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

J Gen Intern Med. 2020 Jan;35(1):133-141. doi: 10.1007/s11606-019-05511-8. Epub 2019 Nov 8.


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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Accountable Care Organizations*
  • Aged
  • Cost Savings
  • Cross-Sectional Studies
  • Humans
  • Longitudinal Studies
  • Medicare*
  • Michigan
  • United States