Specialties: missing in our healthcare reform strategies?

G iven the amount of frenetic healthcare reform preparation occurring with accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and bundling demonstrations, are we overlooking—or quietly ignoring— medical and surgical specialists and subspecialists in our planning? It may seem to specialists that they are off the healthcare radar screen for now. Yes, a few medical homes and ACOs are specialty based, and some commercial health plans and for-profit entities are creating accountable care scenarios with specialists in oncology, end-stage renal disease (ESRD), and a few other medical conditions. Bundled payment demonstration projects are frequently identified with specialists, but in reality these payment models currently fit some specialties better than others. Specialists account for the majority of U.S. physicians, but the actual number of physicians involved in these initiatives is only a small percentage of the specialty workforce. Most specialists are independent and are not hospital based or hospital employed. Even if the organizations where they practice are working with ACO, PCMH, or bundling models, they are not often directly involved. Over the years, healthcare executives have been careful not to rock the boat with specialists or disturb their productivity under hospital roofs. But aren’t they a major part of healthcare reform strategies? Realize that they have a tremendous ability to change clinical costs and outcomes and to significantly affect local market dynamics. Specialists and their practice administrators have been asking what role they play in ACOs and PCMHs. They are not seeking alternatives to fee-for-service (FFS) but, at a minimum, want to be a player at the table for the new payment models to avoid losing future referrals. The Centers for Medicare & Medicaid Services has not developed a Medicare Shared Savings Program model for specialty care (although ESRD initiatives are in the works), which is understandable, given the significant risk and complexity associated with managing smaller pools of more vulnerable patient populations. Then how do ACO and PCMH referrals differ from routine patient visits? Currently, they don’t. Unless the specialists are in a demonstration project or have an arrangement with a commercial insurer, specialty referrals generate FFS compensation, not a value-based payment.