Why specialists are the key players in the next phase of value-based care

When physicians describe the forces reshaping medicine, they increasingly point not to a new device or a breakthrough drug but to the economics underneath their work. The move from fee-for-service to value-based payment is no longer theoretical. For a growing number of specialists, it is starting to feel personal.

That change in perception is worth pausing on, because value-based care itself is not new. Primary care organizations, payers and accountable care organizations have spent more than a decade building the contracts, attribution logic and quality infrastructure that define these models today. What is new is their expansion into parts of the system that have, until recently, sat at the edge of the conversation. Specialty care is the most consequential of those parts.

There is a structural reason for that. Much of the spending these models are designed to manage — advanced imaging, procedures, device costs, postacute utilization, the full arc of an episode from diagnosis through recovery — originates in specialty settings, not in the primary care office. Yet for years, the clinicians formally held accountable for total cost of care have been primary care physicians. How is that changing today?

Value-based care: Anchored in primary care

The dominant approach has been to anchor accountability in primary care. Primary care physicians are attributed a panel of patients, made responsible for managing the total cost and coordination of their care, and rewarded or penalized accordingly. That structure has accomplished a great deal. It established a foundation for population health, gave organizations a clear locus of accountability and demonstrated that coordinated care can lower costs without sacrificing quality. Much of what we know about making value-based care work, we learned through primary care.

A changing model of care

But the same structure creates a real tension as specialists are drawn in. When the cost of an episode is driven by specialty decisions while the accountability and the financial upside sit with primary care, specialists can find themselves evaluated — and, in practice, indirectly managed — without a clear role in governance or a meaningful share of the rewards. Many are willing to participate, but only on the condition that their contributions to outcomes, efficiency and cost management are recognized and compensated in a way that feels both clinically and financially fair.

Bridging that gap has proven difficult, and the difficulty is not mainly technical. It is a question of model design. A specialist asked to change referral patterns, reduce avoidable imaging or coordinate more tightly around an episode is being asked to do real work and, often, forgo revenue the fee-for-service world would have rewarded. If the model offers no shared savings, no seat in decision-making and no data showing how their choices affect the broader picture, the arrangement reads less like a partnership than a cost control imposed from the outside.

The path forward is to design models that treat specialists as participants rather than as line items to be managed. In practice, that means a few things. It means episode- and condition-based arrangements that hold specialists accountable for what they actually influence rather than folding their performance into a primary-care metric. It means shared-savings and governance structures that give specialty groups a genuine stake and a genuine voice. And it means closing the data gap: making sure specialists can see the same picture of attributed patients, utilization and total cost of care that primary care providers and payers already work from. Incentives, workflows and data have to align across the care team, not just within one part of it.

Collaboration for evolution

None of this requires abandoning what primary care-led models built. It requires extending the logic of accountability outward so that the clinicians who drive much of the spending also help govern it. The alternative — bolting specialists onto an existing structure without changing the structure — risks reproducing the very silos value-based care was meant to dissolve, only under a new payment label.

What is encouraging is that specialists are no longer waiting to be invited. Concerns about cost, access and misalignments with patient priorities are pushing them to engage rather than opt out. Specialists are showing up to the conversation. Will the models be redesigned to make room for them?

Value-based care has spent a decade proving that coordinated, accountable care is possible. The next decade will be defined by whether it can be made genuinely collaborative across primary and specialty care alike or whether it stalls at the boundary it has not yet learned to cross.

Dana McCalley, MBA, is the vice president of value-based care at Navina. She has 15-plus years in health care, with a focus on quality improvement and risk adjustment. She led one of the nation’s top-performing accountable care organizations for nine years and was responsible for helping 700-plus clinicians provide care to 230,000 value-based patients.