Most accountable care models focus on primary care. This leaves specialists on the outside looking in, stuck, for the most part, in a fee-for-service world.
That’s despite the fact that specialty care accounts for about 70% of health care spend.
Primary care-based models are designed to keep patients healthy and prevent disease. That makes sense – work to keep the population healthy.
Specialty care models are different. Since individuals are already in need of specialty care, the models require a different level of risk stratification to ensure clinically similar populations. This allows for the study of variations in care and costs of care – and the model is designed to optimize both.
How can we embrace value-based models in specialty care?
1. Transparently share data. Data needs to drive decision-making when it comes to designing and implementing a value-based care model with specialists.
Physicians want to provide the best care to their patients. Without data, they often have no idea how their care actually stacks up, and if there are efficiencies that can be incorporated to provide better outcomes and make better use of limited resources. Payer claims data can provide some clarity into which disease states or procedures may not be most effectively managed, and/or which clinical practices may have the most opportunity for improvement.
The right claims data can also help stakeholders decide which value-based care model is right for them. A study of cost data for GI conditions, for example, showed very little cost variability for most GI conditions, but revealed high cost volatility among inflammatory bowel diseases like ulcerative colitis and Crohn’s disease.
The study concluded that conditions with more predicable cost and outcomes may be better suited for value-based programs like bunded payments and episodes of care, while more complex conditions require a heavier focus on care coordination, patient engagement, and disease management.
2. Partner to develop arrangements. To build the most effective value-based care models, they should be built collaboratively by health plans, clinicians, and other stakeholders. These models are based on team-care and require the expertise and active participation of all stakeholders.
When everyone is involved in the proverbial sausage-making, they’re more likely to feel their expertise is being leveraged and have more ownership in the finalized care model.
3. Use more carrots than sticks. Though some value-based arrangements do have downside risk, that’s not the best place to start when introducing specialists to a new payment model. A glide path from fee-for-service to value-based care may be the better approach.
Shared savings models are a great starting point to ease providers into value-based care. It’s similar to pilots using a flight simulator before flying a real airplane — in a shared savings model, the stakeholders can get to know each other and reap the rewards of improving care and lowering costs without fear of losing money (i.e. crashing the airplane).
When these three steps are followed — when payers share data, providers are engaged in building the arrangement, and everyone can participate without fear of negative repercussions— success is possible.
To hear further discussion on this topic, check out the authors’ panel discussion at AHIP Institute 2020.