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In 2021, the Centers for Medicare & Medicaid Services (CMS) established a goal to have 100 percent of Original Medicare beneficiaries and the vast majority of Medicaid beneficiaries in accountable care relationships by 2030 as part of the Center for Medicare and Medicaid Innovation’s (Innovation Center) strategic refresh. This means that beneficiaries should experience longitudinal, accountable care with providers that are responsible for the quality and total cost of their care. Accountable care requires access to and coordination of primary care and specialty care to meet the full range of patient needs. As the Innovation Center enters the second year of its strategic refresh, testing models and tools to improve access to high-quality, value-based specialty care is an area of critical focus.
Medicare beneficiaries often experience fragmented and costly care, distinguished by frequent diagnostics, imaging, tests and other treatment approaches delivered by specialists across sites of care.[1] In 2019, Medicare beneficiaries saw an average of 50 percent more specialists in the outpatient setting than in 2000, doubling the number of physicians with whom primary care providers must coordinate care.[2] A 2022 study examining fragmentation of ambulatory care for Medicare fee-for-service beneficiaries found that four in ten beneficiaries experience highly fragmented care, with a mean of 13 ambulatory visits across 7 practitioners in one year.[3]
Medicaid beneficiaries also experience access barriers, with clinics serving a high-proportion of Medicaid beneficiaries routinely reporting challenges scheduling specialist visits. In a sample of community health centers (CHCs) in Medicaid expansion states, nearly 60 percent reported difficulty obtaining new patient specialty visits for their Medicaid patients, particularly for specialists in orthopedics, gastroenterology, neurology, and psychiatry. Barriers for CHCs were primarily related to payer factors – low specialist payment rates, low in-network specialist coverage, administrative burden and lack of Medicaid coverage for telemedicine. Patients most commonly cited long travel distance/time and out-of-pocket costs as barriers to specialty access. [4] Evidence generally suggests that access to specialty care in Medicaid is better than for uninsured individuals, but worse than for those with commercial insurance[5], although this may vary by provider type, specialty area, and state.[6] Service delivery and payment approaches aimed at improving access to and the experience of specialty services, for example electronic consultations (e-consults), could help address access barriers and are a core component of the Innovation Center’s specialty care strategy.