Health Plans

Why specialists are the next frontier of health plans’ value-based care agenda

By Amy Goodman, and Zoe Colman

April 23, 2021 | Article | 4-minute read

Why specialists are the next frontier of health plans’ value-based care agenda

In today’s fast-changing healthcare landscape, health plans are looking to value-based care (VBC) to drive savings, optimize utilization and enhance predictability. These models have predominantly focused on primary care. Yet, as specialists control the majority of healthcare spending, these programs can only go so far in making an impact in the rising medical cost trend. There have been some early efforts around bundled payments, but there is significant opportunity to explore the largely untapped arena of specialist VBC contracting to advance a health plan’s goals.


In considering a strategy for engagement, health plans should assess their specialist groups beyond traditional cost and quality measures to understand which groups in their network are most primed to be partners in the shift to value.


Health plans have already initiated some specialty-oriented models, such as bundled payments and center of excellence programs. Despite these early steps, we believe there are some specialties receiving less focus than they deserve. Cardiology is one of these specialties.


The perceived challenges of the cardiology service line have been deterrents to more advancement in this area to-date. The care journey of a cardiology patient requires high levels of coordination between primary care physicians and cardiologists, often with involvement from multiple cardiology subspecialties. Many cardiology patients face competing comorbidities and behavioral health challenges that can make getting the right care even more difficult. Despite inherent complexities, there are compelling reasons for health plans to consider how to innovate in this area.

Cardiology costs and conditions are on the rise

Cardiovascular disease (CVD) contributes to more than $300 billion in annual healthcare spend and is projected to grow to $1 trillion by 2035. The American Heart Association predicts 45% of the U.S. population will have CVD by 2035 if we do not see changes to our prevention strategy.


Existing VBC strategies remain a small portion of overall spending, and rising costs coupled with increasing comorbidities poses a huge risk for health plans. An increase in CVD will lead to even more spending on expensive procedures, rehabilitation and lifelong care management. Increasing VBC adoption is a key strategy for health plans working to restrain these costs. 

Cardiologist mindsets are shifting toward value

Recent research signals increasing buy-in from cardiologists on the importance of value. Most notably, the American Heart Association collaborated with the Duke-Margolis Center for Health Policy to provide a framework for VBC reform that targets high-quality care from both the patient and provider perspectives. Provider engagement is an evergreen challenge for increasing VBC adoption—health plans should align and capitalize on this paradigm shift while there is momentum in the space.

How health plans can move value-based care (VBC) forward

Health plans looking to advance specialist-focused VBC can take a few key next steps to evaluate and engage with their specialists, particularly cardiologists.

  1. Define the VBC portfolio strategy. Understand which markets, lines of business or specific employer groups are priorities for future VBC innovation. Consider growth goals, medical trend management and existing network strategy and gaps; these will help identify the overall health plan objective for VBC and the right type of specialist engagement for this strategy. Health plans must also consider the needs of their employer clients as they manage a VBC portfolio that achieves strategic and financial goals.
  2. Understand variations in providers as potential VBC partners. Look beyond cost and quality to understand holistic features of groups and how likely they are to be successful VBC partners. Variations in specialist activities—such as their approach to care management, motivations to adapt to VBC and their current culture of risk-taking—will help plans sort and identify groups within their network so they can identify the best targets for each type of VBC model. For example, because these investments are indicative of a group’s ability to succeed under increasing levels of risk, a plan executive might look at groups’ administrative and technological infrastructures to identify which to target for increased VBC engagement.
  3. Identify prime partners for VBC innovation. Once plans have identified the strongest VBC leaders in their networks, they can partner with those groups to codesign new types of VBC contracts and experiment with levers to encourage groups already successful in VBC to take on increasing levels of risk. As an example, to support members at early stages of chronic heart disease, plans could partner with high-performing cardiology groups to develop a model that incents prevention and care management activities rather than procedure volumes.

Cardiologists are a worthwhile entry point, but plans can expand these tactics to be successful across all specialists in their network. As a plan builds increasing levels of specialist relationships and risk-bearing contracts, it will become easier to get buy-in and demonstrate the impact of value-based relationships across specialties. Engaging specialists is essential for health plans to bend the cost curve, and they can start with these tactics in mind.


In the next article in this series, we will explore specialist engagement specific to the mental and behavioral health space.

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