Over 100 million Americans struggle to access primary care. A flawed policy could make it more difficult. The Centers for Medicare and Medicaid Services’ (CMS’) Accountable Care Prospective Trend (ACPT) poorly predicts the cost of care growth and is lowering benchmarks for Accountable Care Organizations (ACOs). In its first year, CMS stepped in to reweight the trend, but stopped short of fixing the policy to protect clinicians from future projection errors. Now in 2025, spending is 90% higher than predicted – potentially costing 375,000 clinicians more than $500 million.

This is reducing clinicians’ crucial revenue and making it harder to keep them in accountable care programs that reward health outcomes instead of volume of services. Doctors must be paid fairly for providing high-quality, preventive care.

Background on the ACPT: The Accountable Care Prospective Trend (ACPT) is a fixed projected growth rate determined at the beginning of an ACO’s agreement period. It is one-third of the ACO’s trend update, blended with national and regional growth rates.

CMS introduced the ACPT for 2024 to address benchmark ratchet challenges. Program-wide benchmark ratcheting occurs when ACOs collectively reduce national and regional growth trends as they reduce expenditures and the number of beneficiaries in the program grows. ACO-specific benchmark ratcheting occurs when an ACO lowers spending during an agreement period. This lowers the baseline historical spending when they renew their contract with Medicare.

The intention: The trend was expected to allow benchmarks to increase beyond actual spending as ACOs slowed overall spending growth. It was also considered an initial step towards administratively set benchmarks, which would no longer rely on the shrinking fee-for-service population.

The challenge: The trend is calculated based on United States Per Capita Cost (USPCC) growth projections. Unfortunately, in the first year alone the projection missed Medicare spending by 48%, failing to reflect the economic pressures facing clinicians. As a result, clinicians lost $154 million for care they delivered. This also led to a 1.3% reduction in ACO benchmarks.

Now in 2025, spending is already 90% higher than the ACPT prediction – potentially costing 375,000 clinicians more than $500 million. Coupled with a lack of advanced alternative payment model incentives, ACOs face greater financial uncertainty, making it harder to keep clinicians in the program.

The solution: CMS must retire the flawed ACPT and replace it with an approach that:

• Pays clinicians fairly
• Reflects an accurate trend system
• Increases the prior savings adjustment
• Allows ACOs to receive regional adjustments and the prior savings adjustment
• Addresses benchmark reset