All-payer value-based contracting in organizations with Medicare ACOs

To measure the prevalence of non-Medicare value-based contracting and participation in contracts with downside risk among organizations participating in the Medicare Shared Savings Program (MSSP).

Cross-sectional analysis of 2022 accountable care organization (ACO) survey.

The author analyzed surveys from 100 organizations participating in the MSSP that reported the number of covered lives they have in value-based contracts in traditional Medicare (ACOs), Medicare Advantage (MA), commercial payers, Medicaid managed care organizations, Medicaid, and direct-to-employer arrangements. We analyzed the distribution of covered lives across shared-savings, shared-risk, and full-risk contracts and analyzed changes between 2018 and 2022.

Respondents reported 15.5 million covered lives in value-based contracts. All respondents have Medicare ACO contracts, and roughly 75% reported value-based contracts with commercial and MA plans. Approximately one-third reported such contracts with Medicaid managed care plans. Seventy percent of covered lives in respondents' Medicare ACO contracts included downside risk for losses compared with 51% of lives in commercial plans and 45% in MA plans. Compared with a similar 2018 survey, the proportion of respondents in value-based MA contracts doubled, and the proportion in commercial contracts rose by half.

Organizations that participate in Medicare ACO models have substantially increased their participation in value-based contracts with other payers. They reported a higher proportion of Medicare ACO covered lives in downside risk arrangements than in commercial or MA contracts.