk score capture.

3. What will be the impact of adding or dropping the provider on the ACO’s financial benchmark?
An ACO’s financial benchmark is driven in part by their provider participants’ historical spend relative to regional spend. Adding providers who are more efficient than their respective regions could have an unfavorable impact to an ACO’s historical benchmark, and vice versa. Across the country, different geographical areas have produced varying trends in utilization, and it’s critical to understand a provider’s risk-adjusted spend relative to their geographic region to quantify the impact to an ACO’s budget. As discussed previously, a providers’ risk score and growth in risk score year over year also have implications for financial benchmarking.

4. How does the provider’s utilization and risk-adjusted spend compare to the region and to peers?
In addition to quantifying the overall impact a provider could have on an ACO’s financial benchmark, it is important to assess their performance on cost efficiency levers relative to peers. This allows the ACO to understand why the provider is more or less efficient, as well as what can be sustained or improved going forward. For example, how does the provider compare to peers on inpatient admissions, ER visits, post acute care utilization, ambulatory spend, primary care utilization, Part B drug spend, and other process and outcome metrics? Answering this question enables the ACO to make informed decisions about roster selection and gainsharing terms.

5. What is the provider’s churn rate?
Year over year, providers lose attributed Medicare Fee-for-Service (FFS) patients because they enroll in Medicare Advantage, see other providers, forgo follow up, or pass away. Understanding a provider’s drivers of churn – including their volume of new patients seen – enables more accurate financial planning and helps ACOs establish infrastructure to mitigate churn, such as implementing tools for patient engagement generating lists to target for AWVs.

6. What is the provider’s patient profile?
Beyond the provider’s risk score, it’s critical to understand the disease burden and historical utilization patterns of a provider’s patient population to ensure proper infrastructure to manage their patients’ conditions. Understanding which episodes are commonly triggered and the drivers of acute exacerbations helps shape the ideal high value network of specialists to put in place for an ACO’s aligned patients.

7. Which specialists should the ACO add to the roster?
If their risk score accurately reflects patient acuity, the addition of specialists to an ACO’s provider roster can significantly increase an ACO’s financial benchmark, as well as drive care improvement and financial savings through aligned incentives. To identify the specialists with the highest value (or highest potential for cost reduction), ACO’s should evaluate specialists’ performance in clinically relevant episodes of care, and consider adding specialists based on their ability to manage chronic conditions and avoid high cost interventions. ACO’s should also consider the specific burden of disease of their patient population and ensure specialists have tools to manage patients in partnership with longitudinal care providers.

8. How will the addition of the provider impact the ACO’s low/high revenue status?
In MSSP, low-revenue ACOs benefit from some added flexibility, such as the ability to share in savings even if their savings rate falls below the minimum savings rate (MSR). Low-revenue designation is also required to be eligible for Advance Investment Payments or to qualify for the new Primary Care Flex Model. The addition of hospitals, Federally Qualified Health Centers or Rural Health Clinics to an ACO’s roster could change the ACO’s revenue designation from low to high.

9. What is the provider’s past experience in ACO models?
Understanding how a provider previously performed in an ACO model and the drivers of their success (or lack thereof) ensures the ACO has in place the necessary infrastructure to support the provider going forward. If a provider has not previously participated in an ACO model, their historical performance should be simulated using the program’s pricing methodology to understand whether adding the provider might introduce unanticipated risks, such as the unexpected attribution of a cohort of patients or unfavorable performance compared to an abnormally geographical efficient region.

10. Does the provider have synergistic practice patterns with the ACO?
A sustainable provider recruitment strategy must consider whether a provider’s approach to accountable care will align with ACO’s, as well as what types of resources may be needed to achieve alignment. For example, if metrics such as transitional care management compliance, primary care visits per beneficiary, or flu shot compliance are important to the ACO, how does the provider perform in these metrics and what will be required to help them improve?

Beyond the quantitative considerations outlined above, ACOs also must evaluate whether there is a strong cultural fit with their potential provider partners. Full integration of a new provider group into an ACO can take months to years. The ACO should evaluate compatibility before investing significant resources to onboard a new provider. Example questions to ask include:

• What is the provider’s motivation for joining the ACO?
• What is the provider’s expectation around risk sharing, contract management, and use of standardized tools?
• What other risk contracts does the provider participate in?

On the other hand, ACO’s must also demonstrate to their potential provider partners the expected return on investment (ROI) associated with joining the ACO. To make this case, ACOs should articulate:

• How will the ACO’s infrastructure, tools, technology and other resources support the provider in achieving greater shared savings?
• How will the ACO enhance the provider’s ability to deliver high quality clinical care?
• How will the ACO track that projected ROI?

Whether you’re actively curating your provider roster during the annual open window period or looking to drive continuous improvement throughout the performance year, CareJourney analytics can help.