Use of voluntary alignment in the Next Generation ACO model

To describe adoption and use of voluntary alignment throughout the Next Generation Accountable Care Organization (NGACO) model from 2016 through 2021. Voluntary alignment allows Medicare beneficiaries to self-attribute to a particular medical provider or organization by signing a form or making a selection in the MyMedicare.gov portal.

We performed mixed-methods analyses of cross-sectional survey, enrollment, and claims data and coding transcripts of interviews with NGACO leadership.

We statistically compared characteristics of NGACOs and beneficiaries that engaged in voluntary alignment compared to claims alignment. Additionally, we grouped qualitative interview responses into 2 overarching themes that emerged around NGACO leaders' perceptions, use, and experiences with voluntary alignment.

Few NGACOs engaged in widespread use of voluntary alignment. NGACOs that adopted voluntary alignment were similar to those that did not in most respects, although beneficiaries aligned through voluntary alignment were sicker and more expensive than those aligned through claims only. Many NGACO leaders reported they were content with claims-based alignment and did not think implementing initiatives to increase voluntary alignment would be worthwhile.

The analysis suggests possible lessons for using voluntary alignment in future ACO models. NGACO leaders perceived that the use of voluntary alignment was limited by a high implementation effort, a need for patient education, and tight administrative time frames. Perceived benefits of voluntary alignment included attribution flexibility and creating opportunities for beneficiary engagement. Some leaders suggested allowing year-round voluntary alignment sign-up to better integrate voluntary alignment into their regular office workflows.