Building Blocks of Success: Advancing Value-Based Care (VBC) in Specialty Care

Team Innovaccer
Wed 15 May 2024
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Specialty care practices face significant challenges in implementing value-based care. The difficulty of securing contracts with payers and healthcare organizations is exacerbated by limited data transparency and a lack of compelling value propositions. The need for scalable clinical infrastructure and effective engagement with patients and stakeholders presents ongoing hurdles.

Despite these obstacles, value-based specialty care is essential to address the majority of care that primary care cannot fulfill. Specialty care plays a crucial role in managing complex and chronic medical conditions, positioning it as a sector with strong investment opportunities. This alignment of purpose and profitability demonstrates great potential for specialty care practices striving to navigate the current challenges while contributing to improved healthcare outcomes.

Specialty Care Is Critical in Addressing Clinical Outcomes and Healthcare Equity

Specialty care plays a crucial role in addressing clinical outcomes and healthcare spending. Its impact is seen through improved management of complex conditions and chronic diseases, leading to better patient outcomes and potentially reducing the need for costly emergency interventions.

Specialty care providers have advanced training and expertise in their respective fields, as required to achieve more accurate diagnoses and targeted treatments. This expertise enables them to optimize resources, streamline care processes, and reduce unnecessary spending. Additionally, increased access to specialty care can help address disparities in care and improve overall healthcare equity.

A Paradigm Shift Towards VBC in Specialty Providers

While VBC models have primarily focused on primary care, specialists control a significant portion of healthcare spending, highlighting the need for broader VBC adoption. Health plans must evaluate specialist groups based on more than just traditional cost and quality measures to identify potential partners in this transition.

Medicare beneficiaries are seeing more specialists more often now than they were twenty years ago. Recognizing that specialty care is a critical part of the care experience and a substantial portion of overall Medicare spending, the Center for Medicare and Medicaid Innovation (CMMI) has established multiple specialty-focused models for cancer, kidney disease, and bundles primarily for surgical care.

Early efforts in bundled payments are promising, but significant opportunities remain in specialist VBC contracting. Private practices must implement strategies that help them adapt to maintain proficiency in traditional fee-for-service models while gradually engaging innovative methods and technology to transition toward VBC.

Key Factors for Transitioning to VBC in Specialty Care

  1. Addressing significant sources of healthcare spending

Studies have shown that patient outcomes improve under pay-for-performance initiatives, where specialty providers are incentivized to achieve better health outcomes. This fosters a holistic approach, combining the expertise of specialists with the comprehensive oversight of primary care providers. By leveraging data-driven insights, healthcare providers can optimize resource allocation and minimize unnecessary expenditures. Additionally, shifting from a fee-for-service model to value-based care encourages specialists to concentrate on quality over quantity, leading to improved clinical outcomes and more sustainable healthcare spending.

  1. Outperforming fee-for-service models with a focus on quality of care

Under VBC, providers and specialty care practices are incentivized to focus on quality, efficiency, and patient satisfaction, rather than the volume of services provided. This leads to more personalized and coordinated care, improving patient outcomes and reducing healthcare costs over time. VBC enhances patient satisfaction and overall quality of life while also potentially reducing healthcare costs by minimizing redundant services and readmissions.

  1. Overlapping and co-occurring behavioral health conditions

Co-occurring disorders, also known as dual diagnosis or comorbidity, are essential for providing comprehensive care and are particularly relevant for specialty care. These overlapping conditions, including a mental health disorder and a substance use disorder (SUD), can become exacerbated if left unaddressed. Effective management requires an integrated approach encompassing screening, assessment, and coordinated treatment strategies. This may involve psychotherapy, medication management, and complementary care tailored to the individual's needs. By treating both conditions concurrently, healthcare providers can reduce the risk of relapse.

Building Blocks for Success in VBC for Specialty Care

  1. Integrated clinical systems

An integrated clinical system provides the backbone of specialty value-based care, enabling healthcare providers to deliver personalized, coordinated, and efficient care. By integrating electronic health records (EHRs), telehealth platforms, SDoH third-party resources, and other digital tools, providers can seamlessly share patient information, collaborate on treatment plans, and monitor patient progress in real-time. This integration improves patient outcomes, reduces care fragmentation, and enhances the efficiency of specialized care delivery.

According to a report from McKinsey and Company, over 80% of healthcare providers identify integrated clinical systems as pivotal to improving the quality and cost-effectiveness of specialty care. The Centers for Medicare and Medicaid Services (CMS) reports that healthcare organizations leveraging these systems experience a significant reduction in duplicate testing and medication errors, contributing to better patient safety and cost savings.

  1. Maximizing return on investment

Maximizing return on investment (ROI) is crucial for the long-term sustainability and success of specialty value-based care. Strategic investments in robust data analytics tools allow providers to analyze patient data, clinical outcomes, and financial performance, facilitating data-driven decision-making to optimize quality and cost-effectiveness.

Research from the Association of American Medical Colleges (AAMC) shows that providers who participate in training programs focused on value-based care experience a 20% increase in patient satisfaction and an 8% reduction in hospital readmissions. By prioritizing provider education and training, specialty care providers can better understand value-based care principles and effectively apply them in clinical practice, resulting in improved patient outcomes and operational efficiency.

  1. Addressing social determinants of health (SDOH)

Taking SDOH into account is essential for improving health equity and outcomes for individuals, families, and communities. The CDC works with public health departments and community organizations to understand and tackle the impact of SDOH on health. ASPE reviews the evidence and recommends strategies such as policy changes and community-based programs, while NCBI emphasizes the need for healthcare providers, policymakers, and community organizations to address SDOH through targeted interventions and data analysis. Collaborative efforts across sectors are crucial for reducing health disparities and improving population health.

  1. Strategic relationships with payers

Strategic relationships with payers are essential for the success of specialty value-based care. Specialty care providers must navigate complex negotiations to establish payer agreements that deliver tangible returns while maintaining manageable contracts. CMS highlights the growing adoption of risk-sharing contracts, such as bundled payments and capitation models, as healthcare transitions towards value-based care.

Specialty providers must also address challenges such as primary care attribution conflicts and ensure transparent reporting on quality metrics and cost savings. Effective partnerships with payers enable specialty care providers to access necessary resources, implement innovative care models, and drive sustainable improvements in patient care.

Challenges and Opportunities for Specialty Care Practices

Despite the value of transitioning to VBC, specialty care practices, like primary care, are slow to adopt it. The widespread adoption of VBC faces obstacles due to the intricate nature of the U.S. healthcare system. Primary challenges include navigating operational and financial risks while ensuring effective technology integration and data analytics for enhanced care coordination.

There are, however, significant opportunities for success. Engaging specialists in condition-based and patient-centered models can drive better care outcomes. CMMI is aware of the challenges and that expanding accountable care will reduce care fragmentation and unnecessary costs for patients and the health system. Doing so also requires increased access to coordinated and integrated specialty care.

Expanding value-based care to Medicaid and other vulnerable populations can help address healthcare disparities. Strategies that address SDOH and enhance patient engagement are critical for successful implementation. To bridge the gap between the promise and practice of specialty value-based care, innovative approaches and collaboration among stakeholders are essential for driving performance improvement and achieving better patient outcomes.


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