Last week I wrote about the ACO REACH PY2024 results, where roughly 95% of net savings came from the benchmark discount rather than ACO performance. It is worth putting the Medicare Shared Savings Program results beside them, because they tell a different and more encouraging story — with a catch.
MSSP had its strongest year on record in PY2024. And the savings were not evenly distributed. They concentrated almost entirely among the organizations taking real downside risk.
1. The headline numbers
In PY2024, MSSP generated a record $2.4 billion in net savings to Medicare — the eighth consecutive year the program saved money against benchmarks. About 75% of participating ACOs earned shared savings, the highest share in program history, with total shared savings payments of roughly $4.1 billion against gross savings of about $6.5–6.6 billion.
Since 2012, the program has produced roughly $35 billion in gross savings and $13.6 billion in net savings. For a program that has been repeatedly declared underwhelming, that is a substantial record.
2. Where the savings actually came from
ACOs in the highest-risk tracks generated $5.4 billion of the $6.6 billion in gross savings.
This is the finding that should shape strategy. ACOs in BASIC Level E and the ENHANCED track — the two-sided, downside-risk arrangements — delivered more than two-thirds of all savings in 2024. They also produced higher per-beneficiary savings and were substantially more likely to earn shared savings at all.
Two-thirds of ACOs now sit in Level E or ENHANCED, meaning most of the program operates under downside risk. The program’s improvement and its risk migration happened together.
3. Be careful with the causal claim
Downside risk correlates with better performance. That is not the same as proving risk causes it.
Here is where I would push back on the industry’s favorite reading. Organizations do not enter downside risk at random. The ones that opt into Level E and ENHANCED tend to be the ones that already have mature care management, good data, physician alignment, and confidence in their numbers.
So the honest interpretation runs both ways: taking risk sharpens focus and unlocks tools, and organizations that were already capable are the ones willing to take it. Selection and causation are tangled here, and anyone selling you “take more risk and savings will follow” is skipping that step.
4. The per-beneficiary story
Savings are rising per person, not just in aggregate. In 2024, ACOs saved roughly $637 per beneficiary, about a 40% increase since 2021, and returned nearly $240 per beneficiary to Medicare after shared-savings payments.
That trajectory matters because it suggests genuine operational improvement rather than one-time benchmark luck — which is exactly the contrast with the REACH result, where the discount did most of the work.
5. What this means for your next decision
If you are choosing between MSSP tracks, or weighing MSSP against LEAD for 2027, the data supports a specific sequencing: build the capability first, then move up the risk ladder, rather than taking downside risk in the hope that pressure creates competence.
Ask the diagnostic questions honestly. Can you identify rising-risk patients before they decompensate? Do your physicians see and trust their own cost and quality data? Do you know what share of last year’s result was operational versus benchmark mechanics? Organizations that can answer those tend to do well in two-sided risk. Organizations that cannot tend to discover that risk amplifies whatever they already are.
Final Thoughts
The MSSP results are genuinely good news for accountable care, and a useful counterweight to the REACH discount story. Record savings, record participation in earning them, and rising per-beneficiary performance.
But the distribution is the lesson. The savings live with the organizations bearing real risk — and those organizations were, in most cases, capable before they were exposed. As someone who has worked inside a risk-bearing network, my advice is unglamorous: earn your way up the risk ladder. The evidence rewards readiness, not appetite.
If you are weighing a move up the MSSP risk ladder — or between MSSP and LEAD for 2027 — the deciding question is whether your capability is ready, not whether the upside looks attractive. At HealtheNomics I help organizations assess that honestly before they commit to downside risk.
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