By The Numbers: Medicare Continues Pushing Accountable Relationships
The Centers for Medicare & Medicaid Services (CMS) continues to advance its goal of having 100% of Medicare beneficiaries in an accountable relationship by 2030.
New statistics are in for Medicare’s accountable care programs and show 480 Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) and 122 Realizing Equity, Access and Community Health (REACH) ACOs for 2024. The two programs alone have close to 11 million Medicare beneficiaries. When adding in the Kidney Choices ACO model, the total is 13.7 million people in traditional Medicare (i.e.: fee-for-service) aligned to an ACOs. That’s a 3% increase over 2023 and represents roughly 21% of Medicare’s 66 million beneficiaries. If we were to consider and include Medicare Advantage plans (50%), CMS is then at 70% in “accountable” relationships. Let’s see what these new 2024 ACO statistics tell us.
2024 Numbers: Medicare Shared Savings Program (MSSP)
- There are 480 ACOs, up from 456 in 2023.
- There are 15,500 “participant” TINs with these ACOs. Those 15,500 TINs are comprised of well over 600,000 physicians, almost 1,500 federally qualified health centers, some 2,500 rural health clinics and over 500 critical access hospitals.
- Only 19 ACOs elected the advanced investment payment (AIP) option.
- A total of 273 (57%) elected one of the Basic tracks (A-E) with 207 (43%) in the Enhanced track.
- A total of 167 ACOs have elected to use the 3-day stay waiver with almost 2,500 skilled nursing facilities (SNFs) affiliates.
The MSSP has two options for participation – Basic and Enhanced. A total of 273 (57%) elected one of the Basic tracks (A-E) with 207 (43%) in the Enhanced track.
In terms of risk level, Basic A-B are considered upside or one-sided risk only. This means these ACOs can share in savings but will not face paybacks if their costs are too high. For 2024, 159 ACOs elected these one-sided risk tracks, or 33%. [Typically, newer participants or those gaining a bit more experience with value-based models start in these upside risk only options.] Of the 480, there are 321, or 67%, in any of the two-sided risk options. This means they share in any savings but also share in losses when ACO expenditures compared to benchmarks are too high.
| BASIC: LEVELS A-E | ENHANCED |
| A (upside risk only) = 54 | 207 (two-sided risk) |
| B (upside risk only) = 105 | |
| C (two-sided risk) = 5 | |
| D (two-sided risk) = 5 | |
| E (two-sided risk) = 104 |
Additionally, two-sided risk tracks (Basic C-E and Enhanced) are able to access various waiver opportunities, like bypassing the 3-day hospital stay for SNFs or broader telehealth flexibility. With respect to ACOs in these two-sided risk options, 167 will use of the 3-day stay waiver with 2,447 skilled nursing facility (SNF) affiliates.
Of the MSSP ACOs, 204 were high revenue while 276 are considered low revenue. Generically, higher revenue ACOs have been comprised of hospital/health system whereas low revenue ACOs tend to be associated more with physician practices. Beneficiary assignment – understanding the patients that attach to your ACO – is a lynchpin in ACO activities with 149 electing prospective assignment and 331 electing preliminary prospective with retrospective reconciliation.
Nineteen ACOs elected to use a new option called the “advanced investment payment” (AIP) which provides upfront funding from CMS. The funds must be used in the following general categories: health care infrastructure, increased staffing, and benefits to underserved beneficiaries. ACOs must submit their projected AIP spending plans.
In looking at these plans, we see 10 of these ACOs using about $4.2 million for health care infrastructure, including electronic health records, clinical data repositories, case practice management systems and electronic quality reporting. Almost all of the ACOs plan to use $8.6 million of the funds to address workforce, including for community health workers, staff education positions, clinical social workers, a health equity officer, and providers. Only three ACOs indicate plans to use about $630,000 to assist underserved beneficiaries. They would use the dollars for comprehensive assessments and a bit for transportation vouchers and nutrition support.
2024 Numbers: Realizing Equity, Access and Community Health (REACH) ACO
The REACH ACO continues to attract attention as well. The REACH ACO replaced the Global and Professional Direct Contracting model in 2023. The REACH ACO now covers 2.6 million Medicare beneficiaries.
There are three REACH model tracks – standard, new entrant and high needs. For 2024, the vast majority elected the standard track.
| Standard | New Entrant | High Needs |
| 104 | 4 | 14 |
REACH ACOs have what are called “participant providers” and “preferred providers.” Participant providers’ beneficiaries attach to the ACO. Preferred providers form a type of preferred network but their beneficiaries are not required to attach to the ACO. For 2024, there are almost 73,000 participant providers with 118,000 preferred providers for these 122 ACOs. The bulk of both participant and preferred are physicians/non-physician providers but many other entities are also involved. For example, 873 federally qualified health centers are participant providers along with 125 rural health clinics and 29 critical access hospitals.
Under the REACH ACO, all models are two-sided risk—either professional at 50% or global at 100%. Eighty-four percent (103) elected the global option with 19 choosing the professional. There are also three options for capitation payments—primary care (PCC), primary care plus advanced payment (PCC + APO), total cost of care (TCC). Roughly 60% selected the PCC + APO.
| PCC | PCC + APO | TCC |
| 29 | 72 | 21 |
Since all REACH ACOs are in two-sided risk models, they may elect to utilize one of 13 waiver options. All but four elected to use at least one waiver. The most heavily elected waivers are bypassing the 3-day hospital stay requirement before a SNF stay plus various home care options and telehealth flexibility. We are not surprised by this since the 3-day stay requirement is decades old and doesn’t reflect care delivery today. We also are not surprised by telehealth’s ongoing attractiveness and see utilizing the home care options in line with current care delivery trends.
Very few of the ACOs elected to use one of five flexibilities for nurse practitioners or physician assistants (certifying care plans for cardiac/pulmonary rehab or home infusion, certifying hospice, certifying need for diabetic shoes or referring for medical nutrition).
Next Steps
Whether it’s an ACO or some type of managed care like Medicare Advantage or special needs plan, accountable relationships are not going away. Understanding how they impact you now or in the future is important. CLA can help. Reach out today.
Jennifer Boese is the Director of Health Care Policy at CLA. She is a highly successful public policy, legislative, advocacy and political affairs leader, including working in both the state and federal government as well as the private sector. She brings over 20 years of government relations and public policy knowledge with her to CLA. Well over half of her career has been spent dedicated to health care policy and the health care industry, affording her a deep understanding of the health care market and environment, health care organizations and health care stakeholders. Her role at CLA is to provide thought leadership, policy analysis and strategic insights to health care providers across the continuum related to the industry's ongoing transformation towards value. A key focus of that work is on market innovations and emerging payment models. Her goal is to help CLA clients navigate and thrive in an increasingly dynamic health care environment.
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