Physician MarketScan: Specialists Expanding Care in the Home

The next evolution for specialists: Moving specialty care into the home As CMS concentrates on integrating more specialists into value-based care, prioritizing engagement with home care providers emerges as a key strategic imperative. These engagement strategies center around areas such as readmissions, care transitions, longitudinal care, value-based payments, bundled payments, and the expansion of specialty care within a home setting. Market Signals for Home Care The CMS Innovation Center has established a comprehensive strategy to incorporate specialists into value-based payment programs to support access to high-quality, integrated specialty care across the patient journey—both within longitudinal and procedural or acute service delivery and payment frameworks (Figure 1). Figure 1: Aligned Elements of the Specialty Strategy and Beneficiary Care Experience Element #1 Enhance transparency of specialist data and performance measures to increase access to high-quality, accountable specialty care and integration with primary care. Market Signal: The Innovation Center plans to explore and test ways to make these measures available in population-based models to bolster referrals to high-value specialists. Impact to Home Care: The Innovation Center will provide technical support and support alignment across payers by standardizing definitions for an episode of care delivered by a specialist, whether it be in the outpatient or institutional setting. Doing so would facilitate consistency in the marketplace by allowing comparisons of spending and quality across multiple payers and supporting increased accountability for and subcontracting around conditions with downstream hospitals, specialist Physician Group Practices, and/or Post-Acute Care providers Element #2 Maintain momentum established by episode payment models. Market Signal: A new episode payment model would aim to improve care across transitions, which is a common point in the care journey where lapses in quality occur and which are often beyond the reach of primary care-based ACOs. A mandatory approach can further improve and standardize care for beneficiaries across hospital-based and post-acute care transitions, while also avoiding risk selection in participation decisions. We will also focus on how a mandatory model design can increase beneficiary access and provider participation in value-based payment arrangements, especially in underserved areas, and advance health equity. Impact to Home Care: CMS’ Innovation Center is examining potential design features to focus on the beneficiary’s transition of care, such as a shorter, 30-day episode to target readmissions and complications while limiting overlap and facilitating a smooth transition back to their population-based, longitudinal providers Element #3 Create innovations to improve coordination and collaboration, including at the point of referral, between primary care and specialty care physicians. Market Signal: The integration and coordination of primary and specialty care has not been an explicit focus of previous primary care model tests and remains a barrier to beneficiaries receiving high-quality care. Beneficiaries are referred to 50% more specialists today than in 2000, making outpatient specialty care increasingly more fragmented. CMMI’s Innovation Center intends to test strategies that incentivize integration and coordination between primary care and specialty care both before and after the point of initial referral. In the long term, the Innovation Center will examine capitated payments to specialists for defined conditions within the context of longitudinal, population-based models. Impact to Home Care: Home Care should expect greater bundled payment partnerships and advanced clinical specialty models. Element #4 Create a targeted set of financial incentives for ACOs to actively manage specialty care, through possible beneficiary alignment changes and episode cost and quality measures specific to specialist-managed conditions. Market Signal: Over the longer term, CMS may enhance incentives to manage specialty care within population-based models. CMMI will work with stakeholders to explore developing subpopulation targets for high-volume or high-cost conditions. Through these targeted cost and quality measures, ACOs may begin to focus efforts on managing the highest cost, most complex care, particularly for cardiovascular, orthopedic, and pulmonary conditions. Impact to Home Care: Different supports may be needed for independent, physician-led versus hospital-affiliated population-based model participants. Expectations: higher acuity patients treated in the home. Development of expanded clinical specialty models in the home. Specialty care models have focused on inpatient medical and surgical admissions and procedures in hospital outpatient departments. There are episode-based payment models including the bundled payments for care improvement initiative models and a comprehensive care for joint replacement model. “These models have driven transformational change in the delivery of care across transitions, namely between hospitals post-acute care, and community-based supports,” says CMS. Download ArticleDownload the Entire Issue

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Physician MarketScan: Specialists Expanding Care in the Home

The next evolution for specialists: Moving specialty care into the home.

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