Five Ways to Improve Specialty Performance in Value-Based Care Models

In many value-based arrangements, a majority of the expenditures is the result of specialty care.  However, most specialists are paid almost exclusively through a fee-for-service payment system, which prioritizes volume of care delivered as opposed to value delivered.  Therefore, specialty care expenditures directly impact performance in value-based programs.  This is especially relevant for musculoskeletal (MSK) conditions, which affect over 50% of all American adults.  

The ultimate goal is to eliminate unnecessary (and costly) specialty care interventions and to reward the specialists for doing so.  By optimizing patient health and wellness, you will optimize value-based performance.  Here are some key strategies to accomplishing this goal…

1. Engage Specialist Providers

Value-based care and alternative payment models (APMs) are fairly new concepts, especially to specialists.  As mentioned above, their primary reimbursement has always been through fee-for-service care in which quantity is most prioritized.  In many health care organizations, especially larger health systems, specialists may be fully unaware of the various value-based programs (and their performance) that are underway.

The easiest way to improve specialty spend is through engagement with the specialists.  This should include educating them about the various value-based arrangements in which they participate in, as well as the key performance metrics that determine performance in those arrangements.  

2. Measure PROMs

Patient reported outcome measures, or PROMs, are the best quality tools available for most medical conditions.  These are patient-centric assessments that quantitatively report health from a number of different domains, such as physical function, pain interference (the impact of pain on quality of life), and emotional health.

By integrating these measures into workflow, medical providers can gain key insights into the severity of symptoms for their patients.  For example, if a patient presented with knee pain and no other red flag signs and only had mild PROM scores for pain and function, the clear treatment of choice would be an initial course of activity modification and exercise therapy.  If that same patient was evaluated without any PROMs assessed, the provider would be more likely to obtain advanced imaging or specialty consultation which would lead to higher costs and likelihood for unnecessary surgery.  

Even though there is little debate as to the value of PROMs, many organizations struggle to implement high-fidelity collection into everyday practice.  Thankfully, there are a number of review articles   available that provide frameworks and processes for successful integration. Partnership with digital health companies can also help with data collection and application.  

3. Identify high-risk patients early

In patients undergoing major joint replacement or spinal surgery, there is up to 20% risk of post-operative complication if the patient has untreated (or undertreated) mental health conditions, opioid dependence, or other drug dependence.  Surgery itself is expensive (up to $50,000 per episode or more!), and any complication can drastically increase these costs.  

To minimize risks of these complications, it is imperative to identify high-risk patients as early as possible.  Doing so will make the surgical journey safer and higher quality.  One way to do so is to screen all upcoming and/or recently performed surgical cases for risk factors as identified from the medical record, such as prolonged or increasing opioid (or other related substances) use or poorly controlled depression or anxiety conditions.  If you collect PROMs, you can easily identify these patients (with better accuracy than from medical records alone).  PROMs can also be used to identify patients who are at high risk for utilization of emergency department or urgent care for symptom management .

Once at-risk patients are identified, the organization can tailor management programs to ensure high quality of care.  This may include closer primary care follow-up after surgery, enrollment into pain-management programs peri-operatively, or engagement with case management or social work to ensure smooth post-operative course.

4. Share data with specialist colleagues

The best way to help specialists understand opportunities for spending improvement is through data.  In the case of PROMs, it is very likely that participating specialists may not be collecting this data and therefore will be unable to optimize treatment according to these important quality tools.  So too they may not be able to identify at-risk surgical patients with modifiable risk factors.

Value-based leaders should share all relevant data with specialist leadership and colleagues.  On a practical level, this may include average PROM scores in pre-operative patients (patients with normal or mild impairment are the most likely to be receiving unnecessary treatment) as well as PROM score changes post-operatively for common surgical conditions (do they achieve substantial clinical improvement, as defined by thresholds set forth by CMS?).  This data may be invaluable for helping specialty surgeon colleagues train and engage their provider staff.  

5. Align financial incentives

Ultimately, the best way to optimize specialty care expenditures is through tight alignment of financial incentives of all stakeholders in the value-based program.  Specialists are no exception.  There are several different ways to achieve improved alignment.

One strategy would be to allocate an incentive or bonus payment that correlates to organizational performance.  This would directly benefit the specialty group and/or individual providers that contribute to the value-based performance either through financial targets, quality measures, or both.  There are additional strategies that even more tightly link the different stakeholder groups, such as “VBE’s,” or value-based enrollment programs.  These programs create joint ventures that specifically promote value-based care and help avoid pitfalls associated with anti-kickback statues and Stark Law provisions.  A third way to align incentives is for the specialty group to directly benefit from performance-based incentives.  Such an example would be with the specialty group joining a clinically integrated network.  

Summary

Successful value-based care requires alignment and collaboration between all key organizational stakeholders.  With regards to the provider base, that includes both primary care and specialty care.  Please contact us if you would like assistance in improving your specialty value-based performance and achieving superior health outcomes and decreased costs of care.