Here is a structural fact that undermines a lot of value-based strategy: in most ACOs and IPAs, the majority of total cost of care is driven by specialists the organization does not employ and cannot direct. You are accountable for spending you do not control.
Pretending otherwise is why a lot of primary-care-centric VBC strategies quietly stall — and two CMS moves are bringing the problem to a head.
1. Where the cost actually lives
Primary care is where patients are attributed. Specialty care is where the money is spent.
Attribution and care management in most ACOs run through primary care, which is appropriate — that is where the longitudinal relationship lives. But the largest share of total cost of care flows through specialty and hospital-based services: surgeries, procedures, imaging, specialist-driven admissions.
If your value-based strategy ends at the primary-care door, you have optimized the part of the spend you can see and left the larger part untouched.
2. The engagement problem is clinical, not contractual
You cannot fix this purely with contracts. Specialists respond to clinical relationships, peer credibility, and data they trust about their own patients — not to a memo from a network they do not feel part of.
This is where a clinical translation layer matters: someone who can sit with a cardiology or orthopedics group and discuss variation in their episode costs as a clinical conversation, not an accusation. Engaging specialists in total cost of care is a physician-to-physician exercise before it is an administrative one.
3. CMS is forcing the issue — TEAM
With TEAM, CMS stopped asking hospitals to manage surgical episodes and started requiring it.
The Transforming Episode Accountability Model, mandatory since January 2026, holds selected hospitals accountable for the cost and quality of five surgical episodes through 30 days post-discharge. Those episodes are specialist-driven by definition.
TEAM makes surgical-cost accountability unavoidable for hundreds of hospitals — and it rewards exactly the kind of surgeon engagement that primary-care-centric models never built.
4. CMS is also handing ACOs new tools — CARA and episode data
Alongside TEAM, the new LEAD Model introduces CMS-Administered Risk Arrangements (CARA), giving ACOs standardized frameworks and CMS-administered payments to build episode-based arrangements with specialists. CMS is also moving to share specialty episode-spending data with ACOs.
The message is consistent: the next phase of value-based care runs through specialists, and CMS is building the plumbing to make specialist accountability operational. The organizations that learn to use it will have a real edge.
5. The clinical-to-strategy bridge is the actual capability
None of this works without people who can translate between the specialist’s clinical world and the organization’s financial accountability. That is the bridge I keep coming back to: a clinically fluent voice that can show a surgeon their own variation, explain an episode target in terms they respect, and turn “the network needs you to cut costs” into “here is where your patients are getting care that isn’t helping them.”
That capability — not another contract clause — is what brings specialty spend under management.
Final Thoughts
The uncomfortable arithmetic of value-based care is that you are accountable for total cost of care while directly controlling only a slice of it.
As someone trained as a physician who moved into audit and strategy, I have seen that the organizations that close this gap do not do it with tighter contracts — they do it by engaging specialists as clinical peers, using the data and the new models CMS is putting on the table. The doctors you don’t employ are where your savings are. The question is whether you can speak their language well enough to get there.
If your value-based strategy runs through primary care and stops there, you’re managing the smaller half of total cost of care. At HealtheNomics I help ACOs and IPAs build the specialist-engagement and episode-management capability — clinical, not just contractual — that brings the larger half under control.
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