Having a specialist as your primary care physician (PCP) may seem unconventional, but for many individuals with disabilities, it is a practical and often necessary choice. In fact, some state Medicaid agencies and health plans have long-standing policies allowing specialists to serve as PCPs.

The reason is straightforward: people with disabilities face significant barriers to accessing primary care. Many primary care practices either cannot — or will not — serve disabled people. Only 56 percent of U.S. practicing physicians surveyed strongly agreed that they welcome disabled people into their practices, and 82 percent believed that people with significant disabilities have a lower quality of life than those without disabilities. Even willing providers often lack the infrastructure to deliver accessible care. Despite federal and state mandates requiring accessibility, 22 percent of practices report being unable to accommodate someone in a wheelchair, and only 40 percent of physicians feel confident in their ability to provide equal care to people with disabilities.

The resulting “specialist as PCP” model is an expensive way to deliver primary care. It increases costs by relying on specialists for routine care and diverts them from more complex cases. While PCPs may receive some training in disability-competent care (DCC), reversing this trend requires more than peripheral education. It involves addressing systemic barriers — such as the cost of making structural modifications and, in some cases, an unwillingness to serve disabled people. State Medicaid agencies are well-positioned to lead this shift through various strategies, including financial incentives.

Many state Medicaid agencies are already prioritizing payment reforms and investing in strengthening primary care by moving away from traditional fee-for-service payment models toward value-based payment (VBP) approaches that offer enhanced payments and quality incentives for practices. These models present a critical opportunity to reduce disparities in access and directly support DCC.

What is Disability-Competent Care?

Disability-competent care is participant-centered, driven by respect for choice and dignity of risk, and delivered by interdisciplinary teams focused on supporting maximum functioning for a disabled person. DCC removes barriers and promotes accessible care. By delivering primary care with a DCC focus, providers can eliminate traditional fragmentation and medical/institutional bias, resulting in high-quality, streamlined care. Examples of DCC include:

• Personalized care plans that address a person with a disability’s preferences and goals in the most accessible and integrated setting;
• Accessible facilities with adaptive equipment;
• Interdisciplinary, relationship-based, integrated care teams with expertise across primary care, mental health, and community services;
• Capacity for home-based episodic care; and
• Flexibility for providers to spend the time necessary to address the full range of a person’s health and support needs.

Medicaid Primary Care Payment Levers to Support DCC

States seeking to support DCC within primary care settings may consider how to provide sufficient payment to address the needs of individuals with disabilities and develop payment incentives aligned with DCC. Below are three payment levers Medicaid agencies can consider. While some are specific to VBP models, others can be implemented alongside FFS payment arrangements.

1. Provide enhanced PMPM payments for practices to support DCC

Whether as part of broader VBP arrangements or within an FFS context, states may consider providing enhanced, per-member-per-month (PMPM) payments to support DCC. These payments can help cover practice activities that are not adequately reimbursed through existing payment arrangements — such as extended appointment times, reasonable accommodations for accessibility needs, or care coordination for individuals with disabilities.

One way to implement this policy is to offer enhanced PMPM payments to practices that demonstrate state-defined DCC capabilities. This could incentivize a wide range of primary care practices — regardless of the number of individuals with disabilities they serve — to adopt DCC components. For example, Connecticut’s PCMH+ program requires participating practices to demonstrate “competencies in care for individuals with disabilities,” such as including DCC-related questions on health assessments, adjusting appointment times, and addressing physical and communication barriers to care. Similarly, Colorado Medicaid developed a Disability-Competent Care Assessment Tool to strengthen primary care providers’ DCC capacity and help members find practices providing DCC. While these initiatives do not include add-on payments for DCC-specific capabilities, states could consider enhanced PMPM payments to further support the adoption of such activities.

Another approach to enhanced PMPM payments is providing an additional add-on payment for each person with a disability served by a practice. This arrangement would particularly benefit practices serving a high number of individuals with disabilities. While there are no existing examples of such a program for people with disabilities, Ohio’s CPC for Kids program uses a similar approach for pediatric care: practices that meet state-defined quality standards receive an additional $1.00 PMPM, on top of the baseline care coordination payment, for pediatric members attributed to the practice. States could develop a similar payment approach to provide practices enhanced payment for individuals with disabilities.

2. Use primary care VBP models to pay for and incentivize DCC

States that have implemented or are developing Medicaid primary care VBP models can consider how to design such models to support DCC. In addition to an add-on PMPM payment, states can consider using risk adjustment to adequately compensate providers for serving individuals with more significant disabilities and tying payment to quality measures related to DCC.

Risk adjustment is a method of modifying payments to health care organizations based on the relative health and expected health care service use of the population served by the organization. In advanced primary care VBP models — including shared savings or population-based payment arrangements — Medicaid agencies may explore how to risk adjust provider payments or incentives to factor in the level of disability or functioning within a provider’s attributed population. For example, functionally based risk adjustment modifies payment based on factors such as activities of daily living, instrumental activities of daily living, and level of functional limitation. While not generally used for primary care payment, states like New York and Wisconsin use functionally-based risk adjustment to set rates for long-term services and supports programs. Similar approaches could be adapted for primary care contexts to help mitigate perverse incentives for providers to avoid serving people with more significant disabilities and ensure they are adequately compensated for doing so.

Tying primary care payment to DCC-related quality measures can further incentivize providers to adopt DCC practices and monitor progress. For example, under Massachusetts Medicaid’s Hospital Quality and Equity Incentive Program, hospital incentive payments are tied to measures such as the percentage of encounters in which “members with disability were screened for accommodation needs related to a disability.” In prior iterations of the program, hospitals were financially incentivized to provide the state a list of their accessible medical and diagnostic equipment and develop a plan to improve accessibility for this equipment. While this example focuses on hospitals, similar quality-linked incentives could be adapted for primary care settings to support DCC implementation.

3. Implement grant programs to cover the upfront costs of DCC

States can also consider ways to address the upfront costs of DCC-related delivery system reforms — such as removing physical and programmatic barriers to access, training staff, and updating processes. Paying a primary care practice an enhanced rate for serving people with disabilities won’t be effective if a disabled person can’t get in the front door.

Although many disability accommodations can be low or no cost, some structural changes to provide disability-competent care are cost-prohibitive for smaller offices, such as installing an elevator. Medicaid agencies could incentivize Medicaid health plans and other partners to develop grant programs to support primary care practices in making these types of changes. Since 2018, for example, Centene Corporation, one of the nation’s largest Medicaid managed care plans, and the National Council on Independent Living have operated the Barrier Removal Fund through their Provider Accessibility Initiative, awarding over $2.3 million to improve disability access at 248 provider practices in 16 states. Similarly, Inland Empire Health Plan in California offers an Accessible Clinics Program that provides accessible exam table/scale combos for eligible network providers at no cost.

Getting Started

Ensuring that primary care is delivered in a disability-competent manner addresses a longstanding gap in care for individuals with disabilities. States exploring payment reform options to support DCC can consider the following initial steps:

• Standardize demographic disability data collection infrastructure to enable primary care practices and Medicaid finance staff to consistently identify Medicaid enrollees with disabilities and assess the accessibility and quality of care they receive.
• Engage people with disabilities and provider organizations to identify state-specific barriers to implementing DCC and co-design solutions that reflect lived experiences.
• Evaluate existing delivery system and payment reform initiatives, such as primary care provider competency assessment models, to understand how DCC principles can be integrated into existing state efforts.
• Analyze primary care utilization data to determine if any disability-specific disparities in utilization may require targeted interventions.
• Assess primary care provider workforce data to gain insight into disability representation and identify opportunities to foster a supportive work environment for all providers.

These strategies can help Medicaid agencies identify appropriate DCC payment levers tailored to their local context. They also lay the foundation for providing accessible, high-quality, and cost-effective care for members with disabilities — moving away from the costly and often inappropriate “specialist as PCP” model.