Emphasizing Specialty Care with Value-Based Care Models

The move to value-based care in the United States is failing to fully achieve the Quadruple Aim of improving patient engagement, the health of a population and clinician engagement while reducing the total cost of care. This failure may be due to current accountable care models that focus on primary care and ignore specialty care.

Specialty care accounts for the majority of health care activity (doctor visits and medical spend) among Medicare beneficiaries. In fact, in 2009, specialty care accounted for more than half of office visits to physicians and nearly 70% of health care expenditures. In this new paradigm of value-based care, specialty care, which can help slow chronic disease progression and reduce complications, should become the principal driver of accountable care.

Benefits of a Specialty-Focused Accountable Care Environment

Medicare covers a large population of patients with multiple chronic conditions. In 2010, approximately 21.4 million Medicare beneficiaries had at least two chronic conditions and accounted for the bulk of health care services provided under Medicare. There are multiple, chronic conditions that require not only management by specialty and primary care physicians, but also data exchange and a common understanding between patients and physicians of treatment goals and monitoring. A specialty accountable care organization (ACO) environment would better  address the complexities of those with chronic conditions and may help physicians achieving the following outcomes for patients:

• Improved clinical results. Specialists know their areas of health care and delivery systems better than generalists. Additionally, as key lead physicians for their patients, specialists have the opportunity to better improve patient experience and outcomes, especially when using the evidence base of their specialty to inform care.
• Reduced cost of care. Specialty care drives the bulk of Medicare spending. Patients with chronic conditions account for approximately 75% of US health care expenditures, and 96 cents of each Medicare dollar fund chronic disease treatment and management. There is an opportunity to save more money with specialty care, not only because that is where the majority of the health care costs are, but also because precision medicine and most new and innovative treatments are in the province of specialty care. Thus, specialists need to be more at the center of efforts to control costs in ACOs.
• Enhanced patient engagement. The average Medicare fee-for-service (FFS) patient visits two primary care clinicians and five specialists annually. Patients with multiple chronic conditions visit even more specialists and fewer primary care clinicians. Thus, the greatest opportunity to enhance patient engagement is with the specialist. However, most ACOs diminish contact with specialists by encouraging primary care physicians and patients to use them only when truly necessary and to find specialists who use fewer resources—and therefore, keep costs low—in their practices.
• Increased specialist accountability. Leaving specialists out of ACOs and other value-based constructs creates division and a lack of accountability on their part to participate in the necessary changes to achieve better outcomes and lower costs. In the process of redesigning value-based care, specialists—not only primary care physicians—need to be fully engaged. Developing ACO constructs that include or are led by specialists positions both the ACOs and the specialists to more effectively deliver on the whole Quadruple Aim.

Evidence for Specialty Providers Achieving ACO Objectives

Current care models that provide intensive, specialty-focused, value-based care have succeeded in delivering on the Quadruple Aim. The following models cover a range of specialties and have a reimbursement structure different from traditional Medicare FFS while borrowing significantly from the ACO construct in other ways.

• Chronic Condition Special Needs Plans (C-SNPs). C-SNPs are coordinated care plans offered under Medicare Advantage with enrollment limited to individuals with specific severe or disabling chronic conditions, including, but not limited to, chronic heart failure, diabetes, cancer and end-stage renal disease (ESRD).
• ESRD Seamless Care Organizations (ESCOs). In the United States, patients with ESRD make up approximately 1% of the Medicare population and account for 7% of Medicare spending due to disease complications, comorbidities, and high rates of hospital admissions. In 2015, the Centers for Medicare & Medicaid introduced the Comprehensive ESRD Care (CEC) Model to help address the complex needs of these patients. The CEC Model established ESCOs consisting of dialysis centers, nephrologists and other providers to coordinate care for patients on dialysis. In addition, The Center for Medicare & Medicaid Innovation (CMMI) has existing value-based models in place for CKD and ESRD patients.
• Oncology Care Model (OCM). In 2016, CMMI announced the OCM, a 5-year, multipayer model established to test innovative payment strategies promoting high-quality and high-value cancer care.
• Other specialty care coordination solutions. One digital care coordination solution called SonarMD—a specialty-focused population health entity offered to patients with Crohn’s disease by participating gastroenterologists—reduced hospitalizations and outpatient visits, which led to savings of $6500 per patient annually.

Conclusions

As the health care system continues to incorporate more value-based models, specialty ACOs represent a unique approach toward achieving the Quadruple Aim. Specialists in specialty ACOs have a greater obligation to lead care while improving outcomes and cost-effectiveness of the care delivered. This is consistent with the approach defined in the executive order signed on July 10, 2019, to launch Advancing American Kidney Health.

Specialty ACOs are also positioned to succeed in adding value for other reasons. Most importantly, managing several patients with the same underlying disease and comorbid complications can help an ACO perform care coordination and use common solutions for similar problems. Regardless of certain inherent challenges—such as specialty–primary care interaction, patients moving between two types of accountable care entities and appropriate information transfer—specialty ACOs deserve greater consideration as we strive to deliver better results for patients, for the clinicians caring for them and for all payers.

This content has been summarized, with permission, from The American Journal of Accountable Care.