What Is Value-Based Specialty Care?

The traditional fee-for-service healthcare landscape is shifting rapidly. While primary care led the first wave of value-based care (VBC), private-equity investors, venture capitalists, and payers are now targeting a much larger market: specialty care.

Familiar VBC models emphasize preventive care with measures and incentives that, if followed, set a quality standard of care and keep members out of specialty episodes. However, specialty services are a major driver of U.S. healthcare spending. Thus, specialty care is a critical battleground for comprehensive cost containment.

Forward-thinking healthcare leaders prioritize risk-sharing frameworks. By integrating high-cost specialties into risk-bearing structures, new VBC business models eliminate waste, improve patient outcomes, and capture financial upside.

Investing in Specialty Care

High-cost specialties like cardiology, oncology, and orthopedics represent the next frontier for systemic cost containment through value-based care. Oncology, for example, offers wider potential savings when providers reduce variation in diagnostic testing, standardize chemotherapy protocols, and shift appropriate fusion treatments to home settings.

Payers are accelerating their investments in specialty care because research shows that episode-payment models offer stability. By engaging specialists in risk arrangements, organizations actively control spending, meet benchmarks, generate savings for payers and providers, and uphold patient care quality.

The Centers for Medicare & Medicaid Services (CMS) is accelerating capitated payments and incentivized structures for specialty care to help keep costs in check and standardize care. New CMS programs include the Ambulatory Specialty Model (ASM), a model that holds select specialists accountable for cost and quality in managing chronic conditions, and the Transforming Episode Accountability Model (TEAM), a bundled-payment model that makes hospitals responsible for coordinating complete surgical care.

To manage financial risk under these new CMS mandates, innovative payers and health systems are heavily increasing their investments in specialized platforms that prioritize innovative digital health, data-supported treatment pathways, outpatient-focused integrated care, and more.

What’s to Come for Specialty VBC

Specialty care is moving to structured VBC payment models and leaving fee-for-service behind, according to McKinsey & Company. Episode-based bundles are leading the way, and new models are pushing into more specialties. So, what’s to come for specialty value-based care?

• More specialty model launches. CMS and payers will test models that target high-cost specialties and episodes, including selectively mandatory programs.
• Broader specialty participation. Independent specialists and specialty groups are likely to be pulled into VBC more often as payers look for measurable savings and better outcomes.
• Better infrastructure. Success will depend on data tools, care navigation, referral management, and analytics that can track outcomes across multiple specialists.
• Harder attribution questions. As specialty VBC scales, organizations will have to solve who “owns” the patient, how to avoid duplicate incentives, and how to coordinate primary care.

The clearest near-term trend for specialty VBC is expansion. Including more contracts for oncology, orthopedics, cardiology, nephrology, and surgical episodes, plus an increase in pressure to bring specialists into risk arrangements. Industry analysts also expect stronger use of partner organizations and technology platforms to help practices manage risk, data, and care coordination.

AccuReports: Your Tool to Address Specialty Care Spending

AccuReports is an interactive healthcare financial analytics platform that payers and providers use to better manage performance in risk-based contracts. The web-based platform brings information together from multiple sources, so users can spot trends, drill into root causes, and act on opportunities to improve financial performance.

To learn more about FRG, your partner for healthcare financial intelligence, contact us online or call 888-466-1025.