Unlocking Success in Value-Based Care: Why Focusing on Specialized Populations is Key

With the value-based care (VBC) market predicted to grow to $43.4 billion by 2031, this healthcare model continues to gain momentum, prioritizing patient-centered, outcome-focused approaches. Personalized care addresses the shortcomings of traditional fee-for-service models, which have long prioritized treatment volume over patient outcomes, further driving up costs while often failing to improve long-term patient health. In fact, recent reports from 2024 indicate that over 50% of Medicare beneficiaries are enrolled in Medicare Advantage plans that align with VBC frameworks, resulting in a 25% increase in provider participation in VBC implementation last year.

In the face of VBC implementation challenges such as operational complexity, technological demands, and financial risk, some adopters of this model reported measurable successes. Humana, for example, had 30% fewer inpatient admissions in 2022 among its VBC patient population compared to those who were members of traditional Medicare, saving over 200,000 admissions. 

One approach to navigating these challenges when implementing personalized care is by starting with specialized populations, allowing organizations to test, learn, and refine their approach. This focus helps manage transition risks while addressing the personalized needs of certain groups, including those traditionally underserved in healthcare.

Focused interventions lead to lower costs and better outcomes 

Specialized populations, such as aging groups, patients with chronic conditions, or rural residents, often receive inconsistent and inadequate care due to the common one-size-fits-all approach of traditional healthcare models. By focusing on specific groups, healthcare organizations can develop customized interventions tailored to their needs such as care pathways, education programs on chronic disease treatment, or public health surveys to track the health progress of certain populations. Interventions can lead to more impactful care appointments, limiting unnecessary visits, treatments, or testing, and ultimately optimize patient health and reduce costs – all benefits aligned with VBC principles. 

A 2022 study published by the American Diabetes Association demonstrated the benefits of interventions for diabetic patients utilizing Diabetes Care and Education Specialists (DCES). The study explores how DCES groups can enhance access to resources, lower the risk for diabetes treatment complications, improve quality of life, and reduce hospitalizations through evidence-based interventions. DCES groups often include dieticians, pharmacists, endocrinologists, and even psychologists to ensure all aspects of a patient’s health are measured for a tailored care plan. In the US alone, the number of adults diagnosed with diabetes is expected to triple by 2060, making the need for interventions and targeted care even more critical for this population. 

Women 65 and older also represent a specialized population with unique health challenges often overlooked by traditional models, such as post-menopausal care as well as bone, breast and pelvic floor health. By creating care pathways specific to this group and taking a patient-centered, integrated approach – such as longer or more frequent visits, demedication strategies, and advanced screenings – health outcomes improve, potential issues are addressed early, and overall costs decline. Fostering deep patient engagement also plays a role in successfully deploying care pathways, as gaining trust among these groups allows them to take a more active role in their health leading to better results.

Implement clear benchmarks for model scalability

Not all patients require the same level of care, showcasing the importance of targeted strategies supported by measurable benchmarks to evaluate and improve clinical approaches. Establishing clear metrics such as hospitalization frequency, medication adherence rates, care team responsiveness or cost trends during treatment is crucial for evaluating progress and driving continuous improvement for specialized populations. For example, healthcare organizations implementing a VBC model can measure the reduction in hospital readmission rates by implementing comprehensive discharge planning, medication management, and follow-up care programs. Decreasing the percentage of patients who require re-hospitalization within 30 days of discharge, is one way to validate the cost-effectiveness of investing in proactive, preventative care.

Another example is the Total Care Model developed by Agilon Health which outlines metrics to aid physicians in implementing VBC and help them identify gaps in care, specifically for those with chronic conditions like diabetes. Some metrics utilized in this model include annual wellness visit completion rates, hospital admissions and readmissions, and cost of care. As a result of this model, Medicare Advantage patients with diabetes saw an overall improvement in Hemoglobin A1 control, leading to a 19% reduction in out-of-pocket costs in 2020 and 2021. 

Additionally, since 2019 Stanford Health Care has been rolling out its own VBC virtual model, the eConsult program, allowing primary care physicians to seek specialist input without requiring patients to schedule in-person visits with specialists. By focusing on patient results and physician adoption measurement, Stanford found that 55% of patients avoided the need for in-person specialist visits, showcasing improved efficiency and resource utilization. Importantly this approach offers a better patient experience and is particularly beneficial for rural or older populations as it reduces healthcare access barriers and provides specialist care for patients who may face geographic or transportation challenges. 

Driving better outcomes through risk stratification

While measurement can provide data for better care plans, it also plays a crucial role in managing financial risks within VBC models. A large hesitation for healthcare leaders considering a personalized care approach is the financial risk associated with shifting from fee-for-service to outcome-based reimbursement. Focusing on specialized populations can help identify shared health challenges within specific groups to address these risks, enabling more precise and effective care. Patients with higher risk scores can then receive more intensive interventions tailored to their needs, while lower-risk patients benefit from appropriately scaled services, ultimately improving overall health and optimizing resource allocation. Right-sizing care to the patient’s need allows the at-risk provider to reduce costs and financial risks.

Research is also essential when assessing risk factors, especially for managing specialized groups with unique health needs. For example, chronic diseases disproportionately affect certain subpopulations, with Black adults experiencing higher rates of hypertension,  Hispanic adults facing increased risk of diabetes, and increased risk of osteoporosis in Asian adults. Additional focused research into specific groups like these can provide healthcare experts with critical insights into how social determinants of health (SDOH) and other factors drive disease progression, enabling the development of more precise, subpopulation-tailored risk stratification models.

Understanding SDOH is crucial for effective risk stratification within VBC models. By incorporating these social and environmental factors into assessment frameworks, healthcare providers can better predict health risks and resource needs across different populations. The CDC reported that social determinants of health have a greater impact on health outcomes than genetic predispositions, underscoring the critical role of SDOH data in risk scoring. This approach enables providers to better predict costs, allocate resources effectively and design interventions that address medical and socioeconomic barriers – key requirements for success in VBC. 

The shift to a VBC model represents more than an evolution in healthcare delivery – it demands a fundamental redesign of our healthcare system and the economic models to support it. Beginning with specialized populations offers healthcare organizations a strategic pathway to this transformation, allowing them to address disparities while developing scalable, evidence-based care models. As successful outcomes and cost savings continue to demonstrate the model’s effectiveness, healthcare leaders who embrace this approach can improve care delivery and lay the foundation for a more equitable, sustainable, and truly patient-centered healthcare system.

Editor’s note: The author has no financial relationship with any of the companies / products mentioned.

Source: Peach_iStock, Getty Images

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