Providers are Key to Success of Value-Based Specialty Programs | AHIP 2024

Successful value-based specialty programs begin with partnering with providers, agreed panelists at a session at the annual AHIP meeting in Las Vegas.

CMS defines value-based care is an integrated and patient-centered approach to managing a patient’s healthcare. Specialty care is focused on managing conditions with high treatment costs, including oncology, cardiovascular, kidney disease, and conditions that can be treated with high-priced gene therapies. Patients with these conditions care receive care from multiple providers. Coordinating this complex care and measuring the value of this care is the basis of value-based care programs.

Jeremy Wigginton, M.D.

But different stakeholders define value differently, Jeremy Wigginton, M.D., chief medical officer at Capital Blue Cross in Harrisburg, Pa., said during the session. “Patients see value as access and satisfaction. Providers see it as sustained revenue. You have to make sure you are able to address those before you begin.”

For providers, it’s important to address operational complexity to better align providers, who may be participating in multiple programs with different pathways and different metrics. “Doctors say, ‘when we see patients, we don't know what their insurance carriers are and we don't know what value based program is used.’ We have to create programs that create results.”

Wigginton said plans must have provider buy-in before implementing any value-based program. “If you create a program that is customized with 10 custom measurements, you won’t get provider support. That's what we want,” he said.

Engagement with providers must start before the development of any program. “This engagement shows physicians that have a stake in the program you’re not trying to just cut their revenue,” Wigginton said.

Employers, Wigginton said, want to know whether these programs stabilize costs. “We keep using the three-letter dirty word ROI. We have to create narratives around return on investment; that is the expectation. But when we talk about value-based specialty care, ROI is not where to look. We really need to be starting to think about this as patient-reported outcomes.”

Willington advocates for an approach to support high-cost specialty care that is focused on upfront policy management, creating partnerships with other organizations and education across the continuum, not just patients.

, Bobby Green, M.D.

For patients, value-based specialty care helps to fill in the gaps in the care journey, Bobby Green, M.D., co-founder, president and chief medical officer at Thyme Care, said during the session. Thyme Care is a company in Nashville that provides technology for care navigation in the oncology space.

“Think of navigation as this broad umbrella to include things such as proactively reaching out to patient's electronic patient record and making sure that patients should be getting the care,” he said.

“Cancer is this big, hairy problem with lots of expenses. I think traditionally, there was some reluctance to, to address that but costs keep going up. The newer drugs have complexity to the model.”

CMS has led in this area, introducing in 2014 the Oncology Care Model. CMS recently announced an update to its Enhancing Oncology Model, a voluntary payment model for providers that aims to improve care coordination and quality.

A second cohort of providers will begin in July 2025. CMS had made a few changes for 2025, updating provider payments for patients who are dually eligible for Medicare and Medicaid and requiring providers to pay back CMS when costs exceed a certain benchmark.