Reimagining the Specialist’s Role in Value-Based Care

Primary care has long been considered the "quarterback" of value-based care (VBC). However, a stark reality remains: primary care providers (PCPs) directly influence only about 2.5 cents of every Medicare dollar spent¹. The other 97.5% of healthcare spend occurs largely within the realm of specialists, often through high-cost episodes or chronic condition management.

In a recent Pearl Health webinar, Dr. Cameron Berg, EVP of Clinical Strategy at Pearl sat down with industry experts Theresa Dreyer, George Aloth, and Dr. Ryan Grant (bios below) to discuss why the traditional "episode-based" payment logic is failing and how the industry must evolve to include specialists in risk-bearing arrangements.

1. Attribution Is More Complex Than We Think

One of the most persistent challenges in VBC is attribution, deciding which provider is responsible for a patient’s costs and outcomes. Historically, patients were attributed to primary care providers, but this approach does not work for all specialties. Cardiology, for example, is a longitudinal specialty where patients move in and out of risk pools and comorbidities complicate management.

As George explained, specialists can be attributed to patients in several ways: sub-capitation, network full-risk models, or pay-for-performance arrangements. Each approach has trade-offs, and there is no one-size-fits-all solution. The right model depends on the specialty, the patient population, and the type of care being delivered. Getting attribution wrong can undermine both clinical outcomes and financial incentives.

2. Moving Procedures Outpatient Reduces Costs But Not Surgeries

Shifting procedures to outpatient or ambulatory surgery centers (ASCs) lowers facility fees but does not necessarily reduce the total number of surgeries. As Dr. Grant pointed out, asking surgeons to manage total cost of care is like asking a pool contractor whether you need a pool. Specialists are trained to deliver care safely, not to decide whether surgery is necessary or redesign care pathways.

ASCs are designed to fill the table. Just like a restaurant wants every seat occupied, ambulatory centers are incentivized to perform procedures, not reduce them. Elective surgeries, especially spine and knee operations, remain major hospital revenue drivers. While shifting site of care improves efficiency, it does not automatically reduce utilization.

3. Post-Acute Care Management Drives Most Savings Today

Theresa explained that much of the financial benefit in current VBC models comes from managing post-acute care rather than reducing procedures. Surgical DRGs are billed as fixed amounts, so hospitals do not control the cost of the procedure itself. When hospitals are given total cost-of-care responsibility, they focus on stepping down post-acute care, for example sending patients home with home health instead of to a skilled nursing facility, or automating certain tasks like discharge coordination.

Models like TEAM attribute costs to hospitals and standardize these post-discharge processes. While these approaches generate measurable savings, they do not drive behavioral change among surgeons or influence whether surgery is needed.

4. ACCESS and LEAD Offer Hope Through Coordination and Benefit Design

There is reason to be optimistic about both models. ACCESS and LEAD use digital care coordination and innovative benefit design to encourage appropriate care. ACCESS is particularly promising to Dr. Grant because it waives copays, removing financial barriers and helping patients complete recommended care. LEAD may also offer options to reduce copays and includes strategies like Part D buydowns and nested bundles.

These models show promise in aligning patient behavior, clinician engagement, and system incentives. 

5. The Path Forward Requires Data, Competition, and Incentives

To move specialists toward value-based behavior, three elements are critical:

• Reducing data lags is imperative. Waiting months for claims data makes it impossible for clinicians to act in real time. Near-real-time information allows physicians to make informed decisions during the care process rather than reacting after the fact. 
• Physicians are competitors by nature, and one of the most effective ways to drive change is to show them hard data on how they perform relative to peers. When combined with clear financial or professional incentives, this competitive benchmarking can encourage durable behavioral change.
• Finally, while mandatory participation might seem like the most straightforward approach, voluntary participation may actually be more effective. Clinicians who choose to opt into VBC programs may be more engaged, responsive to timely data, and more likely to adopt the protocols and workflows that support better outcomes.  Success likely depends on connecting timely data with meaningful incentives and giving clinicians the ability to act, rather than relying solely on top-down mandates.

Conclusion

Specialists are indispensable to the shift toward value-based care, but current models often fall short of aligning incentives with clinical decision-making. Attribution challenges, post-acute savings-focused incentives, and site-of-care shifts can improve efficiency, but they do not always change clinical behavior.

The path forward lies in better data, thoughtful benefit design, voluntary engagement models, and incentives that encourage both clinicians and patients to do the right thing. As Dr. Berg noted, there is fertile soil for change. Clinicians and systems want to improve care, but success will require smarter models that truly integrate specialists into the value equation.