By Lynn Carroll

Tight alignment of primary and specialty care is essential to meeting the goals of value-based care (VBC), a reimbursement model designed to facilitate better clinical outcomes through greater care coordination, while reducing healthcare costs.

To encourage coordinated, patient-centered care, the Centers for Medicare and Medicaid Services (CMS) Innovation Center has launched the Transforming Episode Accountability Model (TEAM), a mandatory, episode-based alternative payment framework that rewards health services rendered by multiple providers to treat a single condition. By holding participants accountable for spending and quality performance, healthcare providers have a financial incentive to improve care coordination and quality of care.
Under TEAM, participating acute care hospitals are given a target price for covering all costs associated with the episode of care. This includes hospital inpatient stay, outpatient procedures, and post-discharge services such as skilled nursing facility stays or follow-up visits with providers.

Specialty care accounts for roughly 60% of total care costs in the U.S., in large part due to the prevalence of chronic diseases in the U.S. population. Thus, for care models based on episodic pricing (such as CMS’s TEAM) to succeed, gaining buy-in from specialists is imperative.

The challenge is that specialists traditionally have been reimbursed on a volume-based, fee-for-service (FFS) basis. Consequently, many specialists are reluctant to jeopardize a reliable FFS revenue stream by gambling on an experimental VBC payment model. Fortunately, more specialists are becoming aware of the clinical and cost benefits of collaborative care.

Building VBC programs that meet the needs of primary care providers and specialists, however, necessitates an understanding of a specialty’s specific cost structure and care networks. After all, a cardiologist’s costs per patient will be dramatically higher than a dermatologist’s, both for diagnosing and treating conditions. It makes little sense, then, to shoehorn specialists into rigid VBC models that are poor fits for their areas of medical practice.

Episode-based programs, where hospitals have accountability for the outcome of surgical episodes, including post-acute care, encourages the alignment of specialists and hospitals. To achieve success in these programs, hospitals and specialty practices need technological infrastructure that is modern and scalable. The deployment of tools for engagement, steerage, and information sharing are a necessary part of successful care coordination – optimizing care transitions from acute to post-acute settings. Alignment between primary care, specialty care, and hospitals in programs like TEAM can deliver on the promise of patient-centered, value-based care.

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