Mar 14, 2020
Emphasizing Specialty Care with Value-based Care Models

There is a shift to move all sectors of health care away from traditional fee-for-service models that pay clinicians based on the number of patients seen or procedures performed to value-based care. Value-based models reward clinicians for improving patients’ clinical outcomes. Over the past decade, an influx of accountable care organizations (ACO) in primary care have reduced costs and improved patient health.


These models have yet to move completely into specialty care which drives the bulk of Medicare spending. In 2009, specialty care accounted for more than half of office visits to physicians and nearly 70% of health care expenditures.


What are some of the benefits of incorporating value-based care into specialty care?  


In 2010, approximately 21.4 million Medicare beneficiaries had at least two chronic conditions. The typical end-stage renal disease (ESRD) patient has four or more chronic conditions. While ESRD patients represent 1% of Medicare beneficiaries, they account for 7.2% of Medicare medical costs. 


Transitioning chronically ill, medically complex patients to ACOs and away from fee-for-service specialty care has the potential for:  


  • Improved clinical results. By using the evidence base of their specialty to inform care delivery, specialists can improve their patients’ experience and their clinical outcomes.  
  • Reduced cost of care. The majority of health care costs occur in specialty care. Precision medicine and innovation are also prolific in specialty care. Promoting innovation and efficiency in ACOs will help control costs. 
  • Enhanced patient engagement. The average Medicare patient visits two primary care clinicians and five specialists annually. Patients with multiple chronic conditions visit even more specialists and fewer primary care clinicians. Specialty care is an untapped area to transform and increase patient engagement.
  • Increased specialist accountability. Leaving specialists out of ACOs creates division between them and primary care clinicians and fosters a lack of accountability. Developing ACOs that include or are led by specialists will better position them to achieve the Quadruple Aim


Impact of existing specialty care ACOs


Value-based care has successfully moved into some areas of specialty care, driving greater innovation and a renewed focus on reducing costs. Here are some examples:


  • Chronic Condition Special Needs Plans (C-SNPs). These Medicare Advantage care coordination plans are designed for individuals with specific severe or disabling chronic conditions.
  • ESRD Seamless Care Organizations (ESCOs). ESCOs were established in 2015 to address the complex needs of ESRD patients. They connect dialysis centers, nephrologists and other providers to coordinate the care of patients on dialysis.
  • Oncology Care Model (OCM). Created in 2016, this is a five-year, multipayer model testing innovative payment strategies that promote high-quality and high-value cancer care.
  • Other specialty care coordination solutions. Digital health solution SonarMD reduced hospitalizations and outpatient visits for patients with Crohn’s disease, which led to savings of $6,500 per patient annually.


Ultimately, and despite inherent challenges, positioning specialists and specialty ACOs to deliver better results for patients, clinicians and for all payers is what’s needed to move the entire health care industry forward.