Moving beyond financial incentives to engage specialists in ACOs

 Moving beyond financial incentives to engage specialists in ACOs

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Accountable Care Organizations are struggling to find specialists to improve value-based care, although it is a top priority Centers for Medicare and Medicaid Services.

Meanwhile, ACOs face considerable challenges in effectively engaging specialists, according to a recent study from the Institute for Accountable Care in the American Journal of Managed Care.

The predominant influence of fee-for-service payment structures on specialist behavior was cited as a major hurdle by 58% of ACOs.

The study analyzed 101 Medicare ACOs participating in either the Medicare Shared Savings Program or the Realizing Equity, Access, and Community Health (REACH) ACO model as of 2023.

The researchers found while most ACOs prioritize specialist engagement, less than 10% indicated high levels of engagement in value-based care initiatives.

ACOs are actively seeking to involve specialists in their efforts, including integrating them into quality improvement projects (38%) and organizing collaborative sessions to establish evidence-based care pathways (30%).

Financial incentives play a significant role in encouraging specialist participation, with approximately half of ACOs offering such incentives.

These incentives target various aspects of performance and behavior, with 36% focused on clinical outcomes, 29% on cost outcomes, and 21% on patient satisfaction.

Lack of data is another challenge. More than half (53%) of respondents highlight a lack of data to evaluate specialist performance, and nearly half (49%) express concerns about insufficient resources or bandwidth to effectively address specialist alignment.


Study author Rob Mechanic told Healthcare Finance News the biggest challenge ACOs face is the lack of good data on specialist performance, particularly with respect to quality.

“There’s a lack of good measures and not much transparency in specialties that do have robust quality data,” he said.

From his perspective, the first strategy is engaging specialists in a dialogue and helping them understand the ACOs goals.

“ACOs are trying a lot of different things: sharing specialist performance data with PCPs, organizing specialist e-consult programs, working with specialists on quality improvement,” Mechanic said. “No single strategy is dominant.”

Even though financial incentives were identified as a key factor in encouraging specialist participation within ACOs, he said he personally believes financial incentives aren’t the most important element.

“Having a culture of quality and information systems that make it easy for specialists and primary care providers to collaborate is essential,” he explained.

This is more likely when ACOs have large integrated multispecialty groups where physicians all use the same electronic medical record.

“Financial incentives probably carry more weight for independent specialists. But referrals are even more important,” he said.

Mechanic noted independent specialists would collaborate if think they’re at risk for losing referrals.

“It is important to compensate specialists for their time,” he added. “Medicare only pays specialists about $50 for an e-consult with primary care so ACOs may need to supplement this.”


Mechanic said specialty care is fragmented in a lot of markets – especially when a lot of the specialists are independent.

“Specialty physicians are primarily paid fee-for-service and earn a lot,” he said. “Not all are willing to spend time coordinating with primary care.”

He noted doctors are busy and a lot of ACOs struggle getting the attention of specialists, and many ACOs don’t have staff or bandwidth to meet with specialists and encourage them to work with their ACO given other demands.

Mechanic said one of the more common strategies is working with specialists to improve quality and develop care pathways based on best practices.

“Specialists care about quality and tend to be more receptive to improving patient care than on finding ways to reduce spending,” he said.

The study noted the Center for Medicare and Medicaid Innovation (CMMI) strategy includes giving ACOs “shadow bundles” to help them understand their performance in episodes of care.

The strategy includes expanding bundled payment models, creating new models with explicit incentives for PCPs and specialists to collaborate, and potentially setting subpopulation-, condition-, or procedure-specific spending targets for ACOs.

Mechanic said while he believes this is generally the right strategy, he’d like to see ACOs get specialist data based on all the specialists’ Medicare patients including Medicare Advantage – not just ACO patients.

He called the CMMI’s recently announced mandatory bundle program “an important step” forward but noted it will impact hospitals more than ACOs.
From his perspective, greater transparency regarding specialty costs and outcomes will be critical to facilitating collaborative care delivery between primary care and specialty providers.

“It allows physician groups and ACOs to make better informed referral decisions,” Mechanic said. 

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