The Pioneer Accountable Care Organization program is now down to 19 programs, out of an original 32, worrying those who have pushed for skilled nursing facilities to embrace the concept.

Franciscan Alliance in Indianapolis, Genesys PHO in Michigan, and Renaissance Health Network in Pennsylvania have now left the program, now in its third year, Modern Healthcare first reported Thursday.

In August, Sharp HealthCare in California dropped out, despite improving readmission rates and decreasing use of skilled nursing facilities.

The news arrived the same day that Avalere Health released an analysis that said 59% of Medicare Shared Savings Program participants had below-average quality scores. The only ACO that had to repay CMS had achieved better than average quality.

“These ACO results reveal a potential disconnect between achieving high-quality care as indicated by the ACO quality measures and the ability to achieve savings,” said Erik Johnson, senior vice president, Avalere Health.