Trends in Engaging Specialists in Value-Based Care

Value-based care, a healthcare delivery model in which providers are paid based on patient health outcomes and the quality of services rendered, has the potential to reduce overall healthcare costs and transform the healthcare industry. While billions of dollars were invested in value-based models of care delivery over the last decade, they fell short of delivering on this promise. [1] Physician engagement is crucial to the ultimate success of these models. While much emphasis is placed on engaging primary care physicians in value-based care efforts, specialty care providers have had limited opportunities for engagement thus far.

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Impetus for Engaging Specialists in Value-Based Care

There is growing recognition of the need to engage specialists better to build a more value-driven healthcare system successfully. Specialists comprise approximately 70% of all US active physicians and oversee the vast majority of health care spending. [2],[3] Research has also identified a shift in outpatient care for Medicare beneficiaries towards greater levels of specialty care. [4] Despite their vital role in patient care, less attention has been devoted to engaging medical and surgical specialists in value-based care efforts in comparison to their primary care colleagues. This is partially due to the structure of accountable care models, which place a greater emphasis on primary care. In addition, specialty-focused accountable care models to date, such as bundled payment models, tend to focus on acute events and major procedures. This reflects only a limited component of specialists’ impact on managing care throughout the patient journey. [5]

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Specialty Care as an Area of Focus for Value-Based Care Strategies

Healthcare payers are demonstrating an increased awareness of specialty care providers’ critical role in achieving value-based care success. In response, governmental and private payers are adopting value-based care strategies that more effectively engage specialty physicians while enhancing the integration and coordination of primary and specialty care.

In November 2022, the Centers for Medicare and Medicaid Services’ Innovation Center (CMMI) identified specialty care as a new area of focus in its value-based care strategy, with plans to “test models and innovations that support access to high-quality, integrated specialty care across the patient journey.” This strategy included four key elements as follows: [6]

• Enhance specialty care performance data transparency
• Build upon acute episode and standalone condition-specific models, targeting areas where beneficiaries experience gaps in high-value care
• Create financial incentives within primary care for specialist engagement
• Create financial incentives for specialists to affiliate with population-based models and move to value-based care

CMMI’s strategy will include the deployment of mandatory models, such as the Transforming Episode Accountability Model (TEAM) that is proposed to launch in January 2026. This model will be mandatory for selected hospitals as a component of the Innovation Center’s comprehensive specialty care strategy.

Commercial payers have followed suit, as evidenced by Blue Cross Blue Shield of North Carolina’s value-based contract with Fresenius Medical Care North America and Strive Health to serve patients with chronic kidney disease.

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Pursuing the Promise of Value-Based Care Through Specialist Engagement

Healthcare organizations can employ several strategies to engage specialists more effectively in the pursuit of high-quality, efficient care as opportunities for specialist participation in accountable care models expand. Such strategies include:

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Increased Collaboration and Coordination with Primary Care Physicians [7]

Effective care coordination between primary and specialty care physicians can result in improved outcomes, an enhanced patient experience, and cost reduction by preventing duplication of services. This can be achieved through:

• Clearly defined roles and responsibilities, formalized via care coordination compacts
• Timely, productive communication
• Effective data sharing

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Adoption of Evidence-Based Clinical Pathways

Evidence-based clinical pathways integrated across providers can guide specialists in standardizing care and reduce clinical variation and inefficiency while providing a consistent level of quality care for patients.

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Robust Information Flows and Analytical Capabilities

Performance measurement and reporting, as can be achieved through the use of scorecards and dashboards, allows for peer and best practice comparisons in the pursuit of value-based care goals. The use of “shadow bundles,” which CMS began providing to ACOs in February 2024, can also be a helpful tool for increasing specialist engagement via data sharing. Shadow bundles refer to claims data for services, supplies, and the associated payments for discrete procedural- and/or condition-specific episodes of care. [8] This information can be used by specialists and the organization to understand better where opportunities for cost and quality improvement exist.

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Curate a Preferred Network of Specialty Care Physicians

Curating a preferred network of specialty care physicians can help ensure patient access to high-quality and cost-effective specialty care. Specialists who communicate effectively with primary care physicians, demonstrate greater levels of patient service, and deliver high-value care should be pursued and rewarded by the organization with additional referrals. [9]

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Effective engagement of specialists in value-based care is a principle whose time has come to successfully deliver on the promise of reducing healthcare costs and transforming the healthcare industry.

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Reprinted with Permission from Healthcare Administration Leadership & Management Journal, Volume 2, Issue 4, pages 147-148, Copyright © 2024, American Association for Physician Leadership, (800) 562-8088; www.physicianleaders.org.