This year, the Innovation Center is advancing into the third year of its strategic refresh, aiming to achieve a significant milestone by 2030, i.e. having all traditional Medicare beneficiaries and the majority of Medicaid beneficiaries engaged in accountable care relationships. Accountable care includes healthcare providers responsible for enhancing care quality, coordination, and health outcomes for a specific patient group, guided by population-based metrics and financial benchmarks.

Achieving the CMS vision requires a comprehensive approach that goes beyond primary care. This approach addresses the bulk of the total cost of care and quality opportunities that primary care alone cannot support. This is where the importance of specialty care comes into play, delivering high-quality, coordinated care that addresses the full spectrum of patient needs.

What is Value-based Specialty Care?

Value-based specialty care is a healthcare delivery model where patient care quality and cost are linked to outcomes. In this approach, healthcare payment is tied to the value of care patients receive, emphasizing improved patient outcomes and cost-effectiveness.

The Challenges of Fragmented Specialty Care

Medicare beneficiaries often face fragmented and costly care, characterized by several diagnostics, imaging, tests, and treatments specialists provide across various care settings. A study in 2022 revealed that Medicare fee-for-service (FFS) beneficiaries experienced highly fragmented care, with an average of 13 ambulatory visits across seven practitioners in one year. This increasing fragmentation underscores the need for improved coordination between primary and specialty care to enhance patient outcomes and reduce healthcare costs. In 2019, Medicare beneficiaries saw an average of 50% more specialists in the outpatient setting than in 2000, further aggravating the challenges of care coordination and patient management.

Critical Elements of Successful Specialty Value-Based Care Models

High-performing models must focus on three key elements to excel in the complex healthcare landscape and deliver high-quality, patient-centered care. These models include managing complex conditions, and integrating with existing healthcare systems to enhance patient engagement and outcomes.

Improving Transparency of Specialty Care Performance Data

The CMS Innovation Center’s particular care strategy strongly emphasizes enhancing the transparency and accessibility of specialty care performance data. This is the first essential element of their approach, which aims to provide clinicians, hospitals, and other healthcare entities with more comprehensive and standardized data across various models and programs. The Innovation Center has undertaken a coordinated effort to roll out multiple data initiatives tailored to support different types of providers and participants.

In February 2024, the Innovation Center began offering shadow bundles data to Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program and the ACO Realizing, Equity, Access, and Community Health (REACH) Model. The shadow bundles data includes summary information from raw claims, with ACOs can leverage to better engage with specialists and manage their beneficiaries’ specialty care needs.

This care-standardized episode-of-care data gives ACOs valuable insights into specialist care patterns and utilization, empowering them to make more informed decisions and establish their episode payment initiatives. By providing this standardized episode data, the Innovation Center aims to enhance transparency and consistency across the healthcare system, enabling ACOs and other providers to compare cost and quality.

Creating Incentives for Primary Care Providers to Engage with Specialists

The Innovation Center explores innovative approaches to incentivize greater engagement between primary care providers and specialists. For example, the Making Care Primary (MCP) Model aims to expand access to advanced primary care services to a broader range of healthcare organizations, catering to a more diverse patient population. This model facilitates collaboration between primary care organizations participating in the program and their Specialty Care Partners by introducing new model-specific codes.

In addition to efforts to integrate specialty care with advanced primary care models, the Innovation Center is exploring strategies to encourage greater involvement of specialty care providers with primary care providers and beneficiaries in Accountable Care Organizations (ACOs).

By leveraging the existing structure of the Quality Payment Program’s (APP) Merit-based Incentive Payment System (MIPS) Value Pathway (MVP) program, the Center plans to concentrate on geographic areas with a strong presence of longitudinal, population-based models. This focus aims to create opportunities for specialists to collaborate effectively with primary care clinicians seeking to establish meaningful partnerships in specialty care within the value-based care framework.

Incentivizing for Specialists to Affiliate with Population-Based Models

To empower ACOs to deliver high-quality, cost-effective care, the Center is also exploring strategies to create financial incentives to encourage specialists to affiliate with population-based models and move to value-based care. This helps ACOs address the specialty care needs of their beneficiary population, particularly those who have faced barriers in accessing specialty services. This strategic change aims to facilitate longitudinal, accountable, and coordinated patient care.

The shift to accountable care is essential in reducing care fragmentation and unnecessary costs, benefiting patients and the healthcare system. However, achieving this goal requires enhanced access to well-coordinated and integrated specialty care. Providers can foster collaboration between primary and specialty care across various care settings with a more patient-centric approach to meeting patients’ diverse needs and preferences.

Conclusion

Value-based specialty care, a crucial component of care management, focuses on delivering high-quality, coordinated care that addresses the full spectrum of patient needs while also aiming to reduce unnecessary costs and improve overall health outcomes. This model incentivizes healthcare providers to deliver efficient and effective care that prioritizes patient well-being and outcomes over the volume of services provided.

Stakeholders across the healthcare ecosystem must collaborate and invest in the key elements of successful specialty value-based care. Persivia’s Specialty Care program is designed to offer care recommendations at the point of care, providing valuable insights to healthcare providers, care managers, and patients when needed.

Persivia leverages advanced machine learning algorithms and AI to refine risk stratification models. By effectively managing the volume of patient data, Persivia can accurately predict which patients are at risk of becoming high-cost individuals. This proactive rising risk strategy enables healthcare providers to identify and intervene early with personalized healthcare strategies, improving patient outcomes and healthcare costs.

Persivia’s Specialty care program goes beyond traditional care models by offering personalized pathways for each patient. It identifies Care Gaps for each individual to ensure that no aspect of care is overlooked. These pathways include guideline-based recommendations on therapy, enabling healthcare providers to tailor treatment plans to meet each patient’s specific needs.

The program also includes real-time alerts specifically tailored for discharge disposition, ensuring that patients receive the necessary care and support after hospital discharge. This feature helps to reduce readmissions and improve patient outcomes.

Get in touch with our dedicated team of health tech experts to learn more about our specialty care programs.