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Integrating episodes of care within your population health infrastructure can drive higher value specialty care and increase savings earned. While CMS aims to support more coordination between bundles and ACOs, organizations should set a specialty care strategy that works for them.
Specialty care accounts for a disproportionate share of healthcare expenditures in the US, driven in part by remarkable advancements in diagnosing, preventing, and treating serious illness. Responsible for an estimated $2 trillion dollars annually and 63% of all medical expenditures, specialty care is also a substantial source of variation in quality, outcomes, and access. This critical component of whole-person care remains fragmented and inaccessible for too many patients, particularly among younger Medicare enrollees with disabilities. To achieve meaningful progress in the transition from fee-for-service to value-based care, specialty care must be embedded within longitudinal care redesign efforts and alternative payment arrangements.
Despite its outsized relationship to low value care, specialty care has been largely peripheral to payment reform efforts to date.
Acute and chronic episodes of care offer an effective tool to identify variation in specialty care performance, optimize referrals and engage specialists in improving outcomes. For over a decade, CMS and the CMS Innovation Center have operated limited bundled payment models simultaneously with population based total cost of care models. The concurrent sets of models generally created more options for providers to transition to value-based care and have led to critical learnings and favorable results in certain types of episodes. However, to date, the overall impact of episodic models including Bundled Payment for Care Improvement (BPCI), BPCI Advanced, Comprehensive Care for Joint Replacement and the Oncology Care Model have not yielded transformative improvements in quality or cumulative savings to Medicare. Further, the asynchronous and overlapping nature of the different programs has led to complications with attribution, benchmark setting, savings allocation, and specialist engagement.