All ACOs, regardless of payment model, are built on a vision of primary care services to patients. Medicare attributes patients to your ACO based on the plurality of primary care services. CMS attributes a patient to a participating specialist only if the patient has not seen a primary care physician in the ACO or at other providers, and the specialist is providing “primary care” services to the patient.
But the vision of the primary care ACO rarely holds up to reality—for either care delivery or economics. The shortage of primary care physicians, complicated by time constraints, often dictates that patients who could be managed by primaries are referred to specialists. Conversely, complex conditions in patients are often appropriately treated by specialists, not primaries. Specialists manage uncontrolled diabetes and COPD or asthma when patients require intensive treatment. High risk, problematic conditions such as coronary artery disease, heart failure, and atrial fibrillation require specialty care.