As healthcare shifts more toward value-based care, diabetes management remains one of the toughest challenges for primary care teams. While these providers are the frontline of chronic disease management, the old-school brick-and-mortar model is struggling to keep up. Between the growing complexity of modern endocrinology and the sheer number of patients needing help, the traditional system is hitting a breaking point.
For organizations focused on total cost of care and meeting quality metrics, it is important to look at where the current system loses value. Identifying these gaps is the first step toward building a healthcare network that actually scales.
The Specialty Bottleneck: The Shortage of Endocrinology
There is a massive shortage of endocrinologists today. In a traditional referral model, a primary care doctor identifies a patient with a high HbA1c and sends them to a specialist. The problem is that wait times often stretch into months.
During this gap, the patient’s health rarely stays static. Often, their condition worsens, leading to expensive ER visits or hospitalizations for complications like hyperglycemia. For an ACO, this delay shows up as lower quality scores and higher costs. It also leads to provider burnout, as primary care teams are left to manage complex cases without the specialist support they need.
This isn’t about a lack of clinical skill. It is about a lack of time. Traditional diabetes care is episodic, with patients seen only every few months. But diabetes is a 24/7 condition. When glucose data is only reviewed during a brief office visit twice a year, clinical inertia takes over. Decisions are based on old data, and the chance to prevent a crisis is missed.
For an ACO, this inertia is a major financial drain. Uncontrolled diabetes is a primary driver of costly complications like kidney disease and heart failure, which significantly spike the risk-adjusted cost of a patient population.
“Nearly 70% of U.S. counties are currently endocrinology deserts, leaving primary care to manage complex cases without a safety net.”
Specialist Integration
To move from reactive to proactive care, forward-thinking organizations are moving away from the “refer and wait” model. Instead, they are integrating specialist expertise directly into the primary care workflow through a combination of eConsults and telehealth.
This hybrid approach changes the entire timeline of care. When a primary care provider has a question about a complex patient, they can use an eConsult to get specialist guidance in a matter of hours. This means the patient gets a specialist-vetted treatment plan before they even leave the clinic or shortly after their initial appointment.
If the case requires more hands-on management, the patient can be bridged immediately into a virtual endocrinology clinic. This telehealth layer handles the heavy lifting of remote monitoring and frequent medication adjustments. It keeps the patient within the ACO’s ecosystem and ensures that their data is being tracked in real time, rather than waiting for the next quarterly check-up.
This seamless loop between the PCP and the virtual specialist ensures that no one falls through the cracks. It keeps care in the lower-cost primary care setting whenever possible, but provides an immediate safety net for high-risk patients.
Improving Population Health
The goal for any ACO is to reduce high-cost events by getting the small things right. Traditional primary care is the foundation, but it needs a boost from digital specialty services to be effective at scale. By weaving eConsults and telehealth into the daily routine, ACOs can close care gaps faster, protect their shared savings, and give patients the immediate support they need.