Value‑based care, capital and control: Why independent physicians need a direct path beyond enablers

For many independent primary care physicians (PCPs), “going value‑based” now means signing on to an accountable care organization (ACO) or an enablement platform that takes a large slice of savings in exchange for infrastructure the practice cannot afford to build itself. The policy intent may be better care at lower cost, but the U.S. Centers for Medicare & Medicaid Services (CMS) has designed models around capabilities most small practices simply do not have. The result is a quiet dependence on investor‑backed middlemen that too often win more than the clinicians actually doing the work.

The goal of policy should not be to eliminate enablers, but to end unnecessary dependence on them. Independent primary care practices should be able to become their own “enablers” through direct access to timely data, prospective support and clear guardrails — building on lessons from past model failures rather than repeating them.

Learn from the past, don’t repeat it

Past “PCP‑direct” models, such as Primary Care First and Making Care Primary, struggled for reasons that go well beyond physician readiness. They tied payment adjustments and, in some cases, downside risk to total‑cost benchmarks heavily driven by hospital and specialist spending that primary care does not fully control. They layered complex financial mechanics on top of already thin margins and demanded new reporting and transformation work without sufficiently stable or durable prospective funding to cover the real cost of care management and data infrastructure. When they failed to show rapid net savings, CMS ended them early, leaving practices with stranded investments and reinforcing the perception that primary‑care‑centric models will not be supported long enough to justify the disruption.

That history shapes the present. Independent primary care practices are being asked to manage risk in an environment where Medicare fee‑for‑service updates have lagged behind inflation and practice costs. Many practices already devote disproportionate staff time to Medicare patients relative to the revenue those patients generate, especially when they invest in care coordination, outreach and quality reporting. Expecting them to layer a full ACO‑like infrastructure on top of that without stable, prospective support is simply unrealistic.

Even in newer efforts like ACO Primary Care Flex, which does increase prospective primary care funding, participation still requires operating inside a two‑sided‑risk ACO by taking on shared‑loss exposure driven largely by hospital and specialist behavior. For low‑revenue, thin‑margin independent practices, “Flex” becomes a dangerous proposition rather than a safe bridge into advanced risk.

Can physicians do everything needed without value-based care enablers?

Meanwhile, CMS models are built on a broader design in which patient, specialist and hospital incentives are not aligned. Patients remain essentially “free‑range” in traditional Medicare. Hospitals and specialists are often paid more for doing more. Primary care is then held accountable for total cost trends it can influence but not fully control. In that context, downside risk becomes a financial gamble even for sophisticated practices.

It is, therefore, not surprising that many independent PCPs feel they cannot participate directly without an enabler. They need capital, analytics, care‑management infrastructure, contracting support and risk protection that CMS has largely chosen to route through intermediaries instead of providing directly. CMS models often assume sophisticated operational capabilities while giving independent practices only limited direct access to the timely claims‑based reporting, prospective funding and financial protections needed to function on their own.

Who is really driving the savings?

This is the central design error: treating the enabler as the primary driver of savings when the real engine is physician behavior supported by actionable information and aligned incentives. Shared savings are created when primary care clinicians prevent avoidable admissions, manage transitions well, reduce unnecessary downstream utilization, improve adherence and intervene early with high‑risk patients. Enablers can help by organizing data and contracts, but that support is not the same as the clinical work that actually changes the total cost of care.

Much of the infrastructure and “wraparound” support that ACOs and enablers provide looks impressive on paper — care pathways, dashboards, committees, branded programs — but those features do not reliably translate into lower total cost of care. What consistently drives real savings is enabling frontline clinicians with timely, patient‑specific, actionable information so they can make better decisions at the moment of care: knowing which patients were just discharged, who is at highest risk for readmission, where specialty and facility spending is spiking, and which gaps in care remain open.

CMS already recognizes that accountable care depends on data sharing, beneficiary alignment, quality measurement and operational insight. Under current rules, ACOs can obtain beneficiary claims data and performance information, but access is organized at the ACO level rather than as a direct operational feed to every participating independent practice. In practice, that means the entity in the middle becomes the gatekeeper for the data physicians need to manage their panels.

That matters because most small and midsize primary care practices do not have the capital to build population‑health analytics platforms, hire reporting teams, finance care coordinators and absorb downside risk at the same time. CMS itself has acknowledged in other primary care models that predictable prospective payments, infrastructure support and hybrid payment approaches help practices maintain staffing and deliver whole‑person, team‑based care. The agency already understands the solution; it has simply not extended those tools broadly enough to physician‑led accountable care within Medicare.

So where should we start?

A practical starting point is a standardized operational reporting package delivered directly to participating primary care practices in PCP‑direct models. Most of these data elements already exist in CMS claims and model operations; the gap is not whether CMS has the information, but whether it will package it in a timely, practice‑facing way that substitutes for the operational analytics now supplied by enablers. That package should include the following:

• Prospective attribution lists and monthly panel updates.
• Demographic and risk information.
• Claims‑based utilization trends.
• Admission and emergency room notifications.
• Specialist and facility spend visibility.
• Preventive‑care and chronic‑care gap status.
• Medication adherence and polypharmacy flags.
• Practice‑level benchmarking on cost and quality metrics.

In parallel, CMS should strengthen and enforce requirements that every hospital use simple, existing electronic medical record technology to send real‑time electronic admission, discharge and transfer notifications directly to a patient’s primary care provider. CMS has already adopted admission-discharge-transfer notification conditions of participation for hospitals using certified systems, but independent PCPs still frequently experience those feeds as unreliable, delayed or routed indirectly rather than as straightforward, real‑time alerts they can act on. This is not a technology problem; it is an implementation and discipline problem.

Picking the right pathways

If CMS paired this data infrastructure with more realistic direct‑participation options, independent PCPs could participate without defaulting to enablers. Two core pathways, alongside a reformed enabler option, would go a long way.

1. Direct participation without prospective payments

This option offers simplicity for practices that want to avoid the complexity of up-front payments:

• The benchmark would be 25% historical and 75% regional, recognizing that incentives across patients, hospitals and specialists are not aligned with primary care.
• Savings would be shared 50/50 between CMS and the practice.
• CMS would supply the standardized, timely reporting package described above.
• Performance year 1 would be a transition year, and subsequent participation would remain voluntary, but if a practice had two consecutive performance‑year losses after the transition year, it would face a 10% fee‑for‑service reduction for the subsequent year, similar in spirit to Merit-based Incentive Payment System penalties.
• Termination for the next year’s participation would be moved from July to 30 days after final reconciliation for the previous year, so practices are not forced to commit before they know how they actually performed.

This structure provides a clear upside, transparent limited downside and removes the “all‑or‑nothing” risk that currently drives practices to seek shelter under an ACO or enabler.

2. Direct participation with prospective payments

This option is tailored for practices that need stable up-front dollars to hire care managers, invest in data support and redesign workflows:

• The benchmark would be 30% historical and 70% regional, reflecting the additional CMS investment through prospective payments.
• Shared savings would be split 40% to the practice and 60% to CMS.
• CMS would not recoup prospective payments for the first two years of losses, giving practices a genuine transformation runway.
• CMS would provide the same standardized operational package.
• After two consecutive loss years, the practice would face a 5% to 15% fee‑for‑service reduction the following year, but no open‑ended downside risk.
• Termination timing would again be tied to the final reconciliation for the previous performance year.

CMS should tie prospective payments to documented investment in core value‑based functions — care management, coordination, outreach and data work — rather than allowing those dollars to disappear into general overhead. Practices that invest and still fail to generate savings would face limited consequences; practices that do not invest at all and repeatedly underperform would face stronger consequences.

3. Enabler participation with guardrails

Enablers should remain available, but with more transparency and limits:

• CMS should require any nonprovider entity sharing in savings or global budgets to disclose how funds are distributed among primary care, specialists, hospitals, infrastructure, administrative expense and profit.
• CMS should reward organizations that adopt higher‑cost practices with at least two consecutive years of costs above their regional benchmark and that demonstrably improve over time. This could include enhanced shared‑savings percentages or infrastructure payments and reduced or waived downside risk during a defined transformation period.
• Because independent PCPs do not control most downstream hospital and specialty spending, any model that relies on enablers should explicitly reduce downside‑risk percentages for participating practices, while still offering a meaningfully higher share of upside savings to clinicians — avoiding “all‑or‑nothing” or strict 50/50 splits that blunt incentives for practices actually changing care.
• CMS should cap the share of savings that enablers may retain — say, at 30% — unless they can demonstrate extraordinary and measurable value beyond routine reporting and contracting support.

A lesson from Medicare Advantage

This is not foreign territory. Medicare Advantage (MA) organizations operate under medical loss ratio rules that generally require at least 85% of premium revenue to be spent on clinical services and quality improvement, limiting what can be captured as administration and margin. If MA plans face that discipline, it is reasonable to ask why ACO enablers can capture far larger slices of physician‑generated savings with far less transparency.

CMS can expand practice participation by offering a menu of pathways that pair transparent, claims‑based operational reporting with multiyear accountability for cost and quality — using prospective care‑management payments where appropriate and a pure shared‑savings track where they are not. In every pathway, fee‑for‑service reductions should be reserved for practices that repeatedly miss clearly defined goals rather than be imposed up front on clinics that are already investing in better care. High‑performing primary care practices should keep a substantially larger share of the savings they generate, so that the clinicians making day‑to‑day decisions — not intermediaries — receive the primary financial rewards for lower total cost and better outcomes.

The goal is not to eliminate enablers. The goal is to end unnecessary dependence on them, preserve them as an option, reward organizations that help weaker practices improve, cap what intermediaries can extract from shared savings, and put Medicare value‑based care back where it belongs: in the hands of the clinicians whose decisions actually create the value.

Robert Resnik, M.D., MBA, is a board-certified internal medicine physician practicing in Cary, North Carolina. He earned his medical degree from Eastern Virginia Medical School and completed his residency at East Carolina University. He also holds an MBA from Duke University.