Why specialty care will be crucial to value-based success
The transition from traditional models to outcome-based reimbursements in specialized healthcare face big challenges, offset by large growth opportunities.
Value-based care represents a healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes. Under this model, providers are incentivized to help patients improve their health in a more economically efficient way rather than through than the traditional fee-for-service approach by which providers are paid based on the quantity of care services they deliver.
Specialty value-based care (VBC) extends the premise of outcomes-based reimbursement into specific areas of healthcare that involve high levels of expertise and technology, such as orthopedics, oncology, cardiology and neurology.
Development of specialty value-based care
The development of specialty value-based care has been notably slower than general value-based care models for several reasons.
Complexity of specialty care. Specialty care involves complex and chronic conditions that require highly specialized treatments. The variability in patient responses to treatments and the high stakes involved in specialty care make standardizing practices and outcomes challenging, which is a foundational aspect of value-based care.
Data integration challenges. Implementing value-based care in specialty care requires robust health information technology systems that can integrate and analyze large volumes of data from diverse sources. Many specialty care providers have been slow to adopt these advanced data systems.
Risk adjustment. Accurately adjusting for risk in specialty care is more difficult than in primary care. Patients requiring specialty care often have multiple co-morbidities or severe conditions that complicate outcome measurement and comparisons across providers.
Payment models. Developing reimbursement models for specialty care that accurately reflect the quality and efficiency of care, while also incentivizing innovation, is exceedingly complex. These models must account for the high costs of specialty drugs and therapies, which can distort incentives if not carefully managed.
Regulatory barriers. There are significant regulatory hurdles to implementing specialty value-based care models, including ensuring compliance with the Stark Law, which governs physician self-referrals, among other regulations.
Main areas of growth
Despite these challenges, there are several areas of growth in specialty value-based care.
Orthopedics. Programs like the CJR (Comprehensive Care for Joint Replacement) Model have demonstrated success in improving the cost-effectiveness of joint replacement surgeries and are being expanded to cover other orthopedic procedures.
Oncology. One of the earliest adopters of specialty VBC, oncology has seen the development of numerous models aiming to improve outcomes while controlling costs. The OCM (Oncology Care Model) launched by the Centers for Medicare & Medicaid Services has paved the way for further innovations in this area.
Cardiology. New models are being developed for cardiology care, particularly around heart failure and coronary artery disease, which aim to reduce hospital readmissions and improve patient outcomes through better outpatient management.
Neurology. Particularly in the treatment of stroke and epilepsy, value-based care models are being explored to optimize recovery and manage chronic conditions more effectively.
Four keys to specialty VBC success
The transition to value-based care in the specialty space has significant challenges, but promising growth areas.
Those organizations who will succeed with specialty VBC will quickly move beyond the required data integration and regulatory checkpoints, and will position themselves to execute on the nuanced elements of more robust and sustainable models.
Healthcare leaders and their teams need to focus on these four key areas if they want to be successful.
Improved outcomes. Specialty VBC models are intent on achieving the best possible health outcomes for patients, which is especially important for those with complex or chronic conditions. These models incentivize healthcare providers to adopt the most effective treatments and interventions, reducing variability in care and focusing on long-term health improvements.
Enhanced satisfaction. These models often lead to higher patient satisfaction as they promote more patient-centered care, with increased time spent on consultation and less on unnecessary interventions. The focus on outcomes and patient engagement can improve the overall patient experience.
Holistic care. Specialty VBC models take into account the whole patient, integrating care across multiple specialties and providers. This holistic approach is vital for treating the entire spectrum of a patient’s health needs, particularly for those with multiple chronic conditions, ensuring that all aspects of a patient's health are managed in a coordinated manner.
Cost efficiency. By aligning payment structures with outcomes rather than services rendered, specialty VBC encourages the elimination of unnecessary procedures and tests, leading to more cost-effective care. This can significantly reduce healthcare spending, which is crucial in a time when healthcare costs are continuously rising.
The healthcare landscape continues to evolve towards specialty value-based care. The future of specialty value-based care looks promising, with the very real potential to significantly improve patient outcomes while controlling healthcare costs, ultimately leading to a more sustainable healthcare system.
Focusing on strategic adaptation and proactive management, leaders can not only ensure their organizations are competitive but are also providing high-quality, efficient care that truly meets the needs of their patients. This forward-thinking approach is essential for any healthcare organization aiming to excel in the new era of value-based specialty care.
Dr. Crystal Crider, DHA, MHA, FACHE, eFACHDM is an executive fellow of the American College of Health Data Management, fellow of the American College of Healthcare Executives, vice president of product at Enlace Health, graduate faculty scholar at the University of Central Florida and MHA instructor at Auburn University at Montgomery.