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The American Journal of Managed Care July 2018
Differences in Spending on Provider-Administered Chemotherapy by Site of Care in Medicare
Yamini Kalidindi, MHA; Jeah Jung, PhD; and Roger Feldman, PhD
The Development of Diabetes Complications in GP-Centered Healthcare
Kateryna Karimova, MSc; Lorenz Uhlmann, MSc; Marc Hammer, MPH; Corina Guethlin, PhD; Ferdinand M. Gerlach, MD, MPH; and Martin Beyer, MSc
Value-Based Health Insurance Design: How Much Does Socioeconomic Status Matter?
Bruce W. Sherman, MD, and Carol Addy, MD, MMSc
Insights on Site-of-Care Cancer Research: Both Quality and Cost Information Are Necessary to Guide Policy
Kavita Patel, MD, MPH, and A. Mark Fendrick, MD
Examining Differential Performance of 3 Medical Home Recognition Programs
Ammarah Mahmud, MPH; Justin W. Timbie, PhD; Rosalie Malsberger, MS; Claude M. Setodji, PhD; Amii Kress, PhD; Liisa Hiatt, MS; Peter Mendel, PhD; and Katherine L. Kahn, MD
Prices for Physician Services in Medicare Advantage Versus Traditional Medicare
Julius L. Chen, PhD; Andrew L. Hicks, MS; and Michael E. Chernew, PhD
Forgotten Patients: ACO Attribution Omits Those With Low Service Use and the Dying
Mariétou H. Ouayogodé, PhD; Ellen Meara, PhD; Chiang-Hua Chang, PhD; Stephanie R. Raymond, BA; Julie P.W. Bynum, MD, MPH; Valerie A. Lewis, PhD; and Carrie H. Colla, PhD
Postdischarge Engagement Decreased Hospital Readmissions in Medicaid Populations
Wanzhen Gao, PhD; David Keleti, PhD; Thomas P. Donia, RPh; Jim Jones, MBA; Karen E. Michael, MSN, MBA, RN; and Andrea D. Gelzer, MD, MS, FACP
Currently Reading
ACOs With Risk-Bearing Experience Are Likely Taking Steps to Reduce Low-Value Medical Services
Margje H. Haverkamp, MD, PhD; David Peiris, MD, PhD; Alexander J. Mainor, JD, MPH; Gert P. Westert, PhD; Meredith B. Rosenthal, PhD; Thomas D. Sequist, MD, MPH; and Carrie H. Colla, PhD
Inpatient Placement: Associations With Mortality, Cost, and Length of Stay
Daniel A. Handel, MD, MBA, MPH; Zemin Su, MS; Nancy Hendry, MSN; and Patrick Mauldin, PhD

ACOs With Risk-Bearing Experience Are Likely Taking Steps to Reduce Low-Value Medical Services

Margje H. Haverkamp, MD, PhD; David Peiris, MD, PhD; Alexander J. Mainor, JD, MPH; Gert P. Westert, PhD; Meredith B. Rosenthal, PhD; Thomas D. Sequist, MD, MPH; and Carrie H. Colla, PhD
Experience with risk-based contracting best predicts active engagement of accountable care organizations in reducing low-value medical services, mainly through physician education and encouraging shared decision making.

Objectives: Accountable care organizations (ACOs) are groups of healthcare providers responsible for quality of care and spending for a defined patient population. The elimination of low-value medical services will improve quality and reduce costs and, therefore, ACOs should actively work to reduce the use of low-value services. We set out to identify ACO characteristics associated with implementation of strategies to reduce overuse.

Study Design: Survey analysis.

Methods: We used the National Survey of ACOs to determine the percentage of responding ACOs aware of the Choosing Wisely campaign and to what degree ACOs have taken steps to reduce the use of low-value services. We identified characteristics of ACOs associated with implementing low-value care–reducing strategies using 3 statistical models (stepwise and LASSO logistic regression and random forest).

Results: Responding executives of 155 of 267 ACOs (58%) were aware of Choosing Wisely. Eighty-four of those 155 ACO leaders said that their ACOs also actively implemented strategies to reduce the use of low-value services, largely through educating physicians and stimulating shared decision making. All 3 models identified the presence of at least 1 commercial payer contract and prior joint experience pursuing risk-based payment contracts as the most important predictors of an ACO actively implementing strategies to reduce low-value care.

Conclusions: In the first year of implementation, just one-third of ACOs had taken steps to reduce the use of low-value medical services. Safety-net ACOs and those with little experience as a risk-bearing organization need more time and support from healthcare payers and the Choosing Wisely campaign to prioritize the reduction of overuse.

Am J Manag Care. 2018;24(7):e216-e221
Takeaway Points

Collective risk taking in financial contracts is the most influential determinant for accountable care organizations (ACOs) in taking steps to reduce unnecessary care. Safety-net ACOs are not likely to take steps like educating physicians on low-value medical services and encouraging shared decision making. ACOs with less experience in risk bearing will likely start to prioritize overuse when they acquire more risk as an organization.
  • ACOs with little experience in risk bearing and safety-net ACOs should be specifically stimulated to reduce overuse with targeted advocacy efforts of healthcare payers and the Choosing Wisely campaign.
  • Research should focus on identifying efficient strategies for waste reduction with specific attention to audit-and-feedback mechanisms on overuse and underuse.
Accountable care organizations (ACOs) are voluntary groups of provider organizations that are collectively held accountable for both quality of care and total spending for a defined group of patients through payment contracts. A promising strategy to improve quality and financial sustainability involves the reduction of low-value medical services. Indeed, prior research shows a modest decrease in the use of low-value care, and thus in spending rates, for ACOs compared with non-ACO providers with predominantly fee-for-service payment models.1 While utilization and related spending have decreased in ACOs, quality scores and care satisfaction have remained similar or improved compared with other organizations.2-4 However, it is not clear what strategies ACOs deploy to lower unnecessary care, nor what features predict a commitment toward overuse reduction.

One way to tackle low-value care is to embrace the Choosing Wisely campaign.5 Choosing Wisely aims to reduce the delivery of low-value medical services by promoting conversations between patients and physicians on the appropriateness of care. More than 70 US specialty societies have defined concise lists of 5 to 10 wasteful interventions that “physicians and patients should question.”5 The synergies of ACOs and Choosing Wisely regarding care improvement and overuse reduction suggest that ACOs committed to reducing low-value care should be aware of this campaign and also work toward actively lowering the utilization of these medical services. In this study, we analyze data from the National Survey of ACOs (NSACO) to determine which strategies are used to reduce low-value care and identify the ACO characteristics that predict the use of such methods.



The NSACO is an online survey designed by researchers at the Dartmouth Institute for Health Policy and the University of California, Berkeley. It questions ACOs (Medicare Shared Savings Program [MSSP] ACOs, Medicare Pioneer ACOs, state Medicaid ACOs, and commercial payer ACOs) on their composition, characteristics, contracts, and capabilities.6,7 A total of 752 ACOs were identified through public documents, provider surveys, scientific literature, and certification by the National Committee for Quality Assurance and invited to participate. Senior ACO executives, including chief executive officers, executive directors, and chief medical officers, filled out the survey. At the time of our analysis, the survey was fielded in 3 consecutive waves, with each wave questioning newly formed ACOs (wave 1, October 2012-May 2013; wave 2, September 2013-March 2014; wave 3, November 2014-May 2015). The median duration between the implementation of the ACO contract to the time of the survey was 11.6 months (interquartile range, 7.1-13.2 months).7 Over all 3 waves, 64% of ACOs filled out the survey. Waves 2 and 3 of the survey were more elaborate, and therefore, ACOs from wave 1 were approached with a follow-up survey asking additional questions during the fielding of wave 3. Questions about Choosing Wisely were not asked in wave 1, excluding from our analysis 93 ACOs that participated in the first wave but not the follow-up survey. Survey questions related to Choosing Wisely included: (1) “Are you aware of the Choosing Wisely program?” and, if the response was positive, (2) “What steps have you taken to reduce the use of Choosing Wisely tests and procedures?”

Multivariate Statistical Modeling

We divided our sample into 2 groups: (1) ACOs not aware of the Choosing Wisely campaign or aware but not taking steps to support it and (2) ACOs taking steps to actively reduce the use of low-value medical services.

We compiled an a priori list of 62 survey responses that could be associated with the decision to take steps to support Choosing Wisely (the eAppendix Table [eAppendix available at] lists these characteristics). Based on existing hypotheses about how these characteristics might affect an ACO’s decision to take steps to reduce overuse, as well as on simple pairwise significance tests, we then selected a subset of 22 variables from this list. We excluded ACO characteristics on quality behavior to prevent potential reverse causality with waste-reducing efforts. To identify the main drivers behind the decision to take steps to reduce overuse within those 22 variables, we used both logistic regression (stepwise regression and LASSO regression) and classification techniques (random forest).8 Stepwise logistic regression was performed both backward and forward. LASSO imposes shrinkage constraints on the variables, resulting in an optimal model with only those characteristics that have a coefficient greater than 0. Random forest stratifies the predictor space in regions with nonlinear boundaries between variables, producing multiple decision trees that are combined into a single consensus prediction. The 3 statistical approaches identified 3 sets of prediction variables, and we subsequently assessed consistency of associations across these 3 models. Furthermore, we evaluated the relative predictive merits of each model by comparing their receiver operating characteristic (ROC) curves and confusion matrices on the basis of their implied misclassification rates (fraction of false positives and false negatives).

Savings and MSSP Quality Scores

CMS publicly reports shared savings payments and the outcomes of 33 quality measures per performance year for each participating ACO. The quality scores are in 4 domains: patient experience (including a measure on shared decision making), care coordination, at-risk measures, and preventive care. We calculated an overall quality score and a quality score per domain for the first 2 performance years of each ACO (the year in which the ACO filled out the survey) using the CMS sliding scale approach, as described elsewhere.7,9 We compared these quality scores and the savings per beneficiary attributed to the ACO according to CMS in the first 2 years with reference to historical expenditure benchmarks, between ACOs taking steps to reduce overuse and ACOs not taking steps, using a 2-sample t test.

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