Dr. Mostashari: The Aledade MSSP ACOs Are Thriving

On August 28, officials at the Centers for Medicare & Medicaid Services (CMS) announced results from the Medicare Shared Savings Program (MSSP) for performance year 2024. There was good news. As CMS noted in publishing a fact sheet on that date, “For Performance Year (PY) 2024, ACOs in the Shared Savings Program achieved the highest rates of shared savings since the inception of the program. Out of 476 ACOs, 75 percent of ACOs, representing 80 percent of the 10.3 million assigned beneficiaries, are earning performance payments totaling $4.1 billion, and Medicare saved $2.4 billion relative to benchmarks. PY 2024 had the highest share of ACOs receiving performance payments and the highest amount of savings for ACOs and Medicare since the inception of the Shared Savings Program."

Further, CMS officials noted on that date, “ACOs had higher savings per capita in PY 2024 compared to PY 2023, $241 vs $207 in net per capita savings and $643 vs $515 in gross per capita savings, respectively.  Net per capita savings represent the savings for Medicare, whereas gross per capita savings are the savings shared by ACOs and Medicare. Low revenue ACOs continue to outperform high revenue ACOs, generating $316 vs $175 net per capita savings. Low revenue ACOs are typically physician-led ACOs or are comprised of FQHC/RHCs, while high revenue ACOs are typically hospital-led. ACOs composed predominantly of primary care clinicians performed better compared to ACOs with fewer primary care clinicians, with $401 vs $219 in net per capita savings. ACOs that achieved shared savings had lower utilization compared to their benchmark across many categories of utilization including hospital discharges, Emergency Department visits and Skilled Nursing Facility stays,” the agency noted.

Meanwhile, leaders at the Bethesda, Md.-based Aledade, a physician enablement company that describes itself on its website as “the nation’s largest network of independent primary care,”  were able to tout results even better than the average among the MSSP-participating ACOs nationwide. They noted on their website that “Aledade’s network, composed of primary care practices and community health centers across the nation in rural, suburban and urban settings, demonstrated that paying for value instead of volume is better for primary care and patients. A remarkable 93 percent of Aledade ACOs earned shared savings, compared to 73 percent of non-Aledade ACOs across the entire MSSP. Aledade’s ACOs earned approximately $390,000 in shared savings per practice. Aledade’s effectiveness across various geographies and patient populations is further highlighted by the fact that its network includes more than 25 percent of all community health centers (CHCs) in MSSP. These organizations face unique challenges serving beneficiaries in underserved communities, requiring additional dedicated resources and innovative approaches to help them reach this level of success,” they said.

Highlights included that Aledade’s 10 CDC-only ACOs “achieved over $585 in savings per beneficiary, +38 percent year over year,” and “earned a total of more than $96 million in shared savings in 2024, +62 percent year over year.

Per all this, Farzad Mostashari, M.D., CEO of Aledade, spoke recently with Healthcare Innovation Editor-in-Chief Mark Hagland about Aledade’s excellent results, and where the program goes from here. Below are excerpts from their recent interview

It sounds as though these results have been all good news for Aledade’s groups, in the MSSP?

That’s right, and beyond Aledade, I want to rise in praise of the Medicare Shared Savings Program, which I really think is a gem. I think it really is underappreciated.

CMS put in its fact sheet, more than $4 billion dollars in savings, better quality and access, lower use of EDs, quality that’s improving faster year over year, and billions of dollars in payments to primary care doctors. That’s just the fact sheet. And what other programs have we seen in Medicare that delivered more benefits to patients, not fewer, more payments to physicians, and saved the taxpayers money? And the only way you can achieve all three things is to reduce bad things happening to patients, reduce hospitalizations, etc. In 30 years of health policy, I’m not aware of a program that has been able to do all three of these things.

As the CMS actuaries noted in June, the U.S. healthcare system is expected to go from the current $5.6 trillion in total U.S. healthcare expenditures to $8.5 trillion in the next eight years Many are still not fully aware of the power of this formula, correct?

You’re correct. And we don’t have a lot of tools in the toolkit to manage rising costs. And it is time—and I will say to their credit, what I’ve heard from Dr. Oz, from Chris Clomp [Deputy CMS Administrator, and Director, Center for Medicare & Medicaid Innovation], who heads the Center for Innovation, is that they want everyone in traditional Medicare to be in an ACO—they’re actually seeing ACOs as an alternative to Medicare Advantage. If a senior wants to be in coordinated care through managed care, great; if they want to be in coordinated care through an ACO, that should be an option. And health plans can deny claims, can require prior authorization, can restrict the network, can put in place benefit designs where people have to pay higher copays. ACOs can do none of those things. We can’t limit care, deny care, or raise copays. We have to do it through giving patients more, not less. And that’s the beauty of this program, in the win-win-win that it creates.

You and your colleagues just saved Medicare a billion dollars. Walk me through the mechanics of that process.

It really is just the strong applications of good primary care. Our partner practices—over 2,000 of them—are community-based primary care practices. And for the first time, they’re actually rewarded for keeping patients healthy and out of the hospital, through primary care. One statistic: the MSSP rates of blood pressure control are up to 79 percent. The historic number given was that only 65 percent of patients with high blood pressure had it controlled. And it’s now risen to 79 percent. And in Aledade, we’re at almost 84 percent.

Just really, really good care management, correct?

Yes, it’s good primary care and prevention. After I left the Office of the National Coordinator for Health Information Technology, I went to Brookings, and while there, we published a toolkit for physician-led ACOs. And we’re doing that exact same thing, and have been doing it for ten years. The one difference I’ll allow is that we are much better now than we ever have been in terms of the technology piece that helps the practices do the right thing.

So the challenge is that the population is aging, and the percentage of Americans living with chronic illness is growing. So even as ACOs achieve real success, there will be new hills to climb, correct?

Yes, that’s correct, and our primary care practices are feeling the weight of that, where every year, their population is getting sicker and having more needs. And we’re seeing more and more financial and regulatory pressures on these practices. And I agree. I think it really is a crisis moment for primary care in this country. And I think these practices need and deserve all the support we can give them from a policy perspective. And we’re doing our part; we’re going to be distributing $500 million to practices.

One thing that numerous people in the know have told me is that, whatever one hears in the news headlines, the senior staffers of the key committee leaders in both houses of Congress, have a healthy consensus on the need to move forward on value-based contracting. Is that your perception as well?

Yes, that’s absolutely true. The Biden administration was wanting to use value-based contracting to further health equity. I think the current leadership wants to give more tools to, and demand more performance from, value-based programs. But I think the fundamental support has been there and continues to be there, not only in the administration, but among policymakers in Congress, to say that the MSSP is working. And whether you’re someone who believes in the private sector solving problems and creating incentives, or whether you’re a believer in primary care, or whether you want to save taxpayers money, the MSSP is a gem, and we need to advance it.

And you believe that the MSSP will continue to advance over time?

Yes, I do believe it will. There are things that policymakers could do to jumpstart growth. I do believe that one of the drags on participation is anytime you have a perception of a surprise or a “gotcha” that makes things seem unpredictable. And we talked about the ACPT issue [the set of issues around the Accountable Care Prospective Trend blended benchmark update; Dr. Mostashari referred to it in his June interview]. And they half-ways fixed it last year, but like a zombie, it comes back again. And it’s alive in 2025, and we’ve got to kill it again. I do think there are things they could do to help create greater predictability in the program. When in doubt, simplify. And with the complexity introduced by that well-intentioned idea—the cure is worse than the problem.

Any last thoughts?

The CMS fact sheet talks about program savings, meaning against the benchmark. The reality is that the actual savings are far greater than program savings, because when an ACO is in the program and they renew, their benchmark goes up, it resets. So if you compare what costs would have been in that ACO over the course of several years, the government is under-counting the savings in the program. And ACOs help reduce cost growth from 9 percent in traditional Medicare to 8 or 7 percent, and that has an impact on Medicare Advantage costs, because what we pay Medicare Advantage plans is pegged to the cost of growth in traditional Medicare. And now that the majority of Medicare recipients are in MA, saving a dollar in traditional Medicare saves more than a dollar in MA. So let’s take all the savings in the program that have been tallied, and more than double them.