How to Support the Adoption and Integration of Specialty Value-Based Care Models: A Conversation Across Multiple Stakeholders

J Clin Pathways. 2024;10(1):28-30.

There has been a slow move to adopt and implement spe­cialty value-based care (VBC) models in the US. Specialty models differ from primary care models, which have been well established (although arguably not uniformly successful) across the country for more than a decade.

As I discussed in an article from the March 2021 issue of the Journal of Clinical Pathways, “The path toward healthier out­comes requires a healthier culture—a culture of respect and humility, which not only allows but promotes and supports a complete re-examination of what really impacts patients’ expe­riences and outcomes.”¹

This thinking appears to have been incorporated in many primary care models, which typically provide physicians with support in the form of up-front data, sometimes clinical sup­port, and almost always financial support to ensure they can create the infrastructure required to achieve more consistently optimal outcomes. This has not been the case for specialty care.

Outcomes Matter Innovations, a group that focuses on sup­porting specialists engaging in VBC models, hosted a Health­care Innovations Summit (the Summit) in Aspen, Colorado, over two days in February 2023. The Summit brought to­gether stakeholders from across the health care continuum to discuss the barriers to implementing VBC models for specialty care, and what can be done to overcome them and integrate the models with primary care. Attendees included providers; payers (both Center for Medicare and Medicaid Innovation [CMMI] and commercial payers); biotech; pharma, tech, and clinical start-up organizations; investors; and legal experts. This article discusses the broad spectrum of perspectives that were presented at the Summit, all of which focused on the move toward comprehensive and collaborative care for patients requiring specialty care.

Day One

The Summit was organized so that day one was truly a listen­ing session. Each of the 23 speakers were given 10-15 min­utes for their presentations. There were no interruptions or questions permitted in order to encourage active and engaged listening. This format provided attendees with a diverse set of perspectives and an opportunity to leverage a broad base of expertise and experience. The depth of information presented and the thoughtful and respectful responses that occurred on day two were extraordinary.

The event focused on how to engage specialists and inte­grate specialty care with more established primary care mod­els to support comprehensive, collaborative care delivery. The group also considered methods for physicians and caretakers of individuals requiring specialty care to better access the patients’ information about their health care journeys, conditions, and needs. Under the current fee-for-service (FFS) payment meth­odology, physicians only have access to this information for the care they have provided to the patients themselves, for ex­ample. There is very little information available about what other care their patient may be receiving and if or how that may complement, interfere, or be contraindicated with new or additional treatment.

A Common Thread

Data was a consistent theme among almost every speaker. For instance, the physicians discussed how data is needed to assess opportunities and best partnerships based on outcomes, not just dollars. They also mentioned how molecular diagnostics can help ensure that a patient receives precisely the medicine they require. The payers discussed the need for data to consistently evaluate performance. Speakers from start-ups, both technical and clinical, talked about how data coordination between vari­ous stakeholders was necessary and described it as the primary focus for understanding gaps and variations that need to be ad­dressed. In addition, the investors mentioned the need for data interoperability and that there is a plethora of primary care op­portunities. They also said they are looking for specialty care models that can effectively manage care and costs of care. From the presentations, it was clear there was agreement among at­tendees about the critical role of data sharing, even before they spoke to each other one-on-one.

There was a review of primary care models, which gen­erally take the form of patient-centered medical homes (PCMHs), where the physicians are accountable for managing a heterogeneous patient population. There is a common under­standing that engaging primary care physicians and achieving consistently good outcomes with effective and efficient use of limited resources requires up-front support, both in terms of data and finances. Physicians in these models typically receive financial support in the form of per-member per-month pay­ments to support the infrastructure and other changes required. Once each measurement period, the physicians also have an op­portunity to share in the savings achieved if they meet the qual­ity and financial metrics. The same is generally true for account­able care organizations (ACOs), which are ostensibly integrated delivery models but are typically based on primary care attribu­tion and focus almost exclusively on preventive care.

The comments about specialty models acknowledged that they tend to address a more homogeneous population (ie, attri­bution is based on clinical similarities) and seek to actively cure or prevent further exacerbation of disease and symptoms while reducing costly and unnecessary care. Although specialty care accounts for the vast majority of physician spending in the US, there are very few successful models focused on managing the care and associated costs for individuals who require specialty-driven care. And the models that do exist do not provide data and financial support up front for the engagement of specialists in these models. There is also some reluctance among those in­volved in VBC models in the primary space to include specialists because savings will have to be shared.

While primary care physicians often very enthusiastically participate in VBC models, specialists are more wary. There is good reason for this. Unlike primary care physicians who re­ceive up-front financial and other support, specialists begin to lose money almost the moment they enter a VBC arrangement. Why? In primary care models, the focus is on preventive care with the idea that up-front support for physicians will provide positive returns in the form of improved outcomes and savings later. This idea tends not to carry over to specialists, whose care is based on treating people who are sick. It may be that those who make the decisions about how to fund these models believe that specialists’ costs are already high, that specialists do not need additional money, and that costs instead need to be cut. As a result, the models are built with shared savings only, which often take years for physicians to receive. The approach of spending money and resources up front to get to the best outcomes later seems to end with primary care.

Providing Effective Care to Patients

There is much discussion in the US today about how to inte­grate specialty care into the primarily primary care–attributed ACO models. CMMI has committed to attributing 100% of Medicare beneficiaries to an ACO by 2030. Much of the focus has been on what primary care physicians require of specialists to be able to care for their community of attributed patients. The Summit participants addressed this topic by asking the following question: What do specialists need from primary care providers and payers to ensure that the most appropriate individuals are referred to them and that they can provide the most effective care to their own and shared patients?

There is currently a backlog across the US for patients to get in to see specialists of all kinds. Primary care physicians’ offices are jammed, and individuals with low-acuity diseases are routinely being referred to specialists, leaving many with higher acuity diseases without timely or appropriate care. It is important for primary care physicians and specialists to collab­orate, but very few models support the addition of specialists. Furthermore, the conversations taking place about integration of specialty care seem to focus on the needs of primary care physicians and tend not to include specialists’ perspectives. Spe­cialists should be included on governing boards and committees of ACOs to ensure streamlined, comprehensive care.

The Summit participants noted that specialty physicians should not be directed by primary care physicians; rather, they need to partner with them and others across the health care continuum. We need to focus on involving specialists in the models’ design and ensuring they are not losing their abil­ity to make clinical decisions by having primary care physi­cians directing patient care. We must also provide appropriate support for this reengineering of care delivery. For many patients requiring specialty care, the specialist is their primary or principal provider.

Day Two

On day two of the Summit, everything was on the table for debate and discussion, including policies, practices, and proto­cols. There was a wealth of technical and practical experience shared from a diverse set of participants that went from bedside to benchwork to budget.

Patrick Roth, MD, neurosurgeon and founding member of New Jersey Brain and Spine, and Deborah Goss, MD, pulmo­nologist at Hackensack Meridian Health, stated that medicine is both an art and a science. “Medicine resides in the sidelines of the science,” said Dr Roth, speaking to the importance of understanding the full scope of patients’ needs, barriers, etc— to understand it is not only the clinical science of care that is required to achieve good experiences and optimal outcomes; social determinants of health can drive up to 80% of patient outcomes, making it critically important to talk with patients and to understand and address those barriers and needs.

Change begins with respect, which has historically been lack­ing between payers, providers, and other stakeholders.² We now have an opportunity to create strong, integrated delivery teams that coordinate and integrate with primary care physicians and other stakeholders. There are many innovations happening in health care, most of which are constrained and may never be put to effective use under our current payment methodologies.

For example, EpiBone, a bone reconstruction company that participated in the Summit, is on a mission to transform skel­etal repair by growing bones from an individual’s own cells. Another Summit participant, Kite, a company owned by Gilead Pharmaceuticals, provides CAR-T cell therapy for can­cer care as an individualized, one-time treatment with curative intent that uses the power of a patient’s own immune system (their white blood cells) to fight certain types of blood cancer. It is necessary to find ways to incorporate these new and inno­vative tools into our models of care.

At the Summit, there were discussions about individuals with chronic conditions who are among the most adversely impacted by FFS models. People living with chronic condi­tions often have multiple comorbidities that are not addressed by a single provider, and under FFS methodology, there is little ability for physicians to collaborate on what is best overall for the patient. When we pay for units of care we wind up with disjointed, disconnected care for those who most need a whole-person view to achieve the best outcomes. CMMI and com­mercial payers recognize the issues in providing care for this patient population: Payers do not have the clinical expertise to assist them, providers do not have the ability to see details about the patient’s health care journey outside of their own office, and companies with new, innovative ideas do not get funded. If we are going to achieve consistently good outcomes, we must come together, as the Summit participants did, and continue to discuss and understand how to best move forward in a coordinated, collaborative, and comprehensive way.

Participants also discussed whether it might make sense to build specialty care medical home models, following the ex­ample of primary care–focused PCMHs. In this case, a special­ist would be at the helm directing care. Because patients with chronic diagnoses such as cancer are typically managed by a spe­cialist and not treated by a primary care doctor, it might be the easiest area to begin incorporating these types of models and not affect the work of the primary care physician. Primary care– attributed ACOs might be willing to refer patients to a specialty care medical home and reduce the ACO’s risk for these highly complex and costly patients, understanding that they likely cannot achieve the same outcomes or cost efficiencies for these patients without specialist intervention and oversight.

There was agreement among the participants that in order to accelerate the adoption and integration of specialty care into the VBC movement, there needs to be a culture change that bears certain considerations in mind. These include working with specialty care providers, utilizing innovations in technol­ogy and medicine, and considering nonclinical factors that im­pact patients’ treatment and ability to get to the best outcomes, such as the ability to adhere to prescribed therapies (eg, patients’ home-based amenities [is there a refrigerator in the home to keep the medicines cold if required?], behavioral health condi­tions, transportation to and from appointments, etc).

These kinds of dialogues need to continue on a regular basis. Payers, providers, and other stakeholders need to listen to each other respectfully to understand each other’s needs, tools, and skills. Fee-for-service payment methodology has not supported collaboration, integration, or comprehensive care delivery. It has also left providers without the ability to fully support their pa­tients and has burdened patients with deciphering how to obtain good health care without any real tools to make those decisions.

The Summit highlighted the need for the participants to listen and leverage each other’s expertise and tools in order to improve care delivery, patient experience, and overall cost of care.