Why specialist engagement is the next chapter for value-based care

For more than a decade, value-based care has largely been built around primary care, and that was the right place to start. Primary care physicians (PCPs) sit at the front of the patient journey and play a critical role in prevention, chronic disease management and care coordination. Yet many decisions that shape total cost of care occur outside the primary care office.

Specialists influence: 

• Treatment pathways
• Procedures
• Site of care
• Post-acute utilization
• The management of complex conditions

They may also see changes in a patient's health status before those changes appear elsewhere in the care system. Extending value-based care into specialty care is therefore an important opportunity to help improve outcomes and manage cost.

Specialty care represents a substantial share of healthcare spending. A 2025 analysis¹ found that 6 specialties, including orthopedics, oncology, cardiology, women's health, behavioral health and nephrology, account for approximately 38% of total medical spending and nearly 68% of commercial and Medicare spending. 

It estimated that up to $100 billion in annual spending may be avoidable through better treatment selection, site-of-care optimization and complication prevention.

Despite that influence, specialists remain less involved in value-based care. Research² suggests they have roughly 50% lower odds of participating in VBC models than PCPs. 

In a 2024 survey³ of Medicare ACOs, 96% of respondents identified specialist alignment as a high or medium priority, but only 11% reported strong alignment with employed specialists and 7% with contracted specialists.

Specialty participation has been voluntary and inconsistent, but recent CMS activity points to a shift. Several models⁴ now bring specialists, hospitals and episodes of care into more direct accountability:

These models differ in structure, but their direction is consistent: Accountability is expanding beyond primary care. 

Under ASM, specialists are expected to establish Collaborative Care Arrangements with PCPs that define responsibilities, information sharing and accountability. Coordination that was once considered good practice is increasingly being embedded in payment design.

As integration becomes more consequential to performance, the places where coordination breaks down become more visible:

• Information moves too slowly. Medication changes, new diagnoses and abnormal results may not reach the primary care team in time to shape follow-up.
• Accountability is unclear. The PCP, specialist and care manager may each assume another person owns the next step.
• Utilization is harder to manage. Without a complete view of the patient journey, duplicate testing, avoidable emergency care and post-acute variation may become more likely.
• Clinical context gets lost. Specialty encounters may reveal changes in acuity or function that should inform care planning, documentation and quality reporting.

Most organizations begin their specialty work with referral management. However, the next layer of maturity is more about the operating model that surrounds it: 

• Build the network. Curate a preferred specialist list, track leakage and make referral patterns visible. This establishes who the organization refers to and where patients go.
• Close the information loop. Move from one-way referrals to structured return of findings, so the specialist has what they need going in and the PCP and care team have what they need coming out. 
• Define roles and activate the team. Replace assumption with co-management agreements to clarify which parts of the care plan sit with the PCP, specialist, care manager and hospital, and alert the team when a specialty encounter changes the picture.
• Share accountability. Bring incentives and measurement together through specialty scorecards, episode analytics and aligned incentives so performance discussions are grounded in data visible to both sides.

Primary care has built the foundation for value-based care, but it cannot coordinate an increasingly complex system alone. 

As financial accountability extends to specialists, hospitals and full episodes, the challenge is architectural: creating shared workflows, connected data and aligned incentives across the care continuum. The next chapter of value-based care will be shaped by how effectively care delivery evolves with that accountability.