CMS Innovation Center: Specialist Incentives for Value-Based Care

This article is one in a series that advocates the need to bring specialty care under value-based care payment models. Click here to read the previous article, VBC Can’t Work Without Specialists On Board.

CMS is doubling down on value-based payments for specialty care. According to their website, “Innovative initiatives will help CMS achieve [their] goal of 100% of traditional Medicare beneficiaries in accountable care relationships by 2030.” To accomplish this, CMS will create new financial incentives for accountable care/value-based care organizations to manage specialty care, in turn creating opportunities for organizations embracing the shift to VBC. Those who want to capitalize on those opportunities should read on to better understand how CMS will shift the healthcare landscape in the fast-approaching future.

The Current Roadmap to VBC and Accountable Care

The innovation arm of CMS has undergone a recent refresh after years of experimenting with value-based payment models. It has a new strategy for developing alternative care delivery and payment models, including the Bundled Payments for Care Improvement Advanced model. Launched as an optional program in 2018, this model holds participating providers accountable for 90-day windows of care. CMS has recently reported that it will extend this program through 2025, as well as expand its scope to include bundled payments for oncology care. The investment into this program and others provides evidence that CMS is focused and designing models that bring advanced primary care to more beneficiaries.

CMS’ Efforts Don’t Stop with Primary Care

The agency is also looking to develop specialty-focused models, with the goal of improving transparency for specialist data as well as various quality metrics. In the short term, the agency has purported that it will enhance the data and dashboards for specialist performance measures, allowing participating providers to compare both cost and quality of care. CMS also desires to improve the coordination between primary and specialty care. To date, primary providers have been the center of VBC coordination and the foremost consideration when managing outcomes and total cost of care. However, CMS has made it clear that the future of value-based payments will also include specialty care. This will result in opportunities for prepared healthcare organizations to address the all-too-frequent disconnect between primary caregivers and specialists.

Inviting Specialists to the Party

To effectively include specialists in VBC, organizations will need more data sharing. Increasing those capabilities will improve transparency around clinician performance. Healthcare organizations should also begin to embed specialty care into their primary care programs, and create incentives within population-based models to encourage that specialty care integration. This integration is a long-term goal for CMS, and would leverage approaches such as subpopulation targets and beneficiary attribution to further incentivize specialty care in the VBC realm. Specialty care needs a seat at the VBC table, and organizations that create one for it will benefit greatly.

What This Means for You

Multi-payer alignment in the VBC realm is now a major theme for CMS. Aligning quality metrics across commercial payers, Medicaid, and Medicare will be key to advancing models that incentivize affordable, quality care. Providers have a better idea of where to invest to improve workflows, implement team-based care, and other value-based strategies when everyone is aligned. Integrating specialist care into the VBC framework will further this alignment and improve patient outcomes by giving physicians and other providers tools to innovate and better coordinate care,

The Bottom Line

The next generation of value-based payment models aims to integrate specialty care and align models across payers. Not only do these goals advance VBC as it relates to “equitable, comprehensive, high-quality, affordable [care]” as the new CMS definition states, but they also attempt to empower providers to put patients first. Delivering this level of care hasn’t always been easy for providers, but CMS has taken important steps to create a future in which providers, payers, and patients thrive. Those who embrace the coming changes should expect to thrive as well.

This article is one in a series that advocates the need to bring specialty care under value-based care payment models. Click here to read the next article, Data-Driven VBC Improves Patient Outcomes.


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