# Strategic Behavior Among Provider Organizations in Risk-Sharing Contracts

> **NIH AHRQ R36** · HARVARD MEDICAL SCHOOL · 2020 · $39,280

## Abstract

Project Summary
Payment and delivery system reform receives significant and increasing attention from health care payers,
providers, and the government. In the pursuit of lowering spending growth and improving quality of care, new
payment models are expanding and incentivizing changes in care delivery. Population-based risk-sharing
models, or Accountable Care Organizations (ACO), are one of these major reforms and brings groups of
providers together to share financial and clinical responsibility for patient populations. While intended to
incentivize higher quality and more efficient health care delivery, these payment models also create new
opportunities for strategic behavior that serves providers’ financial self-interest but may not support these
goals. This study hopes to shed light on how participating providers and organizations may be responding to
incentives in unintended ways and whether they are able to leverage information on the quality and spending
of their own and surrounding providers. Insight into such sophisticated organizational behavior may have
important implications for the success of future payment reform and competition in provider markets, which
aligns with Agency for Healthcare Research and Quality priorities. Focusing on the Medicare Shared Savings
Program (MSSP), one of the largest ACO models in the country, this study investigates whether ACOs
respond strategically to certain MSSP payment rules and will have three aims: (1) study health system ACOs
and referral patterns, (2) study selective ACO participation and reconfiguration favoring lower spending
providers, and (3) study selective ACO reconfiguration favoring higher quality providers. The study will
primarily rely on MSSP ACO Provider and Beneficiary Research Identifiable Files, administrative Medicare
data, a random 20% sample of Medicare claims, and a new, comprehensive, national-level dataset on U.S.
health systems. To study Aim 1, I will employ an event study interrupted timeseries analysis comparing referral
patterns before and after non-system practices begin ACO contracts with health systems. I then compare this
single group trend to several different control groups. To study Aims 2 and 3, I use non-ACO counterfactuals in
an evaluation-based approach that estimates ACO spending and quality effects with and without fixing ACO’s
provider practice configuration to determine the extent to which practice selection affects estimated effects. I
follow this approach with a separate flow analysis that compares practices exiting or entering ACOs with those
that remain to determine whether baseline spending and quality is associated with the likelihood of eventual
exit from or entry into an ACO.

## Key facts

- **NIH application ID:** 9987171
- **Project number:** 1R36HS027531-01
- **Recipient organization:** HARVARD MEDICAL SCHOOL
- **Principal Investigator:** Peter Lyu
- **Activity code:** R36 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2020
- **Award amount:** $39,280
- **Award type:** 1
- **Project period:** 2020-03-01 → 2021-05-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9987171

## Citation

> US National Institutes of Health, RePORTER application 9987171, Strategic Behavior Among Provider Organizations in Risk-Sharing Contracts (1R36HS027531-01). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9987171. Licensed CC0.

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