Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: a Survey of Frontline Clinicians

Abstract

Background: Although the Medicare Shared Savings Program (MSSP) created new incentives for organizations to improve healthcare value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care.

Objective: To assess ACO engagement of clinicians and whether engagement was associated with clinicians' reported difficulty implementing recommendations against low-value care.

Design: Cross-sectional survey of ACO clinicians in 2018.

Participants: 1289 clinicians in the Physician Organization of Michigan ACO, including generalist physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). Response rate was 34%.

Main measures: Primary exposures included clinicians' participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. Our primary outcome was clinicians' reported difficulty implementing recommendations against low-value care.

Results: Few clinicians participated in the decision to join the ACO (3%). Few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few agreed (moderately or strongly) the ACO changed compensation (20%), practice (19%), or feedback (15%) or that it improved care coordination (17%) or inappropriate care (13%). Clinicians reported they had difficulty following recommendations against low-value care 18% of the time; clinicians reported patients had difficulty accepting recommendations 36% of the time. Increased ACO awareness (1 standard deviation [SD]) was associated with decreased difficulty (- 2.3 percentage points) implementing recommendations (95% confidence interval [CI] - 3.8, - 0.7), as was perceived quality improvement (1 SD increase, - 2.1 percentage points, 95% CI, - 3.4, - 0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation.

Conclusions: Clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further longitudinal study.

Keywords: health policy; health services research; healthcare reform; stakeholder engagement; survey research.

Figure 1

Association between clinician involvement in decision to join ACO and recommendations against low-value care. Models compare differences between clinicians who were not involved but were aware of decision to join ACO (panel a) or were involved in decision-making process (panel b) versus the reference group, clinicians who were not involved in or aware of the decision to join the ACO. Models are described in the main text. Survey weights were applied to generalize to the Physician Organization of Michigan ACO. Multiple imputation was used for missing data. ACO, accountable care organization; CI, confidence interval.

Figure 2

A. Association between clinician ACO awareness and recommendations against low-value care. Estimated change is for a 1 standard deviation increase in the ACO Awareness scale. The scale and models are described in the main text and in Table2. Survey weights were applied to generalize to the Physician Organization of Michigan ACO. Multiple imputation was used for missing data. ACO, accountable care organization; CI, confidence interval.

Figure 3

Association between perceived ACO impact on practice and quality and recommendations against low-value care. Estimated change is for a 1 standard deviation increase in either the ACO Practice Change scale (panel a) or the ACO Quality Improvement scale (panel b). Scales and models are described in the main text and in Table2. Survey weights were applied to generalize to the Physician Organization of Michigan ACO. Multiple imputation was used for missing data. ACO, accountable care organization; CI, confidence interval.