Is there a place for specialty care in accountable care organizations?

June 14th, 2017 / By Steve Delaronde

Primary care providers (PCPs) have received most of the attention from accountable care organizations (ACOs).  Specialty care providers, such as cardiologists, orthopedists, and other surgical and non-surgical specialists are still trying to find their place within an ACO, even though they are directly responsible for a larger portion of the national healthcare bill than PCPs.  Why has the “volume to value” movement been a greater challenge for specialists than for PCPs, and more importantly, how can specialists find a place at the “value-based care table”?

Primary care providers (general practice, family practice and internal medicine) account for only a third of office-based physician visits, and an even smaller proportion of direct costs.  Yet PCPs have been the winners in the recent move to value-based care.  Among ACOs participating in the Medicare Shared Savings Program (MSSP) that reported designating a specific percentage of shared savings to clinicians, the mean amount allocated to PCPs was 49 percent of the savings realized compared to 11 percent to specialists.

There are three approaches that payers can take with specialists.  The first is to continue to rely on PCPs as the primary players in value-based care.  This will continue to yield some positive results, but will not have the full participation of those providers that account for the largest share of healthcare spending. The second approach is to create additional opportunities for specialists to participate in value-based care.  The third approach is to develop partnerships between PCPs and specialists that incent them to work together to improve care and reduce costs for the same group of patients.  Below are examples from each of these three approaches.

Provide PCPs with price transparency and quality metrics when making referrals to specialists

Primary care providers within an ACO are accountable for the quality and cost of care delivered to their attributed patient population, however, direct care delivered by PCPs accounts for a very small proportion of the overall cost of treating most patients.  Patients are either referred or visit specialists directly without a referral, and specialists often treat patients without coordinating with the PCP.  The ACO structure is intended to promote care coordination, but it also offers patients the freedom to choose their care providers.  The PCP is often unaware of the cost and quality of care of specialists that provide care to their patients, including the ones that are part of their referral network.  The referral is often based more on convenience than quality with only 15 percent of physicians indicating that they consider quality ratings or outcomes when making referrals.  The development and reporting of quality metrics, as well as greater price transparency, are necessary for PCPs to help their patients make informed choices about the specialists they visit.

Provide a structure for specialists that incents them to deliver care based on value and not volume

Most specialists are paid on a fee-for-service model.  There are some conditions and procedures that are well-suited to value-based care.  The Centers for Medicare and Medicaid Services (CMS) launched the Oncology Care Model in July 2016 which aims to improve care and lower costs through an episode-based payment.  Bundled payments are also the focus of the Bundled Payments for Care Improvement (BPCI) initiative and the Comprehensive Care Joint Replacement (CCJR) program.  Most providers participating in the BPCI choose from 48 clinical episodes to manage with bundled payments, while the CCJR bundles payments for patients who have lower-extremity joint replacement surgeries.  While this is certainly an opportunity for specialists and hospitals to be accountable for providing efficient care across the DRG continuum, it does not provide an incentive to seek alternate types of care or encourage the specialist and PCP to work together to best meet the care needs of the patient.

Identify opportunities for partnership between PCPs and specialists

The real opportunity may be to incent PCPs and specialists to work together to improve care and reduce costs across the same group of patients.  Identifying chronic care patients that regularly seek healthcare services from both a PCP and specialist may be a good place to start.  The top 1 percent of the population that accounts for up to 30 percent of healthcare spending, typically have chronic conditions that are treated by multiple providers.  The use of multiple providers puts this group at greater risk for uncoordinated care.  Additionally, 21 percent of the highest spenders report that they are unable to obtain or delayed getting the care they need, which may lead to higher costs.

The ultimate success of the ACO and the ability for providers to accept downside risk will only come when all care providers – primary care, specialists, and hospitals – develop a partnership that works for all parties and can address the largest cost categories.  In the meantime, there is still an opportunity for further price transparency and quality reporting among specialists that will allow PCPs to refer and guide their patients to the highest quality and most efficient care available.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.