Value-Based Payment for Specialists: 3 Models Build on Primary and Pharmacy Care

How can specialists participate in value-based payment care?

Value-based payment requires the deeper use of electronic health records (EHR) to capture and transmit standardized data.  This analysis will include a review of 3 working models that specialists should consider joining to enhance both clinical and financial performance. These models include high-functioning primary care and pharmacy networks in the US and work accomplished by the American Academy of Physical Medicine and Rehabilitation.


I am a specialist and have practiced Physical Medicine and Rehabilitation (PM&R) in a variety of care settings during the past 25 years. My clinical work aligns well with my administrative roles as CMIO and CIO at multiple community health systems.  It has been a privilege to work with physician leaders in all 22 specialties on people, process, and IT solutions to enhance clinical and financial performance.

In the past decade, the U.S government has invested over $30 billion dollars to support the adoption of EHRs. This has been the most significant workflow and cultural change in my medical career and has resulted in the large-scale EHR adoption by physicians. It is safe to say, we have not yet experienced the long-term benefits from this substantial investment.

One of the motivations for EHR adoption is the movement of physician payment to value-based models collectively called MIPs/MACRA. During the past 3 years, a significant number primary care physicians have adopted the Chronic Care Model (CCM) payment, model. This has significantly increased annual revenue from their panel of Medicare patients. My advice to primary care colleagues:

Evaluate your practice’s financial opportunity to participate in CMS payment for Chronic Care Management (CCM). During my role as senior vice president for a health system in coastal South Carolina, we estimated that the 60 physician group could generate an additional $500,000 of annual revenue if we enrolled eligible Medicare patients into this program.  CMS has enhanced the program to include 3 levels of coding and automatic enrollment which makes this program more feasible for physician practices.

Almost all outpatient EHRs now include a timer which automates the sending of CCM codes for billing.  One CEO of largest vendors proudly told me “this is our fastest growing service with primary care and we are helping our customers be more profitable.” See my full article. 

Specialists are not generally eligible for payment under the CCM model, so what should they be doing to align their work with evolving value-based care?  My answer is simple, build on the work of your primary care and pharmacy colleagues are already doing.

Model 1: A large number of primary care practices have embedded CCM payment into their workflow. For practices that had already embraced patient-centered medical home (PCMH) process, this was a natural progression and allows a practice to bill for non-physician care. Practices can earn up to $5000 to $15,000 more per year per physician by delivering care management to Medicare patients. Examples of primary care management include standard intake and outreach for patients recently seen in emergency care or discharged from the hospital. A number of hospitals and health information exchanges (HIE) are providing daily worklists which alert primary care staff that their patient is transitioning back to primary care.  I have been fortunate to lead quality improvement efforts in both South Carolina and Indiana which implemented such alerts into the workflow of busy,  primary care practices.

Care coordination can entail numerous activities, such as helping with transitions of care, assessing patient needs and goals, care planning, monitoring and following up on referral compliance, supporting a patient’s self-management goals, linking to community resources, and more. Care coordination at the time of care transitions and aided by health information exchange (HIE) and health IT tools holds the keys to more timely and focused communication, better chronic disease management, and reductions in hospital re-admissions and avoidable ED visits.  See full article. 

Specialists should reach out to their primary care colleagues about CCM payment and explore opportunities to improve care coordination around common conditions. This has several benefits including reinforcing your relationship with major referral sources.  As a PM&R physician, it is common for patients with chronic, intermittent low back pain to receive emergency care during a severe exacerbation.  Ideally, we would prevent emergency care, but this is often not possible. The Academy of Physical Medicine and Rehabilitation (AAPMR) established a data registry for spine care to support MIPS participation which could align with the primary care CCM model.

Model 2: The Community Pharmacy Enhanced Service Network (CPESN) was established 3 years ago, leveraging funding from Center for Medicare and Medicaid Innovation (CMMI). The CPESN network has grown to more than 20 states and is being embedded by the majority of pharmacy EHRs, allowing efficient workflows.

This network includes well-established pharmacies that see patients more than 4 times as frequently as primary care practices. These pharmacies are paid to provide additional services for Medicare patients which include medication synchronization, medication therapy management, and care planning.  The pharmacists are required to produce an eCarePlanwhich includes dispensed medications and drug therapy problems in an industry standard CCDA. CCDA is a standardized electronic care summary developed by the American Academy of Family Practice and is required by Meaningful Use 2. Read full article.

Specialists often work in separate EHRs and are dependent upon consumers to share information about prior care including allergies and medications. This can result in complications such as preventable adverse drug events (ADE) and sub-optimal medicine regimens.  When consumers use a consistent pharmacy for medications, pharmacists can serve as a single point of coordination. In my experience, coordination of medications amongst multiple physicians, pharmacists, and pharmacy benefit management (PBM) is not achievable via phone, fax, and separate IT systems. CPESN was designed to optimize medication regimens by providing a combination of services including medication synchronization, medication therapy management (MTM), and medication reconciliation.  Participating pharmacies are paid by Medicare for this service which supports the staffing and IT resources required.  Specialist practices should reach out to pharmacy colleagues to discuss mutual opportunities to help each other receive value-based payment.  In future articles, I will discuss the specific areas for MIPS quality improvement with spine specialists that overlaps with both primary care and pharmacy care management.

Model 3: The AAPMR has established a clinical quality care registry (CQCR) focused on spine care which they are considering expanding to include stroke (annual prevalence 500,000 patients/year)  prevention and rehabilitation.

AAPM&R’s Registy is an easy-to-use qualified clinical data registry (QCDR). A QCDR is a reporting mechanism for satisfactory Merit-Based Incentive Payment System (MIPS) participation that tracks patients longitudinally with an emphasis on quality improvement. The Academy has expanded it’s Registry efforts beyond spine by including a wide range of measures. Learn more in this Fact Sheet.

Other medical specialty organizations are creating similar registries which could be coordinated with existing primary care and pharmacy care networks. For example, it would be ideal for primary care physicians, pharmacists, and spine specialists to coordinate care for very common problems such as low back pain. Given the existing opioid crisis, there are compelling clinical, financial, and community benefits to all participants. Ultimately, this work is most helpful when it supports the essential relationship between consumers and providers.Sketch (7)

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