Challenges Surrounding the Medicare Shared Savings Program


Qualitative study breaks down challenges and priorities of the Medicare Shared Savings Program, as noted by affordable care organizations.

Image Credit: Adobe Stock Images/

Image Credit: Adobe Stock Images/

Affordable care organizations (ACOs) consist of physicians, hospitals, and other healthcare providers who voluntarily provide care to Medicare patients.1 These ACOs are intended to provide coordinated care, while avoiding not only the duplication of services, but medical mistakes as well.

Originally proposed in 2006 and ultimately incorporated into the Affordable Care Act once it was signed into law in 2010, a plethora of organizations have since participated in ACO models. The largest of them all, with more than 400 ACOs, continues to be the Medicare Shared Savings Program (MSSP), which has existed for more than a decade. By 2022, approximately 11 million patients—about one in six Medicare beneficiaries (with one in three of those being in the fee-for-service program)—were attributed to ACOs in general.2

Given that ACOs undoubtedly have had a significant impact on healthcare, a qualitative study published in JAMA Health Forum2 sought to report what the organizations’ leaders felt were the top priorities and obstacles of the MSSP.

With the help of the 2022 MSSP ACO participant list, investigators gathered interested parties. These participants were required to have been a part of MSSP for at least four years, which resulted in a list of 229 eligible ACOs of the 483 organizations that participated in an MSSP in 2022. Those that were eligible were then invited to take part in the study via email.

The specific questions were open-ended and revolved around:

  • How leadership decisions and strategies are expressed to clinicians
  • ACO key clinical and care management initiatives
  • How shared savings are distributed
  • The specifics as to how medical groups are added or removed
  • Additional factors that could impact the program’s success or failure

Of the total 49 ACOs that were interviewed, 34 were associated with hospitals (69%), 35 were medium or large (71%), and 17 were rural (35%). ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Following qualitative interview analysis, there were five main themes: key programmatic initiatives; clinician engagement; shared savings distribution; recruitment and retention; and hospital-associated ACOs.

These individuals noted that there was more of a priority on boosting the amount of annual wellness visits, enhancing coding practices, and improving transitions in care. Many of these ACOs issue at least 50% of their shared savings to participants, which mainly occurred at the practice level.

The study did present its share of limitations. One of which was the fact these reports were only associated with objective improvements in care, as opposed to connecting both qualitative and quantitative analyses to further determine the characteristics of ACOs that are more strongly related to better quality or lower costs.

As a result, the authors of the study concluded that, “Accountable care organizations maintain bipartisan consensus and Congress appears committed to continuing the model, which is the only Medicare value-based payment program authorized by statute. As the Centers for Medicare & Medicaid Services continues to refine the ACO program and introduce new opportunities for clinicians and health care organizations to engage in value-based payment, it may benefit from an understanding of the priorities, strategies, and challenges of ACO leaders, as well as how the incentives embedded in national policy manifest on the front lines of care delivery.”


1. Accountable Care Organizations (ACOs): General Information. Centers for Medicare & Medicaid Services. Accessed March 29, 2024.,Accountable%20Care%20Organizations%20(ACOs)%3A%20General%20Information,the%20Medicare%20patients%20they%20serve.

2. Khullar D, Schpero WL, Casalino LP, et al. Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program: A Qualitative Study. JAMA Health Forum. 2024;5(3):e240126. doi:10.1001/jamahealthforum.2024.0126

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