Does CMS Have Too Many Cooks in the Kitchen?

I am not sure CMS knows how to cook. A few weeks ago CMS released data showing that three ACO programs saved millions of dollars. The End-Stage Renal Disease (ESRD) model saved $75 million followed by Pioneer ACOs saving $68 million and the NextGen model saving $48 million. Some would suggest that these findings support more specialty payment models. Christopher Huryn, a healthcare lawyer at the firm Brouse McDowell reasons, “The most potential savings exist in the medical specialties that provide, and in the patient populations that require, the most costly care.”  Chief research officer at Leavitt Partners, David Muhlestein says that, “The big saver by far was the ESRD model; perhaps there is more opportunity to focus on disease-specific programs.”  Adopting the idea of independent specialty-oriented ACOs would potentially turn around our healthcare delivery problem 360 degrees.

While it is potentially true that specialists of all types have their clinical skills focused on a disease-specific area, the primary care doctor in the ACO context is responsible for the “whole person” and the total cost of care from all sources. What specialists seem to fear is loss of control and lack of participation in shared savings.

Unless the specialists want to manage immunizations, preventive imaging, and all transitional care (TCM) and assume heavier cost responsibility, more isolated specialty-oriented ACOs are not the answer. In fact, if the ESRD- model is to remain successful, this group must be primary care for their patients. Most value-based models presently target only primary care providers, limiting options for specialty providers to earn bonuses if they lower costs and improve the quality of the care they provide.

Specialists serving well-managed ACOs are feeling the pressure from their primary care colleagues to perform at a higher level, reducing cost and delivering better outcomes. Furthermore, specialists may or may not share in savings that are generated. On the other hand, primary care-led ACOs across the nation, with a clear vision and a robust analytical tool, are showing how they can favorably impact the quality and cost of patient care in keeping with the Triple Aim.

The primary care-driven model, even in its present primitive form, cares for the “whole person” which is a shift from the fragmented specialty-oriented care we are trying to change. Specialty- oriented ACOs will potentially continue to silo patient care and just be paid in a different way. This is not a recipe for the systemic changes needed in U.S. healthcare.

On the other hand, CMS must engage in creative thinking to guide the primary care providers toward new methods to hold specialists accountable to a high level of performance and to reward them with a measure of the shared savings to keep them fully engaged.

Population-based models such as the NextGen ACO may be the vehicle for all specialties to cooperate within a community to improve quality and create the savings. Nonetheless, every efficient kitchen needs a chief cook to coordinate a fine meal, and in the new world of healthcare that is the primary care provider.


Craigan Gray

About the Author

Craigan Gray, MD, MBA, JD

Dr. Craigan Gray, Salient Healthcare’s Chief Medical Officer, brings rich experience from private practice, hospital leadership, and governmental health-benefit programs. Prior to joining Salient, Dr. Gray was director of North Carolina’s $12 billion Medicaid program. His time as VPMA at Bon Secours Our Lady of Bellefonte Hospital in Kentucky was distinguished by moving the facility into the top-quality performance tier for Health Grades and CMS health quality indicators. Dr. Gray is a Stanford University trained Obstetrician/Gynecologist. In addition to an MD degree, Dr. Gray holds an MBA degree and a JD degree. He is a Certified Physician Executive and is published in various medical journals.

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