Low-value care and clinician engagement in the Medicare Shared Savings Program: a survey of frontline clinicians

Objectives: Although the Medicare Shared Savings Program (MSSP) created new organizational incentives to improve health care value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care. It is unclear whether this reflects organizational failure to engage frontline clinicians charged with implementing ACO initiatives. Although policymakers have called for fostering clinician awareness of ACO goals and aligning organizational and clinician incentives since the inception of the ACO model, the perspective of individual clinicians has been largely absent. In this study, we asked: Have ACOs successfully engaged frontline clinicians? Is ACO engagement associated with clinicians’ reported ability to implement recommendations against low-value care?

Student Design: We designed and administered a survey to clinicians in one of the ten largest MSSP ACOs in the country. 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 (e.g., “Don’t recommend cancer screening in adults with life expectancy of less than 10 years”). We estimated linear probability fixed-effects models to assess the relationship between ACO engagement and reported difficulty implementing a recommendation against low-value care. In our preferred specification, we compared differences in ACO engagement and difficulty implementing a recommendation among clinicians responding to the same recommendation and who were in same specialty (e.g., urology), clinician type (e.g., physician), and provider organization (e.g., Michigan Medicine). To reduce bias from survey nonresponse, we applied post-stratification survey weights calibrated using iterative proportional fitting. To reduce bias from missing data among respondents, we used multiple imputation and implemented a quadratic-rule procedure to select the number of imputations needed for estimate and standard error replicability.

Results: The analytic sample included 1,289 ACO clinician, comprising advanced practice providers (29%), physician specialists (27%), primary care physicians (18%), internal medicine specialists (16%), and surgeons (10%). Response rate was 34%. We found limited ACO engagement of frontline clinicians: 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 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 (one standard deviation [SD]) was associated with decreased difficulty (-2.3 percentage point [p.p.], 95% confidence interval [CI]: -3.8, -0.7) implementing recommendations, as was perceived quality improvement (1 SD increase, -2.1 p.p., 95% CI, -3.4, -0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation.

Conclusion: ACO clinicians were broadly unaware of and unaffected by ACO objectives and activities. Limited engagement of ACO clinicians may hamper ACO efforts to reduce low-value care.