April 10, 2017

Do you know how your ACO works? These physicians didn't.

Daily Briefing

    Nearly half of physicians participating in Medicare Shared Savings Program (MSSP) ACOs in 2015 didn't know if they could receive shared savings or faced downside risk, according to a survey published this month in Health Affairs.

    The survey, which was conducted between September 2014 and April 2015, asked more than 1,400 doctors participating in Pioneer, MSSP, and Advance Payment Model ACOs about their programs' incentive structure and effectiveness, among other topics. 

    Each ACO model had a distinct incentive structure. Specifically, physicians participating in 2014 and 2015 in:

    • MSSP could receive bonuses for hitting performance targets, but the vast majority were not penalized for falling short of those targets;
    • The Advance Payment ACO Model (made up of ACOs participating in MSSP) received up-front access to capital for infrastructure investments; and
    • The Pioneer Model could receive bonuses and penalties based on their performance metrics.

    The Pioneer ACO program concluded in December 2016, while the Advance Payment model concluded in December 2015.

    Survey findings

    The survey found many doctors participating in each model were not aware how their respective incentive structures worked. Specifically: 

    • 36.5 percent of Advance Payment participants did not know if they or their practice faced downside risk and 16.1 percent said they did face downside risk;
    • 49.5 percent of MSSP participants did not know if they or their practice faced downside risk and 20.6 percent said they did face downside risk; and
    • 49.7 percent of Pioneer participants said they did not know if they or their practice faced downside risk and 19.8 percent inaccurately said they did not face downside risk.

    On the flipside, the survey found that similar proportions of physicians did not know whether they were eligible for shared savings in their respective programs. Specifically:

    • 32.9 percent of Advance Payment physicians said they were not sure whether they or their practice were eligible for shared savings;
    • 45.5 percent of MSSP participants said they were not sure whether they or their practice were eligible for shared savings; and
    • 47.2 percent of Pioneer participants said they were not sure whether they or their practice were eligible for shared savings.

    The survey also found that many doctors were unsure of which of their patients were attributable to an ACO. Specifically, 42.7 percent of MSSP, 21.4 percent of Advance Payment, and 34 percent of Pioneer physicians did not know which of their patients were attributable to an ACO.

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    In addition, the survey found that the percentage of physicians who were involved in the decision to join an ACO varied by ACO model. While about 65 percent of physicians in Advance Payment said they were a part of the decision, only 30 percent of those in MSSP and 19 percent of those in Pioneer said the same, the survey found.

    Overall, the survey found doctors were divided over the merits of ACOs. For instance, across all three ACO models, between 50 and 60 percent of physicians said ACOs were effective for the provision of cost-effective care. And a similar percentage of doctors said ACOs promoted high-quality care. But in both cases, Advance Payment physicians were the most likely to say ACOs were effective—as well as have a more positive view of ACOs overall.

    Comments

    Writing in Health Affairs, Claudia Schur, senior research director at L&M Policy Research, and Janet Sutton, a senior research director at the Center for Health Research and Policy, said the survey findings are potentially concerning because poor physician understanding of ACO models could undermine their efficacy. "The results of our survey suggest that many participating physicians' views are not aligned with ACO goals and that the physicians are divided as to whether or not the ACO model is effective," they wrote.

    However, Schur and Sutton noted that the survey gauged physicians' knowledge relatively soon after the ACO models launched in 2012. Nevertheless, they said that "identifying the most effective strategies to engage physicians is critical to the alignment of physicians' efforts and ACOs' goals" (Whitman, Modern Healthcare, 4/4; Rappleye, Becker's Hospital Review, 4/4; Lagasse, Healthcare Finance News, 4/4; Schur/Sutton, Health Affairs, April 2017). 

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