Finding the right path toward optimizing specialty value-based care
It’s crucial for organizations to manage the total cost of care for patients. That involves preventive care and patient engagement.
In specialty value-based care, managing the total cost of care is essential to achieving financial sustainability while delivering high-quality outcomes.
Specialty care often involves expensive treatments, complex care pathways and a high reliance on advanced therapies. Without effective cost management strategies, healthcare organizations risk financial losses and inefficiencies.
To optimize efforts to reduce the total cost of care, organizations must integrate clinical expertise with financial strategies. Bundled payments, for example, align provider incentives by reimbursing an entire episode of care rather than individual services, encouraging cost efficiency and reducing unnecessary interventions according to the Centers for Medicare & Medicaid Services in 2024.
Predictive analytics can help identify high-risk patients who may require early interventions, avoiding complications and costly hospitalizations. Shifting care to lower-cost settings, such as outpatient facilities, can also reduce expenses while maintaining quality.
Equally important is standardization of specialty care protocols to reduce variation in treatment approaches. Establishing best practices for medication management, diagnostic testing and post-treatment follow-ups ensures consistency and cost control. Additionally, strong collaboration between specialists and primary care providers enables early specialty referrals, ensuring patients receive timely and appropriate care before conditions worsen.
Adopting preventive care in specialty VBC
Preventive care plays a critical role in specialty value-based care (VBC), helping reduce the incidence of advanced disease, avoid unnecessary hospitalizations and improve long-term patient outcomes. Many chronic and high-cost conditions, such as cardiovascular disease, diabetes and cancer, can be managed more effectively through early detection and intervention.
Screening programs are a cornerstone of preventive specialty care, ensuring that conditions are identified in earlier, more manageable stages. Preventive medications, risk-reducing surgeries and early lifestyle interventions help mitigate disease progression and associated healthcare costs, according to “Preventive Strategies for Managing Chronic Diseases in Specialty Care,” from the American College of Physicians published in 2024. Genetic testing and risk stratification models enable specialists to personalize prevention plans based on individual patient profiles.
Beyond clinical interventions, preventive care should extend to patient education and self-management programs. When patients are well-informed about their conditions, they are more likely to adhere to prescribed treatments, engage in healthier behaviors and avoid unnecessary emergency department visits. By integrating prevention strategies into specialty VBC models, healthcare organizations can reduce long-term spending and improve population health outcomes.
Implementing care coordination in specialty VBC
Care coordination is essential in specialty VBC, where patients often navigate multiple providers, medications and treatment plans. Without effective coordination, fragmented care leads to redundant testing, medication mismanagement and avoidable hospitalizations.
Multidisciplinary care teams improve coordination by bringing together different specialists and healthcare professionals to create comprehensive, patient-centered care plans. Care navigators or case managers can facilitate communication between specialists, primary care providers and patients, ensuring seamless transitions between different levels of care.
A well-integrated health information exchange (HIE) system further enhances coordination by providing real-time access to patient records across providers and care settings, according to, “The Role of Health Information Exchange in Value-Based Care Models,” published in Health Affairs in 2024. This ensures specialists have the most up-to-date information, reducing duplication of tests and improving decision-making. Additionally, care coordination efforts should include post-treatment follow-up programs, ensuring that patients adhere to recovery plans and avoid unnecessary readmissions.
Engaging patients in specialty VBC
Patient engagement is a key driver of success in specialty VBC, influencing adherence to treatment plans, patient satisfaction and long-term health outcomes. When patients are actively involved in their care decisions, they are more likely to comply with medications, attend follow-up appointments and take preventive actions to avoid complications.
Shared decision-making enables patients to understand their treatment options, risks, and expected outcomes, empowering them to make informed choices. Digital tools, such as patient portals and remote monitoring apps, further support engagement by enabling patients to track symptoms, receive real-time health insights, and communicate with providers.
Additionally, specialty care providers should incorporate personalized education programs tailored to individual patient needs. Providing resources on disease management, medication adherence and lifestyle modifications encourages self-care and reduces unnecessary reliance on acute care services. Engaged patients are more proactive about managing their conditions, leading to better health outcomes and lower overall costs.
Addressing quality metrics
Effective management of quality metrics is a fundamental part of population health in specialty VBC. These metrics ensure that care is meeting clinical and patient experience standards while preventing unnecessary spending. Key quality measures include:
HEDIS (Healthcare Effectiveness Data and Information Set) Metrics. Used to evaluate specialty-specific performance measures such as controlling high blood pressure, diabetes management and cancer screenings.
Patient-reported outcomes (PROs). Measuring patient experience and quality of life post-treatment, particularly in specialties like oncology and orthopedics.
Readmission and complication rates. Tracking unplanned hospital readmissions and post-procedural complications ensures effective care planning and management.
Specialists must have real-time access to performance dashboards to monitor these metrics and identify improvement areas. Ensuring alignment between clinical teams and VBC financial structures helps reinforce quality improvement initiatives and promote better patient outcomes.
Risk adjustment in specialty VBC
Accurate risk adjustment ensures that providers are appropriately reimbursed for managing complex specialty populations. Specialty conditions often involve multiple comorbidities that impact patient acuity and cost of care, making proper risk stratification essential.
Key strategies for managing risk adjustment include:
Comprehensive documentation and coding. Ensuring that all chronic conditions and comorbidities are correctly documented in patient records to reflect true disease burden.
Provider education on risk adjustment. Training specialty providers on the importance of complete and accurate coding, including hierarchical condition category (HCC) coding for Medicare Advantage and other risk-based contracts.
Data-driven risk stratification. Using predictive analytics to identify patients who are likely to require high-cost interventions, enabling early interventions that reduce preventable complications and hospitalizations.
By improving risk adjustment processes, specialty care providers can secure appropriate reimbursement and ensure financial sustainability in VBC models.
Staying updated on regulatory and policy changes
Regulatory and policy changes significantly impact specialty VBC models, affecting reimbursement structures, quality reporting requirements and compliance obligations. Healthcare organizations must remain informed about evolving regulations to ensure contract alignment and financial stability.
Specialty providers can stay updated through professional associations, policy briefings and industry conferences. Participating in learning collaboratives and value-based care payment networks provides insights into best practices and emerging policy trends. Regular internal reviews of payer contract updates and compliance requirements help organizations proactively adapt to regulatory shifts.
By integrating policy knowledge into strategic planning, healthcare organizations can anticipate changes, optimize financial models and maintain compliance with evolving healthcare regulations.
Managing total cost of care in specialty VBC requires clinical integration, financial alignment and a proactive approach to patient management. By adopting preventive strategies, implementing robust care coordination, actively engaging patients, addressing quality metrics, ensuring proper risk adjustment and staying informed on regulatory changes, specialty providers can achieve high-quality outcomes while maintaining financial sustainability.
As specialty care continues to evolve under value-based reimbursement models, health systems must embrace data-driven decision-making, multidisciplinary collaboration and patient-centered engagement to optimize both cost and quality.
Crystal Crider, DHA, MHA, FACHE, eFACHDM, is a value-based care subject matter expert and thought leader. Dr. Crider holds graduate instructor positions at both UCF and AUM.