The CFA Perspective

Nobody Told the Specialists

Posted by Peter Rastello

6/21/13 10:41 AM

Ian Morrison is one of our favorite futurists and forward-thinkers, so we generally hang on his every word.  In an article entitled “The Bridge from Volume- to Value-Based Payment” (, September 4, 2012); he outlines what he calls “the new future” and how to build the bridge to get there.  One of the barriers to bridge building he sites he refers to as, “nobody told the specialists.”  He states:


“The wisest comment on health reform and the move to accountable care that I have heard was, ‘nobody told the specialists.’  While Choosing Wisely® clearly signals an important change in thinking among specialty society leaders[1], many-rank-and file physicians (particularly those in lucrative procedure-oriented specialties) are afraid of many of these changes and see them as profoundly harmful.  They need to be engaged fully in the redesign discussion, however hard that may be.  And they, too, need to see an economic bridge to the future, one that doesn’t involve a default to what I have dubbed hamster care – i.e., alienated doctors on a treadmill of discounted fee for service – or conversely, everyone trying to do concierge medicine.”


He must be talking about cardiologists in general and interventional cardiologists in particular.  We all know how put upon the cardiologist has come to feel; with the continuing downward pressure on reimbursement, increasing scrutiny over appropriateness of procedures, over-imaging allegations and the like.  Many seem to feel that they have been singled out for special punishment when they are just trying to do their job the best way they know how.  However the enlightened ones know that Bob Dylan was right all those years ago and the “times they are a changin’.”  They just haven’t seen (or been able to envision) any of the good changes yet; a position most of us are in these days.  One trend in particular that scares specialists is the continuing emphasis on primary-care-centric reforms that put specialists in black hats and at the end of the food chain, or so they seem to feel.  This concept has generated some push-back from specialty organizations like the ACC which has even developed its own specialty-centric care model as an alternative.


The ACC may be on to something!  In reality, it seems someone has told the specialists, otherwise why would there be discussions and even movement about the “specialty service-line ACO” concept going on?  In several states, large insurer groups have begun to initiate specialty service line ACO-type arrangements.  In Florida, The Blue Cross Plan, Baptist Health South Florida and Advanced Medical Specialists (an oncology group) established an oncology ACO.  A second with Moffitt Cancer Center was also established. The Blues will contribute 1,000 commercial cancer patients with plans to add patients from its Medicare Advantage Plan.  In Arizona, Banner Health, a pioneer ACO, has set up an ESRD ACO.  CMS is also getting into the ESRD ACO business.  There are currently a half-dozen pediatric ACOs.  Importantly, several insurers have stated publically that they will add other specialty service lines, including cardiovascular, once they have their feet wet with the more “difficult” specialties such as oncology. It is important to recognize that chronic care will be a huge portion of an ACO’s budget.  Successfully decreasing any single specialty chronic care costs within an ACO will have tremendous budgetary implications on its financial performance.  It is obvious to all that many chronic illnesses are represented by cardiovascular disease.


Specialty ACOs are thought to hold great promise of cost savings and improved care.  However, they are universally acknowledged to be so new and unproven that it is unknown how the collaboration between primary care ACOs and specialty care ACOs will work out, since both groups must work together to keep patients healthy.  Perhaps a power struggle is inevitable.  Maybe cardiologists are not in such a bad position after all.  Maybe that black hat isn’t really black after all, but just a shade of gray.  And, maybe the cardiologist doesn’t have to be at the proverbial end of the food chain after all.  We will see.


As always, CFA invites your comments, suggestions and questions.

[1] The national program including many professional societies (including the American College of Cardiology) to promote wise choices by clinicians and patients in order to improve health care outcomes, provide patient-centered care that avoids unnecessary and even harmful interventions, and reduce the increasingly high cost of healthcare.


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Topics: healthcare reform