Value-Based Specialty Care Part I:

Value-based specialty care should be viewed within the context of the move to advanced primary care:

We should define advanced primary care.

Simplified, providers or entities that enable risk arrangements or employ primary care providers accept up to full, total cost of care capitated risk to manage a population of patients (aka patient panel) by payer.

There are other arrangements that facilitate advanced primary care, like prospective, enhanced primary care payments but not full risk accountability, but it’s easiest to view this from the lens of the most comprehensive alternative payment arrangement allowing for the most flexibility in how dollars are used to care for patients.

But first, here are the “primary care provider types”:

• Internal medicine

• Family medicine

• Geriatric medicine

• Pediatric medicine

• General medicine

• and sometimes obstetrics/gynecology and

• Palliative and hospice medicine

• Nurse practitioners, physician assistants, and clinical nurse specialists also fall under “primary care,” though this is a hot area of debate (Partly because of APPs working solely in specialty care and APM model attribution complications this may cause—a story for another day.).

The practice (or providers, or enablers, or organization…you get the idea), agrees to essentially act as both the provider and the payer in total cost of care, prospectively-paid risk arrangements with payers.

There are a host of ways these contracts between providers and payers are structured.

Suffice it to say, the practice (or other entity or “enabler”) holds a large majority of the total dollars the payer is given (by the Federal Government, State Government, Employer, Commercial Payer, etc.) to manage the population over the year, and has to use those dollars to pay for essentially all the healthcare transactions that patient has during the year.

In capitated risk arrangements, the practice/provider type(s) at risk aren’t billing patients for their visits. Volume of visits isn’t the goal. The RIGHT visits with the patients that need it is the goal.

They invest heavily in advanced primary care delivery and providing MORE primary care, even multiples more in terms of volume of primary care, for the right patients at the right times.

They focus on things like:

• Access to the practice in a variety of ways (depending on the community being served).

• Hiring the right providers, clinicians, and supportive staff (think community health workers, medical social workers, nurse educators) to promptly address identified medical and non-medical needs.

• Delivering what I like to call “primary specialty care,” often supported by e-consults.

• Time with patients.

  Time to build trust, understand their needs, develop a strategy to improve their health.

  Communication and connection with patients is a priority.

• Using robust data and population health analytics to identify patients at high risk and rising risk of health deterioration stratified by other factors, and then.

  Outreaching to them proactively to engage them in their care, help stabilize their conditions, work on behavior change, address SDOH issues, etc.

• Accessing and integrating with Admission, Discharge, Transfer (ADT) feeds and Health Information Exchanges (HIEs).

• Using data to identify the highest value specialists of all kinds in the community. This includes specialists that manage complex chronic illness, that treat specific time-limited conditions, that provide care in episodes, and that provide interventional services.

With the trust they build with patients as part of a new, different way of providing primary healthcare, they refer patients who need specialists to those providers who:

• consistently deliver high-value care, as identified by data

• are willing to collaborate and communicate with the primary care practices accountable for the patient’s longitudinal care and health outcomes

• have sufficient access to meet patients’ needs

• (and more—such as specialists in sub-capitated risk with the providers or incentivized in some way to provide high-value care)

Advanced primary care practices MUST pull the right levers to prevent unnecessary and avoidable hospitalizations and address ALL POSSIBLE reasons for low-value spending upstream.

We know this approach to managing population health can be very effective at reducing unnecessary, avoidable, and low value spend and at improving outcomes.

Incentives are growing and improving to move primary care into this payment methodology. Policymakers are engaged.

Upstream funding to primary care and total cost of care risk DOES incentivize a change of practice that has a ripple effect on healthcare utilization across the continuum.

Back to Specialty Care!

We can break “specialty care” up into some broad categories. Of course, many providers fit into more than one category.

You will see numbers four and five below aren’t part of the classic definition of specialists. I think it helps to complete the picture functionally and from a value-based care perspective.

1. Chronic disease specialists: think cardiology, pulmonology, rheumatology, endocrinology, nephrology

2. Specialists who manage care in one or more episodes of care: think orthopedics, oncology, infectious disease, psychiatry, palliative medicine, physiatry

3. Surgeons/Interventionalists (also, naturally, provide care in episodes): think general surgery, orthopedic surgery, cardiac surgery, trauma surgery, neurosurgery, ophthalmology

4. Non-PCP, non-specialists: think hospitalist medicine, emergency medicine, radiology. This 4th “category” is important because their brief, non-episodic, non-longitudinal interactions and interventions can be lost in their own silo, with information never shared meaningfully beyond the hospital setting.

5. Non-Physician, non-Advanced Practice Provider (APP) practitioners’ care: think physical therapy and behavioral health, among a short list of mainstream practitioner types providing evidence-based care. These practitioners can provide and bill directly for care as part of primary care, specialty care, or both.

Let’s go back to the “specialist levers” that advanced primary care practices can pull to reduce total cost of care, improve quality, and drive more spend upstream to proactive primary care.

In full risk contracts, what is saved is retained by the entity taking the risk (Saving happens essentially by reducing avoidable, unnecessary, low-value care.).

So if an advanced primary care practice/organization enters into full financial risk with payers, they own responsibility for the total cost of care spend.

If they don’t provide upstream, in-time care, if they don’t engage patients in their health and healthcare, if they don’t identify and proactively outreach to high-risk patients—they will spend MORE of the total allotted annual spend in avoidable utilization.

1. Chronic disease specialists:

   “Primary secondary care” involves expanding the responsibility of primary care into early stage secondary disease-specific care.

   One way they do this is by having more time and more leverage to work with patients, both themselves and with their clinical support teams and other on-site providers (like behavioral health and physical therapy).

   Another way is through the use of e-consults. This isn’t a deep dive on e-consults, but they are provider-to-provider synchronous or asynchronous collaboration between PCPs and specialists.

   In some models, the e-consult practice integrates directly with the primary care EMR and will flag recommendations to treatment plans, which may include that the patient consult with a local specialist or a specialist via telehealth.

   Other times, the PCP will message the specialist about a clinical question, treatment plan, or anything else they need some assist on, and the specialist responds asynchronously.

   I like these quotes on the American Medical Association’s website (there’s a link to a recorded presentation on e-consults on this webpage):

   “I see myself in the future as being more like an air traffic controller—seeing all the patients with fractures and injuries all across the Delaware Valley, where I happen to practice, and help in guiding them and navigating them into our system at the right point of contact to see the right provider at the right time for the right issue,” said pediatric orthopaedic surgeon Alfred Atanda, MD.

   “The PCPs in these situations are often very well-versed in the problem, but they just need a little bit more reassurance, a little bit of guidance,” Dr. Atanda said. “

E-consults are safely avoiding unnecessary referrals to specialists by giving PCPs access to specialists' knowledge and expertise in a prompt, efficient way.

But it does something else. Something fantastic for primary care as a whole.

A nurse practitioner in advanced primary care recently said to me “One of the things I love about e-consults is I am becoming a more astute, more confident provider. My knowledge base is deepening. I’m learning all the time.”

2. Specialists who manage care in one or more episodes of care:

   Episodes can be impacted using different levers, depending on the type. A PCP practice or organization can and should identify the need for a specialist at the right time and with the right provider.

   Examples:

   • early identification of cancer with proactive outreach and testing at evidence-based intervals leads to the best chance of curative care and less invasive, life-altering treatment needs. The primary care practice will work collaboratively with identified high-value oncologists, who may also be participating in alternative payment models such as the Enhancing Oncology Model.

   • identifying that a complaint of shoulder pain can first be evaluated by the on-site doctor of physical therapy, and that physical therapists are excellent at triaging for additional needs such as imaging. The primary care team and e-consult provider can provide any needed additional support for orthopedist referrals.

     Check out this example:

     

     Appropriateness of PTs ordering advanced imaging was 80%, better than similar studies of physicians (details and much more context can be found through this link)

And consider this:

• Or psychiatry: Behavioral health is notoriously difficult to access. Health literacy and cultural barriers, provider shortages, challenges filling networks, inadequate providers to meet needs, are only some of the many reasons patients with moderate to severe mental illness don’t see a psychiatrist.

  A behavioral health provider embedded in advanced primary care who can address barriers seamlessly and connect patients directly to psychiatry through e-consults, telehealth on-site, and data-driven high-value referrals can make a big difference.

  Incidentally, treating the psychological and psychiatric needs of patients improves their ability to engage in anything else related to their health.

3. Surgeons/interventionalists: For surgeries that are planned in advance, the advanced primary care practice can help direct their patients to high-value providers. Some surgical specialists are in novel payment models and/or operational structures themselves.

   The Comprehensive Care for Joint Replacement Model has been testing putting hospitals at risk for the total Medicare A and B spends for an anchor admission and 90 days after, starting at the day of discharge.

   Levers pulled have depended on the hospital and what it was willing to do to reduce spend below established target prices. A few examples:

   • Require surgeons to optimize patients’ medical risk factors, such as HbA1c under 8, blood pressure control, a maximum BMI threshold prior to scheduling surgery

   • Use of IV acetaminophen instead of IV narcotic pain killers (more effective, fewer side effects, more costly per IV bag

   • Using an adductor block instead of a femoral block to spare the quads and allow earlier mobilization

   • Preparing for a smooth discharge home instead of an inpatient post-acute site of care

   One good example of novel work being done in MSK care is by that of UT Health Austin and specifically, Dr. Kevin Bozic. Dr. Bozic was elected President of the American Board of Orthopedic Surgeons for 2023-2024. Finally, here’s a link to Duke Margolis’ 2022 policy brief Strengthening Specialist Participation in Comprehensive Care through Condition-Based Payment Reforms, which he authored with several others.

   But many surgeries are because of an emergent or urgent issue, and the best long-term outcome will actually depend on protocols the hospitals has in place like the ones above.

   Hospitals have the authority to make significant changes to processes and protocols, medical and non-medical, that can have long-term, even permanent impacts on function, quality of life, mental health, complication risk, patient safety, and more.

   I’ve talked about these before, such as here, where I applaud hospital-at-home, but they include rigorous hospital mobility programs, team-based, individualized discharge planning (I prefer “transition planning”) and staffing up related staff, collaboration with and warm hand-offs to community providers, etc.

   Putting hospitals in contract and at-risk for acute and post-operative care is crucial for incentivizing the roles only they can play well in addressing what happens inside the hospital itself.

   The BPCI-A program and now the TEAM mandatory model (presently in Proposed Rule status) are two examples of acute episodic models. TEAM stands out for its limit to 30 days, putting only the acute care hospital at risk, and requiring patients be connected back to their primary care practices OR they are connected to a new practice if they don’t have provider.

   You can read some of my early takes on TEAM here. Part one of that article can also be found here.

4. Non-PCPs, non-specialists: Let’s limit this to hospital and ER medicine and just talk about hospitalists today. We can debate the merits of hospitalists vs. attending community physicians all day, and there are lots of valid reasons we needed this and similar hospital-only roles filled by hospital providers.

   But the undeniable drawback is that hospitalists don’t know these patients. They aren’t accountable for their outcomes. They are providing hospital primary care, often consulting several specialty providers, and they know little to nothing about the things that our community advanced primary care providers know about their patients. And that knowledge gaps dilutes the degree of impact they can have on individualized continuity of care planning.

   They have no incentivize to do a warm hand-off to community providers, to get involved in discharge disposition (such as discussions about which site of care is optimal, which providers offer high-value service, or discussing patient and family wants vs. needs (Like a family member who wants their loved one to go a SNF “for a while” so the loved one has a break vs. what’s medically necessary and/or best for the patient’s medical care.).

5. Non-physician, non-APP care:

   Hear me out.

   It’s really time we all re-think the possible roles of these practitioner types. Advanced primary care practices already are.

   Here’s the thing:

   Practitioners like PTs and behavioral health clinicians already have the ability to bill for care directly, and though it varies slightly by state, most are licensed to provide care without having to go through a physician or APP gatekeeper as it is. That doesn’t mean the public has good access, understands the roles of non-physician practitioners, or local providers in-network.

   Yes, I’m a physical therapist myself. So I’m keenly aware of the extensive education (now mandated at the doctoral level for licensure in the U.S.) of physical therapists (or physiotherapists, if you prefer) and their top of license scope. I wrote about that in more detail here.

   For brevity’s sake 😁, I’ll just say here that provider types that offer evidence-based, front-line treatment at emergency, primary care, independent practice, and specialty care sites have value yet to be pervasively realized.

   There’s opportunity, without a doubt.

   If I were part of a total cost of care and/or primary care alternative payment model, I would optimize the use of PTs and Behavioral Health clinicians in all settings.

Thanks for reading!

All the best,

Dana