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Every year, health plans quietly bleed millions of dollars – not from fraud or overt mismanagement but something far more routine: the overlooked complexities of managing specialty care.
When most people think of specialty care, they think of high-cost, complex clinical fields such as cardiology and oncology. However, specialty care refers to all healthcare services delivered by providers who are not primary care physicians. This broad category spans critical disciplines like eye care, dermatology, outpatient therapy, gastroenterology, urology, and more.
These services often operate in fragmented silos with little oversight or coordination or are simply not managed at all. As a result, unnecessary procedures, high-cost medications, and unauthorized care slip through the cracks. The real kicker? Many of these costs are avoidable. In addition, they're opportunities for health plans to find significant savings without member abrasion.
The Impact of Specialty Care on Your Health Plan
A recent study published in The American Journal of Medicine highlights how impactful specialty care spending has become for Medicare plans over the last decade. The data showed that, of the 23 specialty categories included, the top four combined for approximately 30% of total Medicare spend – meaning that health plans can no longer afford to leave specialty care management on autopilot.
What may be even more surprising is that ophthalmology ranked as the second-highest Part B CMS-paid specialty, costing Medicare more than $7.3B in 2021. This indicates how eye care, when not carefully managed, can quietly become a major cost center for health plans – and an area of opportunity for cost savings.
For example, some of the key drivers of excessive eye care spend include:
- High-cost injectables for certain eye diseases
- Members seeking care with the highest level of provider when a more affordable level of care would have been indicated
- Procedures performed that are not considered medically necessary
- Surgeries scheduled at high-cost sites of care, such as hospitals, rather than more affordable ambulatory surgery centers (ASCs)
With the right strategy, however, plans can reduce unnecessary spending without sacrificing quality, resulting in:
- Savings up to $1.6M per 100K members through step therapy protocols for Part B drugs
- Savings of $500K per 100K members by directing members to the correct level of care
- Costs slashed by 50% - 70% per procedure by shifting surgeries to ASCs
Smart Specialty Care Management Drives Value
The financial burden of specialty care is not just about high-cost procedures; it’s about the cumulative effect of small inefficiencies that add up across millions of encounters. The inefficiencies are compounded by inconsistent adherence to evidence-based guidelines, overuse of diagnostic testing, and lack of coordination between providers. For health plans, this translates into millions of dollars in avoidable spending each year – costs that are often hidden in plain sight.
To address these issues, health plan leaders are increasingly turning to specialty care management partners like Health Network One. This type of oversight includes the tools, expertise, and infrastructure needed to rein in unnecessary spending while improving outcomes. The result is a more coordinated, cost-effective specialty care ecosystem that benefits payers, providers, and members.
Watch Our Webinar to Learn More About Saving with Specialty
Want to learn more about how effective specialty care management can save health plans millions of dollars every year? Watch the on-demand recording of our recent webinar, Specialty Care Management: The Hidden Lever Plans Can’t Afford to Overlook, cohosted with Medicaid Health Plans of America.
Watch Webinar Recording
Or contact us today at [email protected].