Aligning Specialists & Primary Care to Support Value-Based, Accountable Care

The PCMH Model Did Not Focus on Specialty Care

The advocacy for the PCMH model was built around the imperative to reinvigorate a collapsing primary care system (NEJM). A report from the American College of Physicians (ACP) presented at the organization’s State of the Nation’s Health Care on January 20, 2006, began with the following statement:

 Primary care, the backbone of the nation’s health care system, is at grave risk of collapse due to a dysfunctional financing and delivery system.  Immediate and comprehensive reforms are required to replace systems that undermine and undervalue the relationship between patients and their personal physicians.

The ACP statement introduced the “Advanced Medical Home” model, described as a “practice that provides comprehensive, preventive and coordinated care centered on their patients’ needs, using health information technology and other process innovations to assure high quality, accessible and efficient care.”  The American Academy of Family Physicians , the American Academy of Pediatrics , and the American Osteopathic Association had similar policy objectives. At the urging of Paul Grundy and Martin-J. Sepulveda MD ScD (former executives at IBM) to simplify and align these policies, the organizations developed the Joint Principles of the Patient-Centered Medical Home (2007). For a brief history of the PCMH, see this timeline produced by the Primary Care Collaborative .

While reports (see summaries here, here, and here) have demonstrated many positive effects, including Accountable Care Organization performance, quality measures, patient engagement, and cost, other studies have shown mixed results. In retrospect, one limitation, and a factor that likely undermined the effectiveness of the PCMH, may have been that it focused almost exclusively on primary care and missed an opportunity to include alignment of specialty care. Optimized primary care is necessary but insufficient to drive the quality, cost, equity, and engagement needed. While the ACP produced a follow-up paper, The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices (2010), the goals of whole-person, integrated, seamless, person-centered care may have been better served if the concepts were articulated in a more comprehensive and systems-based model.

It's Time to Align Primary and Specialty Care

The Centers for Medicare & Medicaid Services (CMS) is aiming for 100% of Medicare (FFS) beneficiaries and most Medicaid beneficiaries to be in accountable care arrangements (quality and total cost of care) by 2030 (See CMMI Strategy Refresh document).

 “For models to drive system transformation in this way, the CMS Innovation Center must work more closely with external stakeholders, especially beneficiaries and caregivers, primary care, specialty, and other providers that are most directly affected by models.”

 Recognizing the importance of specialty care to achieve these objectives, the Center for Medicare and Medicaid Innovation (CMMI) described its approach to support person-centered, value-based specialty care in 2022, and a recent Health Affairs Forefront article written by CMS leaders provides an updated description of the strategy.  A quote from that article sums it up nicely:

 A comprehensive approach to accountable care must account for both primary care and specialty care. Specialty care is a critical part of the care experience and a substantial portion of overall Medicare spending. A 2021 research study shows that Medicare beneficiaries are seeing more specialists and seeing them more often than they were twenty years ago. A 2022 study suggests as many as 40 percent of Medicare beneficiaries receive care that is fragmented, with a mean of 13 visits across 7 clinicians in one year.

 The Elements of the updated strategy include:       

1.  Enhance Specialty Care Performance Data Transparency
2. Maintain Momentum On Acute Episode Payment Models and Condition-Based Models.
3. Create Financial Incentives Within Primary Care for Specialist Engagement.
4. Create Financial Incentives For Specialists To Affiliate With Population-Based Models And Move To Value-Based Care.

The Health Affairs post provides descriptions of each of these Elements. I am particularly interested in the following aspects of the CMMI model:

• Performance data transparency (Element 1): How will primary care practices participating in the Making Care Primary model (starting July 2024) use the performance profiles of specialists? Will referrals be redirected to higher-quality, lower-cost “Specialty Care Partners”?
• Financial Incentives Within Primary Care (Element 3): Will the e-consults result in fewer unnecessary referrals and avoidable diagnostic testing and procedures? Will the data shared (Element1) to support these e-consults and coordination be presented in an actionable format and not add to the complexity of primary care and specialty care encounters?

What Do You Think?

1. Will this strategy help CMMI achieve the goal of 100% of Medicare FFS and the “vast majority” of Medicaid beneficiaries under accountable care arrangements by 2030?
2. Will the efforts to align specialty and primary care to drive accountable care, as described by CMMI, improve ACO performance?
3. Will this strategy complicate efforts to generate more investment in primary care?
4. What would you change?

Additional Perspectives:

Engaging Specialists In Accountable Care: Tailoring Payment Models Based On Specialties And Practice Contexts | Health Affairs

Next Steps For Engaging Specialty Care In ACO Models | Health Affairs Accountable Care Organization Initiatives to Improve the Cost and Outcomes of Specialty Care (ajmc.com)

PTAC Recommends CMMI Test ‘Medical Neighborhood’ Advanced APM | Healthcare Innovation (hcinnovationgroup.com)

Follow Up:

The survey from two weeks ago, (Boosting Medicare Star Ratings: What Would You Do?) Complete the survey here (Microsoft Form).

Michael S. Barr, MD, MBA, MACP, FRCP

Sr. Director, Population Health Improvement

Population Health Alliance

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