How Will Value Based Care Spread Beyond Primary Care?

As a specialist, you’re probably aware of value-based care payment models, but you might not know that there are opportunities for you to participate.

For years, value has been absent from health care payment models, mostly because — unlike volume (fee-for-service) models — ”value” relies heavily on outcomes data that can be difficult to obtain and appropriately measure.

Starting in 2012, primary care physicians began tackling those challenges in part by organizing into Accountable Care Organizations (ACOs). Primary care physicians are ideal fits for value-based care because of the “quarterback” role they play in a patient’s overall care, including overseeing total cost.

However, primary care accounts for only 10 percent of the cost of health care. To rein in overall costs, all physicians need aligned incentives around lowering costs and raising quality. 

As a specialist, you can participate in value-based models that reward you for lowering the cost of the episodes of care that you control. Episodes of care include both treatments and chronic conditions, both of which have been largely ignored in existing value-based arrangements.

To help drive value-based models, the Centers for Medicare & Medicaid Services (CMS) has been developing programs for specialists such as Bundled Payments for Care Improvement Advanced (BPCIA), and ESRD Seamless Care Organizations (ESCOs) for end-stage renal disease. 

Commercial payers are beginning to follow suit, using market benchmarks to reward physicians with shared savings if they are able to reduce the cost of an episode. 

At TMA Specialty Services, our goal is to work with physicians and commercial payers to develop episodes that are representative of the wide range of specialist Texas Medical Association members.

If you’re an independent specialist interested in learning more about value-based care, please contact Erica Maltby at erica.maltby@texmed.org