Posted on July 09, 2024 | 2 min read

The Rise of Value-Based Specialty Care


Financial Optimization

Healthcare Data

Value Based Care

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The Rise of Value-Based Specialty Care

Value-based specialty care can help transform care delivery and improve patient experiences and outcomes, so it’s no surprise that it has been major topic of conversation this year. A common refrain heard at healthcare conferences and in industry media is that value-based specialty care is coming, and healthcare organizations can either get on board or get left behind.

Specialty care accounts for roughly 60% of total care costs, which is a testament to the vital role of specialists in achieving positive outcomes. However, dividing up the responsibility for a single patient between primary and specialty care providers often results in disconnected care that tends to worsen as the number of providers involved in a patient’s care increases.

The average Medicare beneficiary sees two specialists (and 30% of beneficiaries see five or more), which makes it clear that truly patient-centered value-based care needs to include specialty care. With care costs continuing to climb, reducing the cost of specialty care and improving long-term health outcomes are a top priority. As a result, alternative payment models (APMs) are expanding beyond primary care and into areas like maternity care, hip and joint replacements, kidney disease, and oncology.

Providers have been slow to embrace value-based primary care. One reason is because they are unwilling to take on additional financial risk; another is the difficulty navigating complex value-based contracts. Above all, providers are hesitant to adopt value-based care because they feel there is a lack of transparency and collaboration from payers.

In order to effectively expand into value-based specialty care, the healthcare industry needs to be prepared to address those issues. Here are a few ways to do it.

Better payer–provider alignment and data transparency

Payers and providers must be aligned on the data and benchmarks for measuring performance in value-based specialty care. Providers often aren’t equipped with the data and analysts that payers, so it’s critical for payers to be transparent with their data to help providers feel confident about entering into a risk-based arrangement. Without an equal playing field, providers will continue to be hesitant to adopt more complex risk-bearing agreements.

Effective monitoring and automation for quality measures and payments

Payers must ensure that quality measures and payment structures are straightforward and easy to monitor and automate. As the complexity of contracts increases with value-based specialty care, payers and providers will need to leverage technology solutions to more effectively monitor performance and automate payments.

Develop holistic, patient-centered care models

The industry needs to develop and incorporate more risk-based arrangements and value-based specialty care models that reward high-performing specialists and focus on the patient’s unique health profile. For example, not every hip replacement is the same. Payers and providers must look holistically at the patient’s health factors including comorbidities and social determinants of health that can affect surgical outcomes. Using AI to account for a patient’s unique health profile and determine appropriate payments for specialists managing episodes of care is one way to ensure patient-centered health care.

In order to overcome the challenges of adopting value-based specialty care, consider exploring technology solutions that improve transparency, allow for more effective monitoring and automation of contracts and payments, and ensure patient-centered healthcare. To learn how Edifecs’ value-based payment and insight solutions can help, connect with one of our experts today.

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