Early Provider Perspectives Within an Accountable Care Organization

ABSTRACT

Objectives: Little is known about how providers within accountable care organizations (ACOs) perceive ACO utility in early stages of operation. We explored initial perceptions of providers participating in the Johns Hopkins Medicine Alliance for Patients, LLC (JMAP), within 6 months of launching as an ACO.

Study Design: Online survey.

Methods: The survey was administered to primary care and cardiology providers in JMAP entities, including medical school faculty and physician practices, a regional ambulatory care network, and 3 additional community practices. We assessed their satisfaction with the care provided and perceptions of the ACO model, inter-provider coordination, and interventions likely to facilitate high-quality and cost-effective care within the organization. We compared perceptions by entity type and provider’s clinical area.

Results: About half of invited providers responded, and a considerable proportion (29%-49%) was neutral in rating their comfort, understanding, or expectations about becoming an ACO. Community practice providers were the most positive about becoming an ACO, and faculty providers were the least satisfied with the chronic care they were providing. Cardiologists reported better coordination with hospital teams than did primary care physicians; cardiologists also reported a higher frequency of communication with primary care practices than vice versa. Interventions to facilitate care coordination and provide more comprehensive care, such as use of care coordinators, behavioral therapists, or support staff to facilitate gaps in care, were considered important for success.

Conclusions: Six months into JMAP operations, providers gave ambivalent responses about their understanding of the implications of being an ACO, and subgroups within the ACO held different views. Data pointed to room for improvement in care coordination and care delivery interventions moving forward.

To improve the quality and efficiency of healthcare, the US health system is increasingly shifting from fee-for-service to value-based payment models. An accountable care organization (ACO), through the Medicare Shared Savings Program (MSSP), is a model created under the Affordable Care Act to facilitate this transformation.^1,2 In collaboration with a payer, provider groups voluntarily assume responsibility for quality and costs of care for a defined population of beneficiaries. If quality and spending targets are met, the provider organization may keep a portion of savings achieved. There are currently more than 740 ACOs in the public and private payer health sectors,³ and most of the US population lives in an ACO service area.⁴ Early results demonstrate potential flattening of the cost-curve, decreased utilization of emergency and postacute care, and improved clinical quality.^5,6

Engagement of healthcare providers facilitates success of ACOs.^7,8 Perceptions of providers regarding ACOs in early stages of development have, however, been largely unexplored. Although previous research has identified effective inter-provider communication and shared objectives as essential to ACO performance,⁹ these dimensions of relational coordination have not been assessed among participants in ACOs at academic medical centers (AMCs). Compared with other settings, the challenges of provider engagement may be different for emerging ACOs at AMCs, which have to combine this new care delivery model with their clinical, research, and educational missions.^10-13

We surveyed providers within a new, large AMC ACO for their perceptions of the model, satisfaction with care provided, assessment of inter-provider coordination, and utility of interventions likely to facilitate high-quality and cost-effective care within the organization.

METHODS

Study Setting

The Johns Hopkins Medicine Alliance for Patients, LLC (JMAP), is a non—risk-bearing MSSP ACO that was launched in January 2014 (Figure).¹⁴ Primary participating entities include: Johns Hopkins University Clinical Practice Association, comprising School of Medicine faculty and physician practices (hereafter referred to as SOM); Johns Hopkins Community Physicians (JHCP), including primary and specialty care outpatient sites; 2 primary care practices unaffiliated with Johns Hopkins Medicine (JHM); 1 cardiology community practice with a preexisting JHM relationship; and 5 JHM hospitals, which are all in Maryland and Washington, DC. There are approximately 2900 providers and 38,000 Medicare beneficiaries associated with JMAP.

JMAP undertook a multi-pronged communication effort at the program’s outset to inform providers and staff of JMAP goals and expected provider and beneficiary impact.¹⁵ Initiatives featured provider- and staff-focused webinars; practice-site “road show” visits; and clinical-, management-, and operations-related committee presentations. In addition, JMAP leadership established 3 regional advisory councils, which include medical and administrative leadership from each clinical site within the JMAP catchment area, to disseminate information and receive feedback on challenges or opportunities.¹⁵

To assess provider engagement and determine future interventions of focus, JMAP launched a provider survey in July 2014, approximately 6 months after ACO operations commenced. The survey was intentionally performed at outset of the organization to serve as a baseline of perceptions and also to assist in identifying priorities and strategies for management. At survey administration, the ACO outreach interventions previously described had been deployed. Medical and quality interventions were early in development and included implementation of care coordination in a high-risk subset of the Medicare beneficiary population in Baltimore through a related initiative. Within the ACO, providers or practices initially referred beneficiaries for care coordination support with JMAP. Early in 2015, the process transitioned to also employ a risk-prediction algorithm to identify beneficiaries most likely to benefit from available services. Other ACO interventions implemented in late 2014 included expanded population health functionality in the electronic health record (EHR) system and internal monitoring of ACO quality measures.

Data Collection and Instruments

We invited all JMAP primary care (internal medicine practitioners, general practitioners, and geriatricians) and cardiology providers by e-mail to complete an online provider survey. The survey was launched in mid-July 2014 and closed in early August. The Johns Hopkins Institutional Review Board and the JMAP Board of Directors reviewed and approved the instrument, which was constructed using both previously validated^16-18 and original items for the purpose of quality improvement (eAppendix, available at www.ajmc.com). Response choices were yes/no or agreement on a 5-point Likert scale, or were open-ended to allow elaboration. The survey included questions in 8 domains, including provider demographics; satisfaction with the care of chronically ill beneficiaries; and coordination, staff support, and resource use in the provider’s group practice.

Another domain asked to which hospital the provider sent beneficiaries most often, how frequently the inpatient and outpatient teams communicated, whether communication was timely, and the extent of shared goals and problem-solving between the hospital and the responding provider—the same dimensions of relational coordination supported in a recent paper by Rundall and colleagues.⁹ Additional domains investigated coordination among providers, providers’ understanding of the ACO, and how likely they believed certain interventions were to facilitate high-quality and cost-effective care.

The final domain included 2 open-ended questions to elicit more general feedback: “Do you have any ideas of how to improve the quality or efficiency of care provided within the ACO?” and “What are things that are being asked of you day-to-day, that, if removed, would not negatively impact the quality of patient care?”

Statistical Analysis

We compared respondents’ demographic and professional characteristics among ACO subgroups using Fisher’s exact tests for categorical variables and Kruskal-Wallis tests for continuous variables. To assess the differences among subgroups in rating coordination, communication, and perception of ACOs, we constructed ordinal logistic regression models to fit the ordered, discrete nature of the Likert-scaled dependent variables, and we adjusted for the respondent’s age, sex, years in practice, medical specialty, and clinical training. We accounted for clustering of responses from the same ACO subgroup using a fixed effect (dummy variable) for each group. To present how respondents rated interventions that may help achieve the ACO’s goals, we calculated the proportion of responses in the top 2 categories of the 5-point Likert scale—“very likely” and “likely”—by ACO subgroup. We examined differences among group preferences using binomial tests. All analyses were conducted using Stata software, version 14 (StataCorp LP, College Station, Texas). We report 2-sided P values and 95% CIs for statistical tests.

RESULTS

Characteristics of Respondents

We distributed the survey electronically to 444 primary care and cardiology providers in more than 40 institutional and community practices. A total of 216 responses were collected, including 99 respondents from SOM, 96 from JHCP, and 21 from the 3 additional community practices. The aggregate response rate was 48.6%. Within SOM, JHCP, and the community practices, the response rates were 49%, 48%, and 50%, respectively.

Most providers were physicians (84%), although nurse practitioners and physician assistants represented 5% to 14% of survey respondents within ACO subgroups (Table 1).

Cardiology providers formed 32% of respondents. Ninety-one percent of respondents were board certified. The average age of respondents was 48.1 years, and duration at current practice ranged from less than 1 year to 42 years (average = 10.6 years).

Coordination of Care

SOM respondents were more likely to assess frequency of communication with hospitals as high than JHCP providers were (odds ratio [OR], 2.3; 95% CI, 1.2-4.2) (Table 2). Ratings of other dimensions of care coordination with hospitals were not statistically different among the ACO subgroups. Cardiology providers had higher odds than primary care providers of favorably assessing frequency of communication (OR, 2.6; 95% CI, 1.4-4.9), goals alignment (OR, 2.2; 95% CI, 1.2-4.1), and problem-solving communication (OR, 3.2; 95% CI, 1.7-6.2) with hospitals.

Cardiology and primary care providers rated alignment of goals between their respective practices similarly (Table 2). Cardiology providers, however, were more likely to report higher frequency of communication with primary care practices than vice versa (OR, 2.2; 95% CI, 1.1-4.4; P = .03). On the other hand, primary care practices were more likely to rate timeliness of communication from cardiology practices favorably than vice versa (OR, 7.9; 95% CI, 3.7-17.0; P <.001).

Perceptions of ACO

When asked to rate their comfort with, understanding of, or expectations about becoming an ACO, a considerable proportion of respondents (29%-49%) chose the neutral response option (Table 3), indicating neither negative nor positive assessment. Generally, the 3 community practices had the most positive view of the ACO model, followed by JHCP respondents, and then SOM affiliates. SOM affiliates were less likely to be comfortable with ACO-induced changes (vs JHCP: OR, 0.32; 95% CI, 0.17-0.62; vs community practices: OR, 0.20; 95% CI, 0.08-0.52), less likely to indicate understanding of the implications of becoming an ACO (vs JHCP: OR, 0.40: 95% CI, 0.22-0.74; vs community practices: OR, 0.15; 95% CI, 0.06-0.38), less likely to express confidence that the ACO model can improve care (vs JHCP: OR, 0.33; 95% CI, 0.18-0.64; vs community practices: OR, 0.19; 95% CI, 0.07-0.48), and less likely to have informed patients that their practice had joined an ACO (vs JHCP: OR, 0.49; 95% CI, 0.27-0.91; vs community practices: OR, 0.10; 95% CI, 0.04-0.27). JHCP respondents were less likely than their counterparts in other community practices to report understanding the implications of becoming an ACO (OR, 0.37; 95% CI, 0.16-0.89) and less likely to tell their patients about the ACO (OR, 0.20; 95% CI, 0.08-0.52). All subgroups reported little desire for an organizational role in the ACO.

Respondents from all subgroups reported similar levels of satisfaction with communication with patients and families at their practices. SOM respondents, however, were more likely than their counterparts in other subgroups to assess teamwork and satisfaction with coordination of care at their practices as being significantly lower. We did not find significant differences in perceptions of the ACO and satisfaction with patient care by providers’ medical specialties.

Interventions Assessed by Providers to Facilitate ACO Effectiveness

Eighty-four percent of respondents believed the provision of care coordinators was likely or very likely to facilitate high-quality and cost-effective care within the ACO (Table 4). Other interventions favored by more than 80% of respondents were: improving communication and coordination of care throughout the care continuum (83%), using support staff to facilitate timely communication of test results (83%), and provision of behavioral therapists to address mental health issues (82%). Providing centralized scheduling for primary and specialty care was the only proposed initiative that garnered support from less than half (42%) of respondents.

There was some, but not complete, overlap among interventions supported by the respective ACO subgroups. Among SOM respondents, interventions with the greatest support were provision of behavioral therapists (79%), support staff for timely communication of test results (79%), and home-based monitoring and palliative services (78%). JHCP respondents expressed strong support for provision of care coordinators (92%), improved coordination throughout the continuum of care (87%), and support staff to identify service gaps (85%). Interventions most supported by providers in the 3 community practices were: quick follow-up with discharged patients (95%), support staff for timely communication of test results (95%), provision of behavioral therapists (90%), and improving communication and coordination throughout the continuum of care (90%). Compared with JHCP respondents, a significantly lower proportion of SOM affiliates recommended provision of care coordinators, support staff to identify service gaps, a 24-hour call center, evidence-based clinical practice guidelines within EHRs, or clinical decision support tools as interventions likely to foster ACO effectiveness.

DISCUSSION

This study provides a comprehensive initial assessment of providers’ perceptions within a new AMC ACO. The findings contribute to the sparse literature on a major “category of influence” on ACO impact: the readiness and perceptions of participating providers to adopt this new delivery and payment model.² Whereas previous assessments of the early phases of ACO implementation have relied on the views and knowledge of ACO administrators only,^8,19 the ACO model is typically provider-driven, and our study draws responses from front-line clinicians and staff for an early appraisal of perceptions.

Six months in, the providers surveyed were, on average, only slightly more positive than neutral on care provided to chronically ill beneficiaries, practice teamwork, and coordination of care with hospitals or other outpatient facilities. Furthermore, about half of respondents responded neutrally when asked to express their comfort with changes due to the new model. They were uncertain whether the ACO would improve care for their beneficiaries, did not understand the practice-level implications, and typically did not mention it to their patients. Considering this, it is not too surprising that few clinicians expressed interest in an ACO organizational role. Nevertheless, since others have suggested previously that involving providers in ACO leadership and governance is important for improved engagement^12,20 and building trust in a new care model,²¹ this clearly represents an area of future opportunity. The community practices reported greatest contentment with joining the ACO and were most likely to discuss their ACO involvement with patients. This finding may reflect their interest in both value-based care models and the more intensive investigation process they conducted to determine whether to join JMAP.

Effective engagement of providers under the ACO model is critical to motivating the care transformations necessary to improve outcomes, and it also influences beneficiaries’ acceptance of this model of care.^7,19 In addition to the awareness deficits discussed above, uncertainty among clinical staff may arise from possible alterations to organizational design or clinical systems that accompany transition to a more collaborative, team-based model. For AMCs in particular, the conversion implies that faculty practices may have more opportunity to participate in team-based care, consider standardization of clinical processes, and ensure that access to both primary and specialty care is emphasized.¹⁰ Furthermore, advancing population health may involve new collaborations with community practices, public health departments, and community social service organizations.¹⁹

Innovative ways previously suggested to increase provider engagement include involvement in shared savings distribution schemes, incorporating quality of care into criteria for promotion, and rewarding clinical excellence.¹¹ In response to the survey results, considerable emphasis has been placed on development of comprehensive communication tactics, as well as implementation of a more robust medical and quality strategy to support identified needs. This strategy includes broadening behavioral health support, access to specialty care, and use of population-based pharmacy support.

On average, respondents were slightly satisfied with the quality of care provided to chronically ill beneficiaries at their respective practices. In their open-ended comments, providers cited difficulty accessing EHR information on encounters outside of the ACO network as an impediment to providing better care. Other recurrent concerns were care coordination challenges within the ACO and inadequate time during office visits for proper attention to beneficiaries with complex conditions. When asked about day-to-day activities that detract from care of beneficiaries, providers similarly mentioned EHR inefficiencies, excessive requirements for documentation, and inadequacy of support staff. These represent overarching systems challenges typically not under direct control of the ACO. These challenges, however, must be addressed at the system level with the ACO as a key stakeholder.

To facilitate ACO implementation, providers favored initiatives to improve communication and coordination of care over enhancements to EHRs and scheduling systems. Coordination and adequate communication across the spectrum of providers in an ACO is integral to success in improving care and reducing spending.^22-24 Cooperation among physicians and acute care facilities relies on alignment of incentives across settings.^2,19 It is worth noting that emphasis on care coordination has been in place within Johns Hopkins Medicine’s Maryland hospitals for the last 5 years due to the state’s all-payer rate regulation,²⁵ as well as other ongoing initiatives. Nevertheless, our results suggest that respondents are uncertain about whether the acute care facilities and outpatient providers share the same goals. Of note, SOM affiliates rated coordination with hospitals higher than did other subgroups. This may reflect the fact that SOM providers are more likely to practice in hospital-based clinics and to have concomitant inpatient responsibilities.

Limitations

An important limitation of our study is that we conducted a cross-sectional assessment of perceptions at a single ACO without a comparison group or pre-intervention counterfactual. A recent taxonomy of ACO structure²⁶ raises the question of whether our results are generalizable to other ACO types. We had a reasonable response rate of 49%, but we did not collect information on nonrespondents in our anonymous survey. It may be that providers who did not participate would have reported lower levels of satisfaction with care and engagement, or that those with greater concerns may have viewed the survey instrument as an opportunity to voice overarching concerns. It is also unclear whether providers’ comments in completing the survey reflect a true understanding of specific ACO goals or interventions, as these may be difficult to extricate from pre-existing programs. This general awareness may evolve over time, and it would be interesting to repeat the survey at a future date.

CONCLUSIONS

The early experience of JMAP, an AMC ACO, supports the notion that even for a relatively integrated system with experience in performance-based payment, engagement is an incremental process.^7,13 Limited physician engagement can be a barrier to achieving goals as an ACO develops, and significant effort needs to be devoted to educating providers on ACO goals and providing opportunities for input. Case studies of emerging ACOs at varying stages of implementation are warranted to educate providers, administrators, and policy makers, and to advance dissemination of innovations successful in enhancing physician engagement and inter-provider coordination under this new, but promising, model of delivering care.

Author Affiliations: Department of Health Policy and Management (JAM, OAF, YJH) and Department of Epidemiology (JHY), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Division of Cardiology, Department of Medicine (SAB) and Office of Physicians (Accountable Care) (SAB), Johns Hopkins University School of Medicine (JHY, MM, SAB), Baltimore, MD; Johns Hopkins Community Physicians (MM), Baltimore, MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions (JAM, JHY), Baltimore, MD; Johns Hopkins Health Care, LLC (JAM, JHY), Baltimore, MD; Johns Hopkins Medicine Alliance for Patients, LLC (SAB), Baltimore, MD; Signature Partners, Inova Health System (MGP), Falls Church, VA.

Source of Funding: None.

Author Disclosures: Dr Berkowitz is the executive director and a member of the Board for JMAP. Dr Poffenroth is the former medical director for JMAP. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. JMAP is affiliated with Johns Hopkins Medicine. The Bloomberg School of Public Health is part of Johns Hopkins University.

Authorship Information: Concept and design (SAB, JAM, MM, MGP, JHY); acquisition of data (SAB, JAM, MM, MGP, JHY); analysis and interpretation of data (SAB, OAF, YJH, JAM, MGP, JHY); drafting of the manuscript (SAB, OAF, YJH, JAM, MGP, JHY); critical revision of the manuscript for important intellectual content (SAB, OAF, JAM, MGP, JHY); statistical analysis (OAF, YJH); provision of study materials or patients (JAM, JHY); administrative, technical, or logistic support (OAF, JAM, MM, JHY); and supervision (SAB, JAM, JHY).

Send Correspondence to: Jill A. Marsteller, PhD, MPP, Associate Professor, Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205. E-mail: jmarste2@jhu.edu.

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