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Reaching the critical mass of participants in alternative payment models (APMs) necessary to move our health care system away from fee-for-service will require a significant increase in specialist participation. Currently, the two most common approaches to payment reform struggle to do this, despite their distinct approaches. Primary care–based models such as accountable care organizations (ACOs) lack clear opportunities for specialist leadership and participation, making it challenging to align financial and clinical incentives or effectively coordinate care. Episodic bundled payments for surgical procedures and deterioration in medical conditions leading to hospitalization do promote efficient, specialist-led care over set time frames (often 90 or 180 days), but these time frames are often too short for long-term specialist engagement, focused on providing appropriate treatments that meet the holistic needs of patients.