Understanding Primary Care & Specialty Care Value-Based Models, Is One Better than the other?

By | July 10, 2022

Currently, a significant portion of value-based care payments has focused on primary care-based models. Whether Medicare Advantage, Medicare Shared Savings Programs, Direct Primary Care, or other value-based programs, they all center on primary care clinicians and services. Though there are a few unique specialty-based models such as BPCI, the vast majority are not.

These models have had a limited impact on the overall Medicare spend. Thus, CMS has launched the Comprehensive End-Stage Renal Disease (ESRD) Care Model to test the idea that a similar model, previously focused on primary care, might deliver greater savings when centered on a single specialty and disease state. And early data reveals that the model succeeded in showing a decrease in Medicare payments per beneficiary, decreased hospitalizations, and triggered a decrease in likelihood of re-admissions in those with ESRD that were in the program.

These findings raise an interesting question. Are we so focused on primary care models that we are losing sight of possibilities that will increase value to those served at a lower cost? Yes, I am a primary care physician, but I am not sure placing primary care physicians as the center stone is the only way of thinking. Though PCPs control much of the cost through their referrals, if one focuses on just “following the money,” controlling spending on the specialty side yields much higher results. Additionally, we tie primary care physicians to primary care services, which is not necessarily correct. For example, it isn’t necessary to link vaccinations and preventive services to a physician; therefore, they can be managed within a specialty model.

Undoubtedly, there needs to be a coordination of function for better care, but why do we believe that needs to be managed within a PCP’s office? In other words, we limit our ability to deliver on value if we think there is a single model versus realizing numerous possibilities to drive the desired results. Hence, one might think of a value-based model as a bundle of bundled payment models. And chronic diseases that are managed by specialists wrapped in primary care services might be a superior model for those with such conditions.

The key to innovation is not falling in love with the solution but falling in love with the problem. Therefore, if our predicament is increasing quality and service while lowering costs. Let us not limit our contemplation to specific methodologies and then attempt to solve our obstacles. Let the issue at hand drive the possible solutions. Innovating will increase when we move from the “or” scenarios to the “and” way of reasoning. One size will not fit all, especially within the complexity of the problem. Let us live in polarity and ask the right questions rather than work backward from a given solution.