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.

Aligning care, sharing risk
Along with mental illness – cancer, heart disease, diabetes, and other chronic diseases account for 90% of the nearly $5 trillion in annual U.S. healthcare expenditures. Alarmingly, four in 10 Americans have two or more chronic diseases. Episode-based care models such as TEAM can be particularly effective in treating polychronic patients who interact frequently with primary care providers and multiple specialists.

Efficient program design and communication are critical to the success of episode-based care models. Risks and incentives, referral patterns, how information is to be shared – these elements of an episode-based program must be clear to all participants.

Data analytics can be leveraged to define and optimize episode-based models. Population health analytics and predictive modeling enable specialists to understand cost drivers and performance metrics under their contracts, improving their chances of success.

VBC contracts can include separate episode-based pricing models for different specialties, such as orthopedics and oncology. They also can opt for an enterprise-based cost model that may work for all participating providers.

In addition to aligning primary and specialty care, it is important in designing episode-based networks to align inpatient care with post-acute care. Patients who are discharged either too early or inappropriately can drive significant costs of care, up to and including readmission.

By standardizing referral pathways and sharing data in real time, participants in episode-based programs can improve outcomes while reducing unnecessary costs. Standardized clinical pathways within specialty care can improve efficiency, optimize patient care, and enhance the ability of specialists to participate in risk-based programs.

Care coordination relies on optimized networks that ensure data is shared and appropriate services are available and efficiently utilized. A cloud-based digital infrastructure can support effective communication and collaboration between primary care providers and specialists. Not only does the right infrastructure and model design improve patient outcomes, it creates a better experience for care teams.

Finally, as organizations move forward with episode-based pricing models, payers increasingly recognize the value of coordinated care networks that include specialists in delivering better health outcomes while controlling costs and resource utilization.

Conclusion
The CMS Innovation Center’s new, episode-based TEAM payment model is designed to reward care coordination and quality of care within programs that include specialists, who traditionally have relied on FFS reimbursements. A scalable, cloud-based digital infrastructure that supports care coordination, data exchange, and payments can provide a foundation for the success of episode-based care models.

About the author: Lynn Carroll is the chief operations officer of HSBlox, an Atlanta-based technology company empowering healthcare organizations with the tools and support to deliver value-based care (VBC) successfully and sustainably.