Finding the most efficient health care delivery system may require a mix of both primary care and specialist care, a new study suggests. The report, published by the Journal of the American Medical Association Network, looked at Accountable Care Organizations (ACOs), a delivery model created as part of the Affordable Care Act. The authors wanted to better understand the relationship between specialist visits and lower spending among ACOs.

The study noted that primary care has received a lot of emphasis with ACO health systems, on the theory that having a dedicated primary care provider will help patients manage and prevent health conditions.

ACOs seek to better coordinate care, since coordinated care is considered to be less costly. The model rewards physicians and health systems for providing quality care, rather than just quantity. The ACO model is overseen by the Centers for Medicare and Medicaid Services, which rewards health systems financially for hitting coordinated care benchmarks.

But the researchers noted that not much research had been done on how specialist care affected the efficiency of ACOs, so this study explored that question, using data from 620 ACOs during a five-year period, 2012-2017.

Finding the sweet spot

The report found that too much or too little specialist care volume tended to increase costs for ACOs. “We found that expenditures were lowest for ACOs with a balanced specialist encounter proportion (40 percent to less than 45 percent), whereas ACOs at the specialist encounter proportion extremes (less than 35 percent and 60 percent or greater) had the highest expenditures” the study said.

The costs associated with the two extremes were different: those systems with relatively few specialist encounters had higher costs from ER visits, while those ACOs with high percentages of specialist encounters had higher rates of expensive procedures such as MRIs.

“These findings suggest that ACOs that provide office visits through a balance of PCPs and specialists may be better positioned to achieve utilization rates that are consistent with lower costs, compared with ACOs that provide office visits through a more skewed PCP and specialist distribution,” the study said.

Not enough incentives for specialists?

The researchers further concluded that ACOs with little participation from specialists may especially want to try a more balanced approach. “We speculated that patients seen only or primarily by primary care providers may receive suboptimal care, especially if they are chronic-care, high-risk patients,” said Vishal Shetty, a University of Massachusetts Amherst Ph.D. student in the School of Public Health and Health Sciences, and one of the study's authors, in an article published by MedicalXpress.

The study suggests that ACOs should create more financial incentives to bring in specialists. “There aren't strong incentives as it stands now for specialists to join ACOs,” Shetty said in the article. “Fee-for-service reimbursement is still a higher incentive.”

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Saving money with ACOs requires the right balance of specialist care

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