Value-Based Transformation of Specialty Practices

Dr. Anil Jain, MD
Tye 30 May 2023
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Embracing Patient-Centric Care: The Rising Impact on Specialized Medicine

The CMS introduced its first value-based program, End-Stage Renal Disease Quality Incentive Program (ESRD QIP), in 2008. Since then, the number of value-based models introduced by the CMS and other healthcare innovators has expanded dramatically. There are now no fewer than 94 value-based innovation programs launched by the CMS alone, with variations and other models piloted or employed by various payers, consortiums, and advocacy groups also in play across the healthcare industry.

Value-based care (VBC) and reimbursement models have been at the forefront of industry discussions, activity, and business ventures for the past 15 years, bringing the concept of value over volume—that is, quality outcomes and cost-efficiency of care delivery vs. free for service—into sharp relief.

Value is defined as the ratio of quality over cost, and should translate into a better patient experience and reduced per capita health expenditures. One of the most successful value-based models among primary care providers (PCPs) is the ACO, or Accountable Care Organization.

ACOs are groups of doctors, hospitals, and other healthcare providers who work together to coordinate care for their patients. They do this by sharing information, developing care plans, and providing preventive care. They’re paid based on the quality and cost of care they provide. If they can provide high-quality care at a lower cost than they would have under traditional fee-for-service Medicare, they can share in the savings.

The Affordable Care Act (ACA) introduced the Medicare Shared Savings Program (MSSP) in 2010, a voluntary program that allows ACOs to share in the savings they achieve by providing high-quality, coordinated care to Medicare patients. ACOs have the potential to improve the quality of care and lower costs for Medicare beneficiaries. While the ACO is a relatively new model, they’ve grown rapidly in recent years. Since 2010, more than 1,200 organizations have held an ACO contract in Medicare, Medicaid, or the commercial sector, and have served tens of millions of patients.

ACOs prioritize preventative care for long-term health and wellness over frequent, episodic care. A greater focus on VBC in the primary care setting was designed to drive fewer referrals and a wiser utilization of healthcare dollars. The CMMI (CMS’s Center for Medicare and Medicaid Innovation, a-k-a the CMS Innovation Center) has been experimenting with various Alternative Payment Models (APMs) that aim to bring the concept of value to primary care, such as the ACO and ACO Realizing Equity, Access, and Community Health (ACO REACH).

These models, however, did not incentivize involvement of specialist physicians who provide services beyond the scope of PCPs’ offices. Consequently, there was a clear absence of clinical and financial alignment between primary physicians and specialists. Specialty care providers were being incentivized for episodic payments, and this led to ineffective referral management, lack of coordination, and dysfunction among members of the care teams. And that resulted in an inability to realize optimal specialty care.

The good news: The CMMI has now developed a strategy to harmonize and enhance care coordination between primary and specialty care practices to achieve true accountable care for patients. They’ve introduced several innovative payment models for specialty areas, such as:

  • The Comprehensive Kidney Care Contracting (CKCC) in Nephrology, to delay dependence of kidney patients on dialysis and to promote kidney transplantation
  • Bundled Payments for Care Improvement Advanced (BPCI Advanced) as a bundled payment initiative to encourage efficient care program redesign for orthopedic practices
  • The Million Hearts Initiative to prevent one million heart attacks and strokes

All of these programs are designed to incentivize high value, cost-efficient specialty care to improve patients’ quality of life.

What Value-Based Transformation Means for Specialty Practices

Specialty practices have traditionally been engaged in providing episodic care to patients whose attribution and, therefore, overall total cost of care risk was assumed by their primary care physicians and practices. With the introduction of value-based payment models for specialties, this scenario is changing, bringing with it novel opportunities for specialists as well as new challenges.

The shift to value-based specialty care has a huge potential to improve care quality and clinical outcomes by enhancing the coordination between primary and specialty care providers, and holding specialists accountable to care and outcome quality. It will also incentivize specialists to manage the cost of specialty care, leading to more affordable and cost-effective care—especially for patients living with multiple chronic conditions and comorbidities, where advances in treatment, and their costs, might be outpacing benefits.

But shifting to risk-sharing in specialty practices is no simple feat. As with primary practices, specialists will encounter various challenges specific to their specialty, stemming from their unique clinical workflows. To harness the clinical and financial benefits of value-based transformation, specialty providers must prioritize technological enablement, just as primary practices have learned to do.

Data readiness is imperative to help specialty practices make sense of patient data, and gain visibility into their contract performance, physician efficiency, cost drivers, and patient behavior. The four pillars of digital enablement and capability building which specialists should focus on are data interoperability, joint attribution, care management workflows, and patient engagement. Let’s drill into each of these pillars.

  1. Data readiness and interoperability Specialty care providers must cultivate essential digital health skills to efficiently gather and consolidate data from various EHR formats and locations. Real-time information transfer between primary care physicians and specialists is crucial. Analytical abilities are needed to better understand the attributed patient population's risk factors. Patient outreach and relationship management capabilities help maintain patient engagement and ensure compliance. Physician engagement tools offer clinical decision support and convey care/coding gap data at the point-of-care. Revenue cycle intelligence prevents claim denials and streamlines reimbursement cycles. Additionally, efficient OR rescheduling solutions minimize lost revenue from canceled elective procedures.
  1. Accurate attribution In addition to data readiness, speciality care providers need to deal with several other integration hurdles which might delay or defy harmony between primary and specialty physicians. The biggest challenge here is how to manage joint attribution of a patient. A chronic patient with renal, neurologic, and peripheral vascular complications will potentially need to be seen by a PCP as well as at least three other specialists on a long-term basis. With value-based reimbursements for primary and specialty providers, there needs to be patient attribution to each physician separately, which will enable accountability and risk-sharing on their part.
  1. Technology-enabled care management workflows Care management has witnessed a metamorphosis with digital care delivery at its core. The evolution and expedited adoption of concierge or boutique care, virtual care/telemedicine, and home-based chronic disease management are some of the modalities of digital-first care which have been embraced by specialties such as gynecology, orthopedics, and rheumatology. In addition, automation of care delivery workflows, digitized care worklists, and intelligent care management insights powered by 360-degrees of patient data has enabled care teams to collaborate more effectively, and prioritize and personalize care delivery for patients with multiple comorbidities. This is especially true in the context of specialty care, where many patients are consulting more than three specialists, and digitally-driven care delivery can improve the quality of care and reduce the propensity to develop acute episodes.
  1. Patient engagement With almost 20% of adult patients in the US taking five or more prescription drugs, it's clear patient engagement must play a crucial role in ensuring medication compliance for better clinical outcomes. Patient engagement is also the simplest, quickest, and the most effective way to share educational material with patients about their illnesses and disease predispositions, and send them reminders on annual health assessments and preventive health visits. A 24/7 contact center embedded in the engagement solution can provide constant support to patients, readily answer their queries, and help guide them to the appropriate care facility in times of need. It’s an instrument to improve patient satisfaction and shift patient behavior from reactive to preventative care.

How Specialty Organizations Can Succeed in This Changing Payment Landscape

With the rising need for specialist practices to become technology-enabled, speciality care providers need an end-to-end data and technology partner who can provide a strong data foundation for them, enable interoperability between primary and specialty practices, and have advanced analytical capabilities which can uniquely cater to each specialty’s needs.

A versatile platform which effectively unifies patient data across physician locations, EHR formats, claims, and laboratories to create a 360-degree longitudinal patient record is the starting point for the digital revolution of speciality care. This single source of truth powers advanced analytics, clinical decision support, care management, and patient engagement to enable patient-centric, high-quality, cost-efficient care.

Cloud-based population health management solutions allow practices to leverage unified patient data for precise risk adjustment, capturing potential codes at the point of care. These solutions identify cost drivers, evaluate physician performance, and develop tailored care management protocols to support patients throughout the care continuum. They also facilitate patient outreach across various communication channels, promoting compliance, enhancing staff efficiency with smart automation, reducing administrative burden, and integrating a robust health equity strategy into care delivery.

These advanced technologies will enable specialty practices to obtain valuable insights on quality and cost-of-care metrics, supporting enhanced clinical outcomes and optimal performance in risk-based reimbursement models. And partnering with a true healthcare technology leader can accelerate value-based care transformation and upscaling of specialty practices.

Learn how Innovaccer’s Data Activation Platform and Population Health Management solution suite has helped support value-based transitions for large specialty organizations. Book a demo with our team of experts to find out more.


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Tags: VBC
Dr. Anil Jain, MD
Chief Innovation Officer, Innovaccer

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