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

  • Adam A. Markovitz
  • Michael D. Rozier
  • Andrew M. Ryan
  • Susan D. Goold
  • John Z. Ayanian
  • Edward C. Norton
  • Timothy A. Peterson
  • John M. HollingsworthEmail author
Original Research



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.


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


Cross-sectional survey of ACO clinicians in 2018.


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.


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.


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.


healthcare reform health policy health services research stakeholder engagement survey research 



This work benefited from guidance on survey development and administration from Lisa Holland, M.A., Tedi Engler, B.S., and Eve Kerr, M.D., M.P.H. The authors acknowledge the Physician Organization of Michigan ACO for its commitment to evaluation and research.

Funding Information

Mr. Markovitz is supported by the Horowitz Foundation For Social Policy, AHRQ grant R36HS025615, and the University of Michigan Rackham Hammel Research Award. Dr. Ryan is supported by National Institute on Aging grant R01AG047932. Dr. Hollingsworth is supported by AHRQ grants R01HS024728 and 1R01HS024525-01A1. The Physician Organization of Michigan ACO provided funds for survey mailings.

Compliance with Ethical Standards

Conflict of Interest

Dr. Rozier, Dr. Goold, Dr. Ayanian, Dr. Norton, and Dr. Peterson have no disclosures to make. The remaining author disclosures are listed in the funding statement.


The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation of the manuscript; or decision to submit the manuscript for publication.

Supplementary material

11606_2019_5511_MOESM1_ESM.docx (1.6 mb)
ESM 1 (DOCX 1655 kb)


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Adam A. Markovitz
    • 1
    • 2
  • Michael D. Rozier
    • 3
  • Andrew M. Ryan
    • 2
    • 4
  • Susan D. Goold
    • 2
    • 4
    • 5
  • John Z. Ayanian
    • 2
    • 4
    • 5
    • 6
  • Edward C. Norton
    • 2
    • 4
    • 7
    • 8
  • Timothy A. Peterson
    • 9
    • 10
  • John M. Hollingsworth
    • 4
    • 11
    Email author
  1. 1.University of Michigan Medical SchoolAnn ArborUSA
  2. 2.Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborUSA
  3. 3.Department of Health Management and PolicySaint Louis UniversitySt. LouisUSA
  4. 4.Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborUSA
  5. 5.Division of General Medicine, Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborUSA
  6. 6.Gerald R. Ford School of Public PolicyUniversity of MichiganAnn ArborUSA
  7. 7.Department of EconomicsUniversity of MichiganAnn ArborUSA
  8. 8.National Bureau of Economic ResearchCambridgeUSA
  9. 9.Physician Organization of Michigan Accountable Care OrganizationAnn ArborUSA
  10. 10.Department of Emergency MedicineUniversity of Michigan Medical SchoolAnn ArborUSA
  11. 11.Dow Division of Health Services Research, Department of Urology University of Michigan Medical SchoolAnn ArborUSA

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