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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
Hello and welcome to Health Affairs This Week. I'm your host, Jeff Beyers. We are recording on 11/07/2025. This is the last episode for the year, so we're publishing this episode on November 21. Thank you for listening.
Jeff Byers:Let us know what you think about the show. Leave a comment in this episode on Spotify. Leave a rating or review on Apple or send us an email at communications@healthaffairs.org. We love hearing from listeners as it gives us a sense of who's listening and what they like about the show. And thanks for listening this year.
Jeff Byers:We'll we'll probably have some best of episodes before we come back in January 2026. So today, travel back in time with me all the way to September 2025. The government hadn't shut down yet. Markets were up. The military gun record had yet to be released.
Jeff Byers:Everything looked fine. Yeah. Sure. It looked fine. I don't know.
Jeff Byers:It's your call, listener. Also in September, CMS released its results for the Medicare shared savings program, its largest shared savings program. The agency stated the program netted a record 6,500,000,000 last year, and it's a signal these value based cares are actually providing value to the system. Another value based care program is the ACO REACH model, which relatively recently released its performance results for 2023, the first full year of implementation under a redesigned model. As it turns out, savings also increased in this model, but Fortune favored participants that were in the model longer.
Jeff Byers:Today on the program, we have Rachel Bonesteel from the Duke Margolis Institute for Health Policy. Rachel and colleagues recently wrote an article in Forefront titled ACO REACH 2023 Performance Results Indicate a pathway to sustainable accountable care, which says what it does on the 10. And at Duke Margolis, she works on projects related to risk adjustment and specialty payment reform. So today on the program, we are gonna talk about Medicare Shared Savings Program, ACO REACH, and the State of Accountable Care. Rachel, welcome to the program.
Rachel Bonesteel:Thanks, Jeff. Looking forward to the conversation.
Jeff Byers:Yeah. So let's talk about MSSP first, because I don't wanna say shared savings again, but I guess I just did. In September, CMS released the shared savings program's recent performance and found the program generated $6,500,000,000 in savings in 2024. This program is more than ten years old. From your position, what are some of the main takeaways or trends that you've seen in this performance?
Rachel Bonesteel:Yeah. Thanks, Jeff. So for the MSSP or SSP program, we're seeing that generally over the ten years of the program, it continues to generate positive momentum towards lower cost and higher quality care for participants. So based on our previous analyses at Duke Margolis as we look at the performance results each year, this is the eighth consecutive year of savings for the program and highest savings in program history. And as you mentioned, there's a 6,500,000,000.0 in savings for 2024, 2.4 of which went to the Medicare program to CMS, and 4,000,000,000 of the those savings went to ACOs, with a slight increase in the number of participants.
Rachel Bonesteel:I think one thing, that's really interesting to note about the results is that for the third year since SSP began, and consistent with last year's performance results as well, the majority of ACOs in the program actually took downside risk at about sixty seven percent. So these are some really interesting findings and definitely indicate a trend toward more interest and momentum for more advanced accountable care models. And I'll say that, my colleagues and I at the institute have been digging into additional findings, around the SSP program.
Jeff Byers:So it's not breaking news.
Rachel Bonesteel:Not breaking news. But so we have been looking at these, over the past, few weeks, I guess, since the results came out. And we'll actually be publishing, results on the 2024 performance, in health affairs forefront later this month, bearing any publication schedule changes. So looking forward to, being able to share those more of those results.
Jeff Byers:Yeah. So we're told that, this podcast is gonna publish on the twenty first. And as you stated before the prep, that article should be live on November 19, so we'll put that in the show notes if it exists. Is there any kind of preview for that that you wanna give?
Rachel Bonesteel:Yeah. So I think, again, mentioning that one of the things that we note in our findings is this general move towards downside risk for ACOs in the program. So again, building on that momentum for more advanced accountable care. We'll also be highlighting some programmatic changes around benchmarks and some of the more technical pieces of SSP, but you can read the publication for more information there.
Jeff Byers:So the MSSP report boasted improving quality regarding blood pressure, depression, and diabetes compared to 2023. The Gallup poll stated this month that The US obesity rate is declining, notably as the use of GLP ones has increased. Also of note, the rate of obesity was about forty percent in, 2022 in The US population and now is thirty seven percent in 2025. With your focus on federal health care transformation, what do you see the government doing to work on continuing this progress?
Rachel Bonesteel:I think I would say for broadly in Medicare accountable care programs and looking at CMS priorities. So both in the SSP program and ACO REACH, which I know we're gonna be talking about, these continue to align with kind of these broader priorities around health care reform focused on managing chronic diseases, encouraging prevention by addressing underlying drivers of health, and then improving access more broadly. So I would say that, again, CMS has, these goals towards managing chronic disease and encouraging prevention, are also key pillars of accountable care models, more broadly. So, given the focus on SSP and ACO reach and some of these performance results, I think that will support the continued momentum towards supporting whole person care for patients.
Jeff Byers:Yeah. So the administration has put out messaging that it wants to improve chronic disease management, and we will look at the use of GLP ones and how obesity is trending downwards, maybe as a cause, maybe as a correlation because of that. Potentially, it could try to build on that momentum. This week, it looked like the Novo, NeuroDisc, and Lilly deal on GLP ones also contains this messaging of trying to prevent chronic diseases, for Medicare and Medicaid beneficiaries. You can kinda argue if the benefit is limited to just Medicare and Medicaid beneficiaries, which to be fair is a lot of people.
Jeff Byers:I might wonder if, preventing chronic disease just before retirement might be more beneficial. Do you see anything in your work at Duke Margolis in the employer covered health care sector?
Rachel Bonesteel:Yeah. I appreciate that, Jeff. And I think a big focus of our work at Duke Margolis and in advancing accountable care more broadly is this idea of multi payer alignment. So as accountable care models are implemented and, there's different design elements or components of these models that help support whole person care for beneficiaries. We recognize that there may be some challenges for providers or organizations that are trying to implement these models.
Rachel Bonesteel:There's different infrastructure requirements, investments that need to be made, different quality metrics and requirements, and this is much easier and less burdensome for providers and organizations to do if these requirements are aligned across lines of business, so across payers, whether this is Medicare, Medicaid, employer sponsored coverage, Medicare Advantage. So a lot of our work is focused around how do you align these different elements across programs. So we're thinking about that a lot, I know that there's work being done, particularly with the Healthcare Payment Learning and Action Network, that's a private public partnership between CMS and private payers and other stakeholders across the system, that's really garnering momentum here. So I would say that supporting that multi payer alignment and alignment of accountable care program requirements across payers is really key for this and helpful to support that whole person care delivery and ultimately improve those outcomes for patients.
Jeff Byers:Moving to your forefront article, you and your colleagues dissect the 2023 REACH performance. Just to set the stage, can you quickly outline the ACO REACH programmatic changes? So 2023 is the first full year of the new changes. Is that correct?
Rachel Bonesteel:Yes. That's correct. So I think taking a step back even further, kind of what ACO REACH is, wanted to share and point out that it's the largest ACO demonstration model or pilot program that's administered by the CMS Innovation Center, which is permitted these flexibilities to test different payment models with the ultimate goal of scaling some of these model elements into permanent programs, including the SSP program. So I guess true to its nature, the model really reaches, I guess pun intended for the stars, as it's really the only full risk model that CMS currently operates. So this supports an opportunity for providers to generate additional savings.
Rachel Bonesteel:As you mentioned, 2023 was the first year of the kind of redesign program with these additional changes. It actually began in 2021 under the first Trump administration. But in 2023, ACO REACH introduced several provisions that were really intended to address unmet health related social needs as well as disparities among Medicare beneficiaries, particularly looking at underserved communities or those in rural areas. Some of these changes included benchmark adjustments or incentives to collect health related social needs data. So those were some of the key program modifications that were introduced in 2023.
Rachel Bonesteel:And I'll say that ACO REACH as a program as a whole was really designed to provide some program and payment flexibility to support, whole person drivers of health, which can really be underlying factors in the progression of poor health or health outcomes.
Jeff Byers:So generally, what are the patient demographics in this model?
Rachel Bonesteel:Yeah. So I think a unique feature of REACH is that there's three different participant tracks. A new entrant track for ACOs that maybe don't have as much experience in accountable care, standard entrants who do have experience in this type of model, and then high needs track ACOs for ACOs that care for patients, that may be more medically complex, including dual eligible beneficiaries. And I think one, aspect of the program to note is, in our research, and conversations we've had with participating ACOs across the past year, one participant in particular mentioned that data collection requirements for the model really incentivized creation of intervention plans targeted at high risk patients, those that may be at risk for health problems like cardiovascular disease or others. And that really allowed them to increase engagement with these at risk patients, when they found that they experienced higher emergency department admissions or unplanned hospital admissions.
Rachel Bonesteel:And so they were able to integrate additional touch points for these individuals to help support keeping them out of the hospital.
Jeff Byers:K. Thanks. So you noted only 14 model participants accounted for 96% of the savings in that performance year. When trying to convince someone of operational organizational change, we know that's hard. So how might a provider weigh the ROI of savings when looking at the relatively small cohort?
Rachel Bonesteel:Yeah. So I think one of the things that we think a lot about with accountable care and acknowledging that it takes a lot of infrastructure and investment to really stand up some of these models. You have to invest in resources, staffing, new workflows, data requirements. So one thing about, our ACO REACH research is that we really found that experience in these programs drives savings. So the more time a participant spends in the program, gains experience, is able to provide this personalized care to its patient populations, they're seeing additional savings garnered.
Rachel Bonesteel:So I think that's one of the things that I would acknowledge that providers are really thinking about in our conversations with ACA REACH participants is that knowing that it takes a lot to stand up some of these programmatic requirements, kind of having that predictability in the future of the model and the ability to continue to operate with the flexibility of the payments offered in ACO REACH is something that can help support that additional ROI as they move forward in implementation of the model.
Jeff Byers:Yeah. You've transitioned to our final question of the day, which I'm I'm curious about that. You know, it looks like sustained participation and experience in these models is what drives implementation and savings. You know, given what we know about the MSSP, what does this mean for providers, especially with what you just said? Do we need to be aggressive about downside risk?
Jeff Byers:You know, a lot of people are reluctant to change, you know, especially transitioning away from not a not a guaranteed thing, but, like, transition away from fee for service. Like, what what's potentially be done if you can look into a crystal ball?
Rachel Bonesteel:Yeah. It's a it's a great question. And I've tried to do a little bit of reading of the tea leaves, but recognizing it's hard to hard to know what will happen. But I
Jeff Byers:think We won't get it exactly right.
Rachel Bonesteel:But I think as knowing that we still have a lot of work to do to shift away from fee for service, there really is a promising path forward given the results from ACO REACH as well as the recent SSP results. Also wanting to know that as of January, CMS announced that over half of traditional Medicare beneficiaries are in accountable care relationships, and this represents the largest increase, when you're looking between 2024 and 2025 participation. It's the largest annual increase since CMS began tracking accountable care relationships. So this really indicates that there is still increased momentum, but, again, recognizing that it is challenging to implement some of these models and support that momentum for moving to downside risk. I know that there's opportunities that CMS has announced recently with the finalized physician fee schedule rule that SSP organizations, not in downside risk, will move to downside risk more quickly.
Rachel Bonesteel:There's also opportunities to explore, continuation of these more advanced payment models and full risk, through ACO REACH and opportunities to maybe scale those into SSP. So I know that policymakers are thinking about various avenues to continue supporting downside risk for providers moving forward.
Jeff Byers:Yeah. Well, that sounds like job security for any health services researcher. So Rachel Bone Steel, thanks for joining us today on health affairs this week. Is there anything you wanna point listeners to, as we close out?
Rachel Bonesteel:Yeah. I think and appreciate the discussion, Jeff. Really enjoyed it. So I will I'll just point to, you mentioned our ACO REACH article that was published in September. This is kind of the follow-up to a two part article series that we published the 2024 that really focuses on qualitative findings from conversations we had with ACO REACH participants for that first full year of the redesign model in 2023.
Rachel Bonesteel:So that kinda digs in a little more into what participants are their experience and what they're hoping for the future.
Jeff Byers:Well, Rachel Bone Steel, thanks again for joining us today. And if you, the listener, enjoyed this episode, please send it to the pardoned turkey in your life, and we will see you in 2026.