“Now is the time to abandon the status quo.”
– Abe Sutton, CMS Deputy Administrator and CMS Innovation Center Director
May 13, 2025
The Trump administration is bringing two forces to bear on healthcare providers. First, the administration is committed to reducing federal healthcare spending by tightening eligibility requirements for Medicaid and ACA Marketplace plans and cutting Medicare and Medicaid payments to providers.
Second, the administration’s Make America Healthy Again agenda prioritizes prevention, patient empowerment, and competition. Part of the strategy involves pushing providers into downside risk arrangements to drive patient engagement and effective management across the continuum of care.
Threatened funding cuts and promised payment reform aren’t anything new, but the political will to implement these strategies is unprecedented. The message to hospitals and health systems is clear: Prepare to do more with less.
This time, you can’t cut your way to success—or even survival. Instead, providers must re-balance the margin equation, starting with clinical enterprise rationalization (i.e., reorganizing and eliminating redundant, low-volume, or inefficient clinical services), which we addressed in the first part of this series. In addition to correcting what you shouldn’t be doing, you must also focus on what you should be doing. To that end, PYA is helping organizations pursue clinical care model redesign i.e., a systematic, patient-centered approach to transforming siloed and episodic practices into a seamless continuum of care.
The starting point for such redesign is a re-statement of organizational purpose: We enable healthy living as opposed to treating disease and injury. No longer can we expect patients to go to the hospital; now, we must meet consumers where they are. Processes and care transitions built on provider convenience—which drive segmented and siloed care—must be replaced with patient-centered processes and care transitions. Paying lip service to this goal is not enough; success depends on well-defined strategies, proven tactics, and supportive technology.
Based on our experience, we have identified five pillars of clinical care model redesign or what separates successes from failures:
1. Access, access, and more access. It’s a simple question: How do patients find their way to you? If the process is difficult and time-consuming, one of two things will happen: Patients will find their way to someone else, or they will forgo preventive services or necessary care.
The answer to the next question is more complicated: How do you eliminate barriers to patients receiving care? Such barriers include lack of time or transportation, lack of awareness or understanding, and financial concerns. Eliminating these barriers requires more than opening a new clinic or starting a telehealth program; it requires direct, meaningful community engagement. This may include patient portals, push notifications, centralized scheduling, and regular follow-up communication. Also, focus on enhancing efficiency and throughput across the continuum of care: Well-run emergency departments and inpatient units improve access to these critical services.
2. Service consolidation. Improving access does not mean you have to be everything to everyone at all sites. Instead, be laser-focused on identifying non-essential redundancies and eliminating them by consolidating services. By concentrating services at specific locations, thus increasing volumes, your teams will become more specialized and skilled, which improves quality and efficiency.
3. Make primary care your primary mission. For too long, health systems have viewed primary care providers (PCPs) as little more than a source of referrals for revenue-generating specialists. PCPs, in turn, have not accepted responsibility for coordinating patients’ care across the continuum, most likely due to a lack of resources and/or lack of financial incentives. Redefining the role, expectations, and rewards for PCPs will position your organization as a leader in patient-centered care.
4. Care management infrastructure. Patients need and want to be shepherded through the continuum of care. Most wasteful spending in healthcare can be found in the cracks into which patients fall when left to navigate the system on their own. It is wholly unrealistic to expect PCPs to play this role without an adequate care management infrastructure. Such infrastructure includes trained and experienced care navigators, well-defined and reinforced care pathways, and other tactics. Appropriate technology is needed to facilitate information exchange, service coordination, and patient engagement.
5. Quality performance standards, measurement, and reporting. More important than reporting on payer-imposed performance measures is establishing and enforcing expectations regarding providers’ engagement in patient-centered care through continual performance improvement activities. This may include but is not limited to adherence to evidence-based protocols, patient satisfaction scores, and complication and mortality rates. Defining, tracking, and reporting on a core set of measures in a transparent manner sets expectations and fosters engagement.
The most important step in clinical care model redesign is the first step, moving from words to actions. Securing the full commitment of the governing body and the executive team will smooth the road ahead. And having an experienced advisor will help you avoid unnecessary detours. Our team can help guide you in the transformation from care delivery organization to a health-enabling community asset.
