Strategies for integrating specialty care into value-based care models
The CMS Innovation Center prioritizes strategies that improve specialty care performance data, implement financial incentives, and support episode-based models.
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- Value-based care models must address both primary and specialty care to improve patient outcomes and reduce spending. A CMS Innovation Center strategy details ongoing efforts to integrate specialty care into the healthcare system.
Past studies have shown that Medicare beneficiaries are seeing more specialists and experiencing more fragmented care. Primary and specialty care providers must be involved in a patient’s healthcare journey to drive more person-centered care.
The CMS Innovation Center strategy includes four pathways that support specialty care coordination and integration in value-based care models.
Improve specialty care performance data
The first element of the strategy centers around delivering enhanced specialty care data to clinicians, hospitals, and other healthcare entities across multiple models and programs. This would require a coordinated rollout of several data initiatives to support different kinds of providers and participants.
In February 2024, the Innovation Center started providing shadow bundles data to accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) and the ACO Realizing Equity, Access, and Community Health (REACH) Model. Shadow bundles data includes summary data from raw claims that ACOs can use while engaging with specialists. The data provides insight into specialist care patterns and can help ACOs manage beneficiaries’ specialty care needs.
Participants in the Making Care Primary (MCP) Model, which starts July 1, 2024, will receive performance profiles of specialty practices in their market, providing a comprehensive view of local specialty care. Participants will receive specialty care metrics and beneficiary-level data through the model’s data feedback tool.
Maintain momentum on episode-based models
The second element focuses on acute episode models and condition-based models that target areas where beneficiaries experience gaps in care. The Innovation Center extended the Bundled Payment for Care Improvement Advanced (BPCI Advanced) Model for two years to maintain and increase provider engagement in episode-focused value-based care.
The Center is considering a model that would incentivize coordination between acute care hospitals and other providers following an acute intervention like a surgical procedure. CMS is also looking at how a model like this could include support for safety net providers and underserved beneficiaries.
Condition-based models allow specialists to assume a more principal role in managing a patient’s care. The Guiding an Improved Dementia Experience (GUIDE) Model, which supports beneficiaries with dementia and their caregivers, begins July 1, 2024. The Innovation Center also launched the Enhancing Oncology Care Model (EOM) on July 1, 2023, and added a new group of participants to the Kidney Care Choices (KCC) Model.
Financial incentives for specialist engagement
The third element shares how the Innovation Center incentivizes engagement between primary and specialty care providers.
The MCP Model has model-specific codes that expand the use of e-consults, supporting ongoing communication among primary and specialty care providers with a shared patient. The model fosters primary and specialty engagement by helping participants be aware of and monitor for gaps in care or outcomes across the care continuum. Participants collect beneficiary-level demographic data and screen for social drivers of health, including food insecurity and housing instability.
The Innovation Center is also considering efforts that encourage specialty care provider engagement with primary care providers and beneficiaries in ACOs. Mandatory and longitudinal specialty-focused models could encourage specialist participation in value-based care, with risk increasing over time.
The Center aims to use a structure focusing on geographic areas with high penetration of longitudinal, population-based models that support opportunities for specialists to engage with primary care providers.
Incentives for population-based model affiliation
The last strategy focuses on creating incentives for specialists to affiliate with ACOs. Strategies must ensure that ACOs can meet the specialty care needs of the beneficiary population and that beneficiaries can access accountable and coordinated care.
The Innovation Center is exploring several options that could be incorporated into population-based models, such as developing subpopulation targets that facilitate new payment approaches for high-volume or high-cost conditions. The Center is also considering how providing data to ACOs can bring specialists into value-based arrangements.
