Engaging Specialists In Accountable Care: Tailoring Payment Models Based On Specialties And Practice Contexts

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Engaging Specialists In Accountable Care: Tailoring Payment Models Based On Specialties And Practice Contexts

This article is part of the Specialist Engagement in Population-Based Payment Models project, supported by Arnold Ventures.

Accountable care models serve as the cornerstone of value-based approaches to expand access to well-coordinated, high-quality, and longitudinal care. Specialist engagement in these models is critical given the increasing role of specialists in managing care across the patient journey, the growing importance of specialized diagnostics and early disease interventions (such as biologics and cell and gene therapies), and an increasing array of specialty care capabilities. Yet, despite their critical role in patient care, specialty care providers have had limited opportunities to engage in accountable care models to date.

Improving meaningful specialist engagement in payment reforms is critical to achieving the Centers for Medicare and Medicaid Services’ (CMS’s) 2030 goal to have most Medicare and Medicaid beneficiaries in accountable care relationships, as affirmed by the CMS Innovation Center (Innovation Center) in its 2022 specialty strategy blog. Achieving this vision requires a range of strategies that consider the various ways specialists approach patient care and the practice contexts in which they operate. Specialty care providers interact with patients at different stages in the care continuum and practice in different clinical and organizational environments. The most common type of specialty payment model so far, bundled payments for episodic and acute medical events, reflects only one component of specialists’ impact on patient care. Specialists focusing more on longitudinal condition management—for common cardiovascular conditions, inflammatory bowel disease, or degenerative joint disease, for example—lack alternative payment models that reflect the type of care they provide.

In this article, part one of two, we discuss how differences across specialty care providers and practice contexts should inform accountable care strategies, especially to achieve effective specialty care engagement and strengthen primary/specialty collaboration. We present these concepts in three sections: describing how different types of specialty care can be engaged in accountable care models, outlining how the practice environment (such as different types of accountable care organizations [ACOs]) affects specialist engagement, and considering the policy and implementation implications for engaging different types of specialists in different contexts. In Part two, we will present concrete recommendations for modifying ACO design and implementation to improve specialty care engagement.

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Duke-Margolis Authors

Katie Huber

Katie Huber, MPH

Senior Policy Analyst

Jonathan Gonzalez-Smith

Jonathan Gonzalez-Smith, MPAff

Assistant Research Director

Asher Wang

Policy Research Assistant


Mark Japinga, MPAff

Research Associate

Frank McStay Photo

Frank McStay, MPA

Assistant Research Director

Mark McClellan

Mark McClellan, MD, PhD

Director of the Duke-Margolis Institute for Health Policy
Robert J. Margolis, MD, Professor of Business, Medicine and Policy
Margolis Executive Core Faculty

Robert Saunders

Robert Saunders, PhD

Senior Research Director, Health Care Transformation
Adjunct Associate Professor
Executive Team Member
Margolis Core Faculty