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From its inception, accountable care policy has centered on primary care. Accountable care organization (ACO) programs have been designed and built on the premise that primary care clinicians and groups should anchor population health. This strategy has rationale. Primary care plays a critical role in both preventive and chronic care management in ways that are fundamental to quality improvement and cost-efficiency.
However, comprehensive accountable care has always required more than primary care engagement. Specialists drive a substantial share of spending, influence diagnostic and therapeutic intensity, determine site-of-service decisions, and shape downstream utilization. Yet meaningful specialist engagement has remained a persistent challenge facing accountable care.
Medicare’s Ambulatory Specialty Model (ASM), which is slated to begin January 1, 2027, represents an important step in addressing this challenge.
Issues With Specialist Engagement In Accountable Care
As noted by groups such as the Medicare Payment Advisory Commission and the Physician-Focused Payment Model Technical Advisory Committee, specialist engagement has been challenging even as accountable care arrangements have matured. ACOs often rely on voluntary specialist alignment and face challenges clarifying roles of specialist versus primary care clinicians. Feedback on cost and performance is frequently diffuse or delayed. Financial incentives may not reach specialists directly, and, when they do, may be too modest to offset fee-for-service incentives. In parallel, the Merit-based Incentive Payment System (MIPS) has struggled to provide specialists with meaningful, clinically relevant accountability. For instance, multispecialty groups can achieve MIPS compliance by reporting on broad primary care- and prevention-focused measures, leaving little room or need for specialist-oriented measures.