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Until recently, the rate of adverse effects with low dose MTX had not been precisely determined due to limited data mainly derived from observational studies, case series and case-reports [6, 7]

We also noted that since an ACO's performance can vary from year to year (in terms of whether the ACO generates savings or losses and is eligible for shared savings or owes shared losses), it is possible for there to be a mixed effect across reopening payment determinations for multiple performance years