A Health Podyssey · 2026-06-23 · 25 min
Key moments - from our scoring
Substance score
62 / 100
Five dimensions, 20 points each
ACOs were originally envisioned by Elliot Fisher and colleagues at Dartmouth as local, clinically integrated networks where physicians and hospitals collaboratively cared for shared patients. But over 15 years, the Medicare Shared Savings Program has evolved dramatically with the rise of third-party convener firms that assemble providers from across the country - a development CMS apparently never foresaw and still doesn't formally track. Dr. Markovitz's Health Affairs study of 2012 - 2021 national data reveals that convener-run ACOs grew from 11% to at least 23% of MSSP beneficiaries, with dispersed networks expanding from 9% to 45% of convener beneficiaries while local single-community ACOs collapsed from 20% to 4%. Most striking: geographically dispersed convener ACOs earned roughly $171 per beneficiary per year in shared savings bonuses - nearly double the $95 earned by local convener ACOs - suggesting either genuine care improvement, selection effects, or strategic cherry-picking of low-cost clinicians. The research examines whether these firms are solving the ACO model's inherent complexity (requiring small practices to act like insurance companies) or exploiting benchmark vulnerabilities using tools like Milliman's ACO Builder, which maps physician costs nationwide for network construction.
ACO conveners are third-party firms like Caravan and Aledade that recruit and assemble clinicians into ACOs, handling the complex administrative, technological, and actuarial functions that small independent practices cannot manage alone. They emerged because the MSSP's complex regulatory structure required practices to perform insurance-like functions (network optimization, risk bearing) that created barriers to participation, which the market filled organically - though CMS did not anticipate this when designing the program.
Convener-affiliated ACOs grew from representing 11% of MSSP beneficiaries in 2012 to at least 23% by 2021. More dramatically, geographically dispersed convener networks expanded from 9% to 45% of convener beneficiaries, while traditional local single-community ACOs collapsed from 20% to 4% of the program.
Unlikely: Dr. Markovitz found that geographically dispersed convener ACOs showed no superior quality performance on aggregate MSSP metrics compared to local or non-convener ACOs, despite earning significantly higher bonuses ($171 vs. $95 per beneficiary annually), suggesting the savings may come from network composition or selection effects rather than care improvement.
ACO Builder is a commercial tool that maps Medicare claims data nationwide to identify high-cost and low-cost physicians, allowing conveners and consultants to systematically cherry-pick low-cost clinicians for network construction - targeting what the vendor describes as 'maximum performance and shared savings' regardless of whether those clinicians share patients.
No; as of 2026, CMS has no published formal records of convener relationships despite the MSSP operating for 15 years, making the program's actual structure and the involvement of third-party firms largely invisible to regulators and the public.
Our reviewer’s read on each dimension, with quotes from the episode.
The episode is substantive for its niche - there are real structural insights about regulatory complexity creating markets for intermediaries and the self-reinforcing loop of gaming - but roughly half the runtime is background context explaining what ACOs are rather than delivering novel claims. Good density within the final third, thinner in the first two-thirds.
every single rule that you add to try to stop gaming makes the program more complex. And the more complex the program gets, the more the doctors and the hospitals need a third party firm to navigate it for them
the same firms that do lower the barrier to entry for, like, these small practices and make it easier to really, you know, improve quality and lower spending, they're also the same firms that make it easiest to win without doing anything
The Milliman ACO Builder example - a commercially sold map of low-cost physicians designed explicitly to cherry-pick networks - is a genuinely eye-opening, underreported detail. The revolving-door framing (CMS alumni running the firms that game the rules they wrote) is a crisp structural observation. However, the broader 'gaming benchmarks in a voluntary program' thesis is not new thinking in health policy circles.
Milliman's ACO Builder, which is essentially a tool for cherry picking low cost doctors. So they went out, bought Medicare claims data on every physician nationwide, mapped out who's high cost and who's low cost, and then they sell you that map
If you look at who runs these convener firms, many of them used to work for CMS. They used to work for CMMI. They are specifically the people who know the rules the best.
Markovitz is a legitimate practitioner-researcher who produced the original study being discussed, has prior published work on selection bias in MSSP in Health Affairs and Annals, and is a practicing physician - so his credibility is earned, not just credentialed. However, he is an academic commentator, not an operator who has run one of these convener firms at scale, which limits the practitioner depth.
I'd spent a lot of time during my PhD dissertation evaluating the MSSP, And one of the things I'd found and published both in health fairs and annals of internal medicine was evidence of selection bias
I'm a primary care physician. I'm a health policy researcher who studies this, I wouldn't have any idea how to build and run an ACO on my own
The episode is notably strong on concrete numbers and named entities: beneficiary share figures, per-beneficiary bonus dollars, relative-spending gaps, and specific named tools and firms. The study design is explained clearly enough to assess its limitations. This is well above average for a policy podcast.
these conveners grew from 11 to at least 23% of ACO beneficiaries in the program
the dispersed convener ACOs had the lowest spending relative to the region of any group, roughly $400 below the regional benchmark. While the dispersed non convener ACOs had the highest, only about $100 below
The host provides competent framing and sensible transitional questions, but there is essentially no pushback - every claim by the guest is accepted and summarized, not probed. The one moment that could have been a sharper follow-up (why quality metrics didn't differentiate dispersed convener ACOs) is glossed over rather than pressed.
Did you have a theory before you conducted the research about how the presence of third party conveners in this ecosystem might affect the ecosystem itself?
Do you have a sense of to what extent all of this is on CMS's radar and how the agency has navigated this tension
Computed from the transcript - who did the talking, and the words that came up most.
Health Affairs Publishing’s Rob Lott speaks to Adam Markovitz of the University of Michigan about his recent paper exploring the growing role of third-party firms in Medicare ACOs , highlighting how they have contributed to wider participation and more geographically dispersed networks while raising questions about how these structures relate to shared savings outcomes. Order the June 2026 issue of Health Affairs .
Transcribed and scored by The B2B Podcast Index.
1 - > Rob Lott: Friends, before we get to this week's paper, a quick 2 - > programming note. This will be our last episode before we take 3 - > a month long summer sabbatical. We'll be off for all of July, 4 - > and we'll be back out there with new episodes, new research, new 5 - > brilliant authors beginning again in August. So let me say 6 - > thanks for a great first half of twenty twenty six, and here's 7 - > wishing you all a happy Independence Day and a happy 8 - > birthday, Shuli.
But first, let's do this one more time. 9 - > Let's talk about accountable care organizations, one of the 10 - > biggest bets that national policymakers have placed over 11 - > the last two decades. The goal, of course, of ACOs is to slow 12 - > cost growth and improve care by incentivizing groups of 13 - > clinicians and organizations to take collective responsibility 14 - > for total cost of care. Organizations earn bonuses when 15 - > average spending for their beneficiaries falls below a 16 - > financial benchmark.
As our guest today describes, ACOs 17 - > were, quote, originally conceived as local clinically 18 - > integrated networks of physicians and hospitals that 19 - > collaboratively care for shared patients, close quote. But a 20 - > funny thing has happened over the last fifteen years with the 21 - > Medicare shared savings program. 22 - > That's Medicare's flagship ACO model. We started seeing ACOs 23 - > made up of clinicians and systems from all over the 24 - > country.
The thing that connects these disparate providers is not 25 - > that they're based in Chicago or Billings, Montana or the Blue 26 - > Ridge Mountains. Rather, they are being brought together by 27 - > third party firms commonly referred to as conveners. Now 28 - > what to make of these conveners? 29 - > On one hand, they manage the administrative and technological 30 - > demands that might otherwise prevent many practices, 31 - > especially small independent practices from participating in 32 - > an ACO at all.
On the other hand, it's not exactly 33 - > consistent with policymakers' original vision and intention 34 - > for the program. Now change like this, after all, can be good. It 35 - > can be bad. But either way, it tends to make people nervous and 36 - > uncertain.
37 - > But here we are, nerves and all. So for our podcast today, let's 38 - > embrace the uncertainty and see if we can learn a little more 39 - > about these conveners and the road ahead. I'm here with doctor 40 - > Adam A Markovitz, an assistant professor of general internal 41 - > medicine and a practicing general internist at the 42 - > University of Michigan. Together with colleagues, he has a new 43 - > paper in the June issue of Health Affairs, studying and 44 - > describing, quote, third party convener firms and the rise of 45 - > geographically dispersed, High Earning Medicare ACOs.
This is a 46 - > really interesting paper on a relatively undercovered topic, 47 - > and I really can't wait to dig in. 48 - > Doctor. Adam Markovitz, welcome to A Health Podyssey. 49 - > Adam Markovitz: Thank you so much for having me.
It's really 50 - > a pleasure to be here. 51 - > Rob Lott: Well, why don't we start with a little bit of 52 - > history? When the ACO model and the Medicare Shared Savings 53 - > Program in particular were first developed, Do you have a sense, 54 - > did policymakers expect the rise of third party conveners? Did 55 - > they foresee this?
And if not, why not? 56 - > Adam Markovitz: I don't I don't think so. I think when ACOs were 57 - > were first being developed, I don't think policymakers really 58 - > foresaw the rise of these third party convener firms. And, you 59 - > know, I think to think about why I I think you really have to, 60 - > like, go back to where this idea originally came from.
So ACO is 61 - > really traced to Elliot Fisher and his colleagues at Dartmouth, 62 - > who first published a paper, honestly, health affairs, I 63 - > guess, nearly twenty years ago called Creating Accountable Care 64 - > Organizations, the extended hospital staff. And, you know, 65 - > at that time, I think the vision was really like a local, 66 - > clinically integrated network of physicians in hospitals that 67 - > were collaboratively caring for the patients that they actually 68 - > share.
69 - > So, you know, essentially a virtual delivery system where 70 - > they could manage the complex needs of their patients. And, 71 - > you know, to put that in context, know, the underlying 72 - > problem we're all wrestling with is fee for service. We worry 73 - > that it pays for volume, not value. And Medicare's first big 74 - > answer to this was Medicare Advantage.
Hand a fixed 75 - > capitated budget to private insurers, and they can basically 76 - > figure out the spending. 77 - > And ACOs at the same time are really traditional Medicare's 78 - > answer to MA. You know, we still want to move off of pure fee for 79 - > service, get away from these problematic incentives for 80 - > volume. But unlike Medicare Advantage, we wanted those 81 - > decisions to sit with doctors, not private insurers.
You know, 82 - > I think the rationale, thinking is that doctors are closer to 83 - > patients, that they have an ethical obligation to do the 84 - > right thing so that they can deliver better care at lower 85 - > cost. So, you know, the whole premise of ACOs is in some sense 86 - > to replace the insurer with the physician. 87 - > But this assumes that ACOs can replace insurers with doctors, 88 - > which means that we actually have to require that doctors act 89 - > like insurers, optimize networks, navigate complex 90 - > rules, bear actuarial risk.
And those are functions that like 91 - > health payers handle centrally all the time, every day and at 92 - > scale. But most practices, especially smaller and 93 - > independent ones just aren't built for for them. They don't 94 - > have the infrastructure, the experience, the financial 95 - > reserves. I I'm a primary care physician.
96 - > I'm a health policy researcher who studies this, I wouldn't 97 - > have any idea how to build and run an ACO on my own. So instead 98 - > of market emerged to do just that. And I think that's that's 99 - > really where the ECO conveners come in. So, you know, in 100 - > hindsight, it should have been obvious that if CMS creates some 101 - > super complicated set of rules for how ACOs are run, how 102 - > benchmarks are set, that some third party firms would rush to 103 - > fill this void and help providers participate.
But no, I 104 - > I don't think we really anticipated this. 105 - > Certainly, this the issues of selection, were certainly 106 - > somewhat foreseeable at the time. People warned about how 107 - > benchmarks could be gamed. A lot of thought went into historical 108 - > benchmarks versus regional benchmarks.
How much should we 109 - > risk adjust. But I don't think we really foresaw that there'd 110 - > be this whole class of third party firms that would become 111 - > the vehicle for, addressing this. 112 - > And, you know, I think that the tell here is that fifteen years 113 - > in, CMS still doesn't have any published formal records of 114 - > these convener relationships. 115 - > Rob Lott: Okay.
So fast forward fifteen years, as you said. Here 116 - > we are. You're about to set out on this study that we're gonna 117 - > talk about today. Did you have a theory before you conducted the 118 - > research about how the presence of third party conveners in this 119 - > ecosystem might affect the ecosystem itself?
120 - > Adam Markovitz: You know, honestly, like like most 121 - > researchers, I I don't I hadn't given conveners a whole lot of 122 - > thought going into this work. I was certainly aware of some of 123 - > the big ones, Caravan, Aledade. I'd seen their publicity on 124 - > social media. I'd seen some talks given, but I I didn't 125 - > really have a clear sense of how much involvement they actually 126 - > had in the program or what their ACOs would really look like.
If 127 - > anything, I sort of vaguely assumed they would be doing the 128 - > obvious good thing that they advertised, you know, organizing 129 - > small, local, independent practices into ACOs. 130 - > And then one day, I was going through the the CMS's public use 131 - > files as as one does in their free time as one does. And and I 132 - > noticed something. Like, there's this column in the public use 133 - > file where it states which states ACOs operate in.
And, you 134 - > know, while a lot of them were just in one state, two state, 135 - > maybe three states, some of them were spread across five, ten, 15 136 - > states, sometimes in totally different parts of the country. 137 - > And that just didn't make any sense to me. 138 - > Like, why would an ACO be organized that way? The whole 139 - > idea is local doctors courting care for shared patients.
I will 140 - > say on the other hand, I'd spent a lot of time during my PhD 141 - > dissertation evaluating the MSSP, And one of the things I'd 142 - > found and published both in health fairs and annals of 143 - > internal medicine was evidence of selection bias, with ACOs 144 - > appearing to recruit low cost clinicians, and that a lot of 145 - > what looks like savings in the program was really that 146 - > selection of low cost doctors. So I think putting together 147 - > these two findings, you know, I did start to wonder whether or 148 - > not these super geographically dispersed ACOs were, you know, 149 - > essentially like a fingerprint for some of that selective 150 - > recruitment, but just done on a nationwide scale that I would 151 - > not have appreciated otherwise.
And then the question is, these 152 - > conveners partly the ones enabling it? 153 - > Because frankly, a lot of what they're hired to do is to 154 - > recruit and aggregate clinicians in the ACOs. So I think that was 155 - > definitely a hunch. But, know, I did wanna hold on to both 156 - > possibilities because I do think there's, you know, there's the 157 - > good story that conveners really do enable participation.
They 158 - > bring this capital, the analytics, the care management, 159 - > to small practices that could never do this on their own. And 160 - > then there's the bad story that they're essentially engaging, 161 - > sort of in arbitrage, aggregating low cost clinicians 162 - > across the country to beat these benchmarks. 163 - > And so I would probably say my prior was that it's probably 164 - > both. You know?
There's probably some good and bad. And honestly, 165 - > that's probably how I still still feel about it having 166 - > performed this study. 167 - > Rob Lott: A a little from column a and a little from column b. 168 - > And so let's dig into what you found when you conducted the 169 - > research.
You looked at national data from 2012 to 2021 and 170 - > examined trends in conveners involvement over time. You also 171 - > looked at how geographically dispersed they were compared to 172 - > non convener ACOs, and then you looked at those associations 173 - > with shared savings. So tell us what you found. 174 - > Adam Markovitz: Yeah.
So using those national data, I I think 175 - > there were really three central findings that we had, you know, 176 - > bearing in mind this is from 2012 through 2021 in the MSSP. 177 - > So first, these conveners grew from 11 to at least 23% of ACO 178 - > beneficiaries in the program. Second, these networks became 179 - > gradually more geographically dispersed over time, 180 - > particularly among these convener run ACOs. So among the 181 - > convener run ACOs, these dispersed ACOs went from nine to 182 - > 45% of beneficiaries versus from one to 8% among nonconvener 183 - > ACOs.
184 - > And meanwhile, these, you know, local sort of single community 185 - > ACOs nearly vanished going from 20% down to 4% by 2021. And then 186 - > the third finding was was about the money, about the bonuses. So 187 - > when you look at the shared savings bonuses, it really was 188 - > the dispersed convener ECOs that earned the most by by really a 189 - > wide margin, earning about a $171 per beneficiary per year, 190 - > while the local convener ACOs earned the least around $95 And 191 - > I think the key contrast though is that among the non convener 192 - > ACOs, that gap between the dispersed and the locally, the 193 - > local ACOs basically disappeared and was not significant.
So 194 - > really, it it was it wasn't just a convener effect. There is 195 - > something specific to the dispersed convener ECOs that 196 - > seem particularly good for earning bonuses. 197 - > Rob Lott: So there are conveners that are operating more locally 198 - > less less dispersed. Is that right?
And those struggled as 199 - > well. Or or perhaps let let's not say struggled. They didn't 200 - > thrive quite as much as the more dispersed ones. 201 - > Is that fair?
202 - > Adam Markovitz: Correct. Yes. Exactly. 203 - > Rob Lott: I wanna ask a little more about the details and 204 - > perhaps some of our the possible mechanisms that might be driving 205 - > these differences.
But first, let's take a quick break. And 206 - > we're back. I'm here with doctor Adam Markovitz, talking about 207 - > the rise of third party convener firms and, geographically 208 - > dispersed high earning Medicare ACOs. So you just told us about 209 - > some of the findings and the fact that those most 210 - > geographically dispersed third party convened ACOs were doing 211 - > really well in terms of earning shared savings.
212 - > And I guess one way to look at that is that, you know, they've 213 - > found the trick and the other way is to say that they're 214 - > really good at what they do. And so I'm wondering, you know, how 215 - > you think about the mechanisms that might be explaining why 216 - > dispersed convener affiliated ACOs earned the highest shared 217 - > savings. 218 - > Adam Markovitz: Yeah. It's a great question.
You know, and I 219 - > wanna be careful here. So this is descriptive study. It's not a 220 - > causal one. 221 - > And second, the mechanisms I'm about to describe are not 222 - > mutually exclusive and some elements of each of them could 223 - > be true.
So I think the first mechanism is the good story and 224 - > it's the story the conveners themselves tell, that they 225 - > genuinely improve care, better analytics, better care 226 - > management, better quality of care, and that's how they lower 227 - > spending. And to at least get at that, we looked at whether these 228 - > dispersed conveners actually had the highest quality performance 229 - > in the MSSP, but we didn't see that. So the dispersed convener 230 - > ACOs scored no better on overall quality metrics than the local 231 - > ECOs or the non convener ACOs.
So they may have been delivering 232 - > better care, but didn't show up in sort of those aggregate 233 - > quality measures. 234 - > The second is actually reverse causality. So it's just simply 235 - > basically the best ACOs that succeed and then they expand 236 - > over time. They grow into new markets and then they look 237 - > dispersed.
And in that story, dispersion is really a marker of 238 - > success and not a cause of it. And because ours was a cross 239 - > sectional study, that certainly is a real possibility that that 240 - > may be driving some of our findings. 241 - > And then the third story I think is is the bad one of strategic 242 - > selection. So that's where conveners are deliberately 243 - > constructing networks to beat spending benchmarks, cherry 244 - > picking low cost clinicians from across the country, regardless 245 - > of whether or not those clinicians share any patients or 246 - > are actually doing anything to subsequently reduce spending.
247 - > And, you know, while the convener firms are not 248 - > advertising this, there is a huge cottage industry of ACO 249 - > consultants, ACO actuaries whose entire job it is to do exactly 250 - > this, and they are not subtle about it. So I think the 251 - > clearest example is a tool called, Milliman's ACO Builder, 252 - > which is essentially a tool for cherry picking low cost doctors. 253 - > So they went out, bought Medicare claims data on every 254 - > physician nationwide, mapped out who's high cost and who's low 255 - > cost, and then they sell you that map so that you can just 256 - > grab the low cost ones and build your network, to be, like as 257 - > they send their website, structured for maximum 258 - > performance and shared savings.
259 - > So to test whether or not that was happening, we basically 260 - > built our own ACO builder, but in reverse. So we took each 261 - > ACO's patients and asked a simple question. How does their 262 - > spending compared to other patients in the same county? 263 - > Because that's the regional benchmark.
And if you've 264 - > recruited low cost clinicians, your patients should look 265 - > unusually cheap relative to their local peers. 266 - > And that's exactly what we found. So the dispersed convener 267 - > ACOs had the lowest spending relative to the region of any 268 - > group, roughly $400 below the regional benchmark. While the 269 - > dispersed non convener ACOs had the highest, only about $100 270 - > below.
And again, this is cross sectional, so this could also 271 - > reflect subsequent savings that the ACOs did, generate. But, you 272 - > know, one thing to note is, like, the firm selling tools 273 - > like ACO Builder, they're not even in our study. 274 - > So we could only identify sort of the formal conveners who 275 - > actually run ACOs and list themselves as, the ECO executive 276 - > or the public contact for the ACO in the public files. But 277 - > there's this entire layer of analytic consultants that's 278 - > essentially invisible to us researchers and I think to CMS.
279 - > And these consultants are not coy about what they're doing. So 280 - > in that sense, I think our paper is to some extent the tip of the 281 - > iceberg. But once you start looking for it, it's really 282 - > everywhere. 283 - > And I think most of us, so I will say as an academic 284 - > researcher, I speak with policymakers, I think most 285 - > people still picture ECOs as like these local ECOs who are 286 - > not sophisticated enough to cherry pick or gain benchmarks 287 - > like this.
And honestly, I don't think a lot of them are, but you 288 - > don't you don't have to be. You don't need your hospital's head 289 - > of pop health to know how to do this. You just need them to know 290 - > someone who does and hire them. And I do think that's exactly 291 - > what they're doing.
292 - > Like, you spend ten minutes on LinkedIn, as I do now, it's wall 293 - > to wall consultants, actuaries advertising the software, 294 - > hosting webinars on you know, there's a new ACO lead program. 295 - > And, like, every day, people are posting about, you know, how you 296 - > should structure your ACO for maximal savings. So I think 297 - > there is this whole industry that is hiding in plain sight. 298 - > It's just not the mental model that we as researchers have been 299 - > bringing to these programs.
300 - > Rob Lott: Remind me to connect with you on LinkedIn after this 301 - > conversation. 302 - > Adam Markovitz: Would be a So 303 - > Rob Lott: your findings highlight this tension, right? 304 - > That's what we're talking about here today between sort of the 305 - > benefit of increased participation made possible by 306 - > third party conveners versus maybe this potential undermining 307 - > of the program when bonuses are achieved through network 308 - > optimization in theory as opposed to actual coordination 309 - > and quality improvements.
And I'm curious, you alluded to some 310 - > of the entities in this ecosystem being invisible to 311 - > CMS. Do you have a sense of to what extent all of this is on 312 - > CMS's radar and how the agency has navigated this tension as 313 - > it's made changes to various ACO models over the years? 314 - > Adam Markovitz: Yeah. And I think that's exactly the right 315 - > way to frame it because it it is a real tension.
Know? So the 316 - > same firms that do lower the barrier to entry for, like, 317 - > these small practices and make it easier to really, you know, 318 - > improve quality and lower spending, they're also the same 319 - > firms that make it easiest to win without doing anything. I do 320 - > think this is definitely on CMS' radar. 321 - > You can, I think, read it right off of some of the recent ACO 322 - > design choices?
So, like, for instance, just thinking about 323 - > ACO REACH, so that's the the ACO model that LEED is now replacing 324 - > in this coming year. So REACH really was CMS' push, sort of 325 - > like in the convener sense, it was their push to try to reach 326 - > these small and rural practices that MSSP had left behind. It 327 - > even opened the door for private firms to directly contract with 328 - > CMS for the first time in traditional Medicare. There's 329 - > not been much empirical work on REACH yet, but our own 330 - > preliminary data show that REACH ACOs are doing some of the same 331 - > things we found in MSSP, selecting these low cost 332 - > clinicians.
333 - > And with the lead, you read some of the design choices, I think, 334 - > as a direct response to some of those concerns. So I, again, in 335 - > my free time as one does, I've read through large portions of 336 - > the RFA, And now they actually ask they have a a question about 337 - > who runs your ACO, and there is a checkbox for conveners. I've 338 - > not looked through MSSP's RFA, so maybe they did did before, 339 - > but to me that was noteworthy. And in terms of how LEED is 340 - > designed to curb selection, they are now starting ACOs on a pure 341 - > historical benchmark rather than a regional one.
So you're 342 - > measured against your own past instead of being rewarded simply 343 - > by finding cheap clinicians relative to their local peers. 344 - > And also like in MSSP but not in REACH, they require the whole 345 - > practice to participate. So unlike in REACH, you can't sort 346 - > of cherry pick individual low cost doctors. And then they 347 - > actually, in their RFA, explicitly ban conveners from 348 - > tin swapping, which means where you basically shuffle the same 349 - > practice between your ACO.
So they say that if a practice is 350 - > in an ACO run by a convener and they leave that ACO, they can't 351 - > join another convener, another ACO run by that same convener 352 - > for three years. So clearly, they are seeing something in 353 - > their data in REACH or in MSP that they're concerned about. 354 - > And they have all this stuff about curbing risk coding. They 355 - > want to use AI infer Abe Sedin talks about AI inferred risk 356 - > scores, which is basically built on objective signals like 357 - > prescription fills rather than the diagnosis codes entered by 358 - > by the doctor.
Mhmm. You know, at the same time, I think 359 - > there's a bigger point, and it is why I'm skeptical that any of 360 - > this will fully or even adequately solve the problem. 361 - > You know, some of these are are genuinely, I think, really good 362 - > ideas. 363 - > But the real big tension here, it's it's not one loophole.
This 364 - > is a all of these are voluntary programs, and they're all built 365 - > on benchmarks and any benchmark can be gamed. And the voluntary 366 - > part of that makes the benchmarks even the most 367 - > problematic because to get people to join, you have to make 368 - > it attractive. And people only join if they think they can make 369 - > money. You can never really tighten down the rules all the 370 - > way without losing the participation that the program 371 - > depends on.
372 - > And then the final vicious loop is that every single rule that 373 - > you add to try to stop gaming makes the program more complex. 374 - > And the more complex the program gets, the more the doctors and 375 - > the hospitals need a third party firm to navigate it for them. If 376 - > you look at who runs these convener firms, many of them 377 - > used to work for CMS. They used to work for CMMI.
They are 378 - > specifically the people who know the rules the best. 379 - > And once you're out of government, of course, you would 380 - > go run a consulting firm about the program that you helped 381 - > create. And, of course, if you are a small practice struggling 382 - > to make ends meet in fee for service and you wanna make money 383 - > from value based payment, of course, you would contract with 384 - > a consultant. So to some extent, this is everyone just acting 385 - > rationally.
But I think it's ended us in a really difficult 386 - > spot. You know? 387 - > So I think that's that's sort of where we've where we've left 388 - > off. 389 - > Rob Lott: Well, a difficult spot, but perhaps a glimmer of 390 - > hope that we might be able to continue learning about these 391 - > conveners and continue studying them with researchers like 392 - > Doctor.
Adam Markovitz and his colleagues who've really done 393 - > interesting, important work with this paper. I encourage our 394 - > listeners to check it out in the June issue of Health Affairs. 395 - > Doctor Adam Markovitz, thanks so much for taking the time to chat 396 - > with us today. Really enjoyed it.
397 - > Adam Markovitz: Thank you. It's really been a pleasure. 398 - > Rob Lott: And to our listeners, thanks for tuning in. If you're 399 - > a rational actor, you might recommend this podcast to a 400 - > friend, leave a review, and, of course, tune in next week.
401 - > Thanks, everyone. 402 - > Adam Markovitz: Thanks for listening. If you enjoyed 403 - > today's episode, I hope you'll tell a friend about A Health 404 - > Podyssey.
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