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Specialty care has emerged as a major driver of increasing US healthcare spending. Specialty care focuses on specific body systems or diseases, such as orthopedics or oncology. Primary care, by contrast, covers a range of health services addressing common illnesses and prevention. Payers and health systems are seeking ways to improve patient experiences and outcomes while appropriately managing costs in specialty care.
To do so, some organizations have adopted value-based-care (VBC) models that share financial risk with physicians. The goal of these models is to provide high-quality care at lower costs, compared with the traditional fee-for-service model in medicine in which physicians are reimbursed based on the volume of services provided. However, compared with primary care, only a fraction of specialty care is actually delivered under risk-bearing VBC arrangements.1
In this article, we focus on four main topics:
- Specialty spending is a leading source of increases in total health expenditures.
- A considerable portion of specialty spending—potentially up to $100 billion a year—could be avoided through VBC approaches.
- The ability to manage spending will vary by specialty, as will the capabilities needed to better serve patients and capture sources of value.
- There are several archetypes of organizations addressing specialty costs, but players typically lack the full suite of capabilities to achieve VBC’s potential.