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When physicians describe the forces reshaping medicine, they increasingly point not to a new device or a breakthrough drug but to the economics underneath their work. The move from fee-for-service to value-based payment is no longer theoretical. For a growing number of specialists, it is starting to feel personal.
That change in perception is worth pausing on, because value-based care itself is not new. Primary care organizations, payers and accountable care organizations have spent more than a decade building the contracts, attribution logic and quality infrastructure that define these models today. What is new is their expansion into parts of the system that have, until recently, sat at the edge of the conversation. Specialty care is the most consequential of those parts.
There is a structural reason for that. Much of the spending these models are designed to manage — advanced imaging, procedures, device costs, postacute utilization, the full arc of an episode from diagnosis through recovery — originates in specialty settings, not in the primary care office. Yet for years, the clinicians formally held accountable for total cost of care have been primary care physicians. How is that changing today?