3 Keys To Bridging Gaps In Value-Based Care

posted by Lawrence Kosinski, SonarMD & Leanne Metcalfe, Health Care Service Corporation

on December 5, 2019

Involve specialists in value-based care to achieve quadruple aim.

As the industry continues to experiment with value-based care to pivot away from fee-for-service, specialty physicians can and should play a larger role in health insurance providers’ value-based care efforts.

There are major savings to be had in specialty care, which accounts for about 70% of health care spend.

While primary care physicians are traditionally seen as chronic care managers, specialists manage the most serious chronic diseases, attempting to halt their progression and control their complications.

Despite this, most accountable care organizations, shared savings programs, and intensive medical homes focus incentives on primary care doctors. Specialists can excel in new value-based payment models when 3 main criteria are met.

1. The right chronic illness

Some specialists are better equipped to move successfully into value-based care because of the types of patients they see.

Gastroenterologists, for example, care for patients with Inflammatory Bowel Disease, which includes Crohn’s disease and ulcerative colitis (UC).

Crohn’s and UC are high-beta conditions, which are symptomatic, chronic conditions that can rapidly deteriorate without patients realizing it, leading to serious complications that can drive emergency room visits, hospitalizations, and unwanted surgeries. As a result, they have highly variable per capita costs and are often treated with high-cost therapies..

These patients can benefit from high-touch care from their doctors.

2. The right data

Patients with conditions like Crohn’s often don’t realize their symptoms are worsening, so they don’t alert their care team.

To jump that hurdle and succeed in value-based care, clinicians need access to regularly reported data from those patients. In a pilot research partnership performed by  gastroenterologists at the Illinois Gastroenterology Group (IGG) in 2013, they asked 50 patients to respond to a short monthly survey of their symptoms. From there, nurses calculated a score related to patients’ symptom severity.

If a patient’s score signified a potential deterioration in their clinical status, nurses would reach out and schedule an appointment before things got worse.

During the year-long pilot, only 1 of the 50 patients was hospitalized, and no one required surgery. Based on the successof the pilot, Blue Cross and Blue Shield of Illinois designated IGG as its first specialty-based Intensive Medical Home. This initiative now involves practices across the state of Illinois, all using the SonarMD program.

A larger-scale study using propensity matched comparison against a control group in 2017 demonstrated use of SonarMD’s care coordination solution resulted in a statistically significant decline in hospitalizations, which reduced medical cost for each person by $6,500.

3. The right support

Having medical staff monitor the patient-reported data and create scores for every patient isn’t scalable. Specialty practices need the right full-time support to manage patients successfully and remain profitable.

External care coordinators can monitor the scores and then proactively connect patients with their physicians if there’s a potential need for intervention, taking the burden off specialty practices.

Specialty providers and health insurance providers can collaborate and align incentives through value-based contracting to improve patient/member outcomes and quality of life.

When the formula is met, involving specialists in value-based care arrangements truly achieves the quadruple aim of improved patient experience, better health of the overall population, lower costs, and happier providers: Patients feel more connected to their doctors, costs are lower, and physicians are more satisfied.


Lawrence R. Kosinski, MD, MBA is founder and Chief Medical Officer of SonarMD. Leanne Metcalfe, PhD is Executive Director, Research and Strategy, at HCSC. 

You can hear more of their insights at AHIP’s Consumer Experience & Digital Health Forum.

" "