For Medicare Advantage plans, the 2027 Star Ratings continue to put significant weight on outcomes. Measures including Plan All-Cause Readmissions, Controlling Blood Pressure and Diabetes Care: Blood Sugar Controlled each carry a weight of 3, while process measures such as Statin Therapy for Patients with Cardiovascular Disease are weighted 1.

That matters because many of the decisions that influence these outcomes happen long before a measure is calculated.

For members receiving musculoskeletal or cardiovascular care, decisions about whether a procedure is appropriate, whether the member is ready for it, where care is delivered and how clinical risks are managed can all affect what happens next.

For health plans, that makes specialty care part of a much broader quality conversation.

Connecting specialty care to quality measures

Patient selection, procedural appropriateness, management of clinical risk and recovery all have a bearing on what happens after an intervention. For a member with hypertension, blood pressure control may be an important part of the clinical picture. For a member with diabetes, glycemic control may factor into readiness for an intervention and the risk surrounding it. Cardiovascular cases can present opportunities to address cholesterol-related risk and evidence-based statin therapy. Medication adherence may also be relevant to the member’s overall clinical status.

These are the same areas reflected in measures such as Controlling Blood Pressure, Diabetes Care: Blood Sugar Controlled, Statin Therapy for Patients with Cardiovascular Disease and medication adherence measures.

The connection is practical. TurningPoint is already engaging with providers during an important point in a member’s care. That interaction can be used not only to determine whether an intervention is appropriate, but also to address the clinical factors that affect procedural risk, recovery and the member’s broader health.

Specialty condition management isn’t a replacement for primary care, pharmacy or population health. It gives health plans another point of intervention, particularly for members already navigating complex, high-impact care.

Working with providers on quality

That broader view of specialty care also changes the nature of the relationship with providers.

TurningPoint works directly with providers on clinical appropriateness, evidence-based best practices, comorbidity management and outcomes. Those areas are also incorporated into our Provider Safety and Quality Awards Program, a value-based incentive program for Providers, which considers measures including revisions, emergency department utilization, readmissions and post-acute utilization.

This matters because specialty care isn’t simply a series of isolated authorization requests. The decisions providers make about patient selection, treatment, clinical risk and recovery can have consequences well beyond the procedure itself.

By working directly with providers, specialty condition management can reinforce evidence-based care, identify clinical risks that may affect an episode and address areas that overlap with the quality priorities health plans are already managing.

The result is a different approach to utilization management. The authorization decision is still important, but it isn’t the only opportunity to improve care.

From utilization management to quality strategy

Health plans will continue to manage specialty care for cost and medical necessity. But there is more value to capture from the clinical work already taking place.

TurningPoint works with providers on patient selection, clinical appropriateness, evidence-based treatment, comorbidity management and the factors that can affect a member’s outcome. That work can connect directly to areas measured through Stars and HEDIS, including blood pressure control, diabetes management, cardiovascular risk, medication adherence and readmissions.

It also affects what happens after the procedure.

Across select musculoskeletal and cardiovascular procedures, TurningPoint program data show meaningful improvements in clinical outcomes. Total hip replacement surgical revision rates decreased 56%. Post-surgical ER visits within 30 days of lumbar spinal fusion decreased 45%. And admissions within 30 days of coronary artery bypass grafting decreased 33%.

The results extend across other procedures as well, including a 37% reduction in 30-day admissions following total knee replacement and a 66% reduction in post-surgical ER visits following pacemaker implantation.

That’s where the broader value of specialty condition management comes into focus. The work starts before an intervention, with the right patient, the right treatment and attention to the clinical risks that can affect the episode. It continues through our work with providers on evidence-based care and the factors that influence recovery.

Specialty care shouldn’t sit apart from a health plan’s quality strategy. The same work that helps health plans make better decisions around complex specialty care can also address the clinical factors being measured and reduce the downstream events they are working to prevent.

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