Heath Reform: Specialists Do What They Do - and Sometimes What They Didn't Used to Do

August 3, 2011 - My wife has a dear friend, her former nursing instructor, who is full of worldly wisdom. Recently, when my wife asked her advice about visiting a specialist, her old friend said,

“Remember, specialists do what they do.”

In short, specialists do what they are trained to do.

There are others ways of saying this, of course.

• Give specialists a hammer, and they will use it to hit the nail they are accustomed to hitting on the head.

• When a primary care specialist refers a patient to a specialist, he or she expects the specialist to do what he or she does.

• When patients visit specialists, they expect specialists to do what they do.

New Twists

There are new twists to these old wife's tales. Specialists are doing what other specialists do. They are extending the reach of their expertise to other specialties – even if means invading other specialized territories. Specialists are subspecializing. They are becoming sons of niches.

The classic example of this is the work of invasive cardiologists who by inserting cardiac stents, are depriving cardiac surgeons of bypass procedures. Now, because CMS has cut fees for stent for cardiologists by 40% or so, cardiologists have become “barbarians” by extending their work services to concentrating on such previously neglected things as mitral valve prolapse, patent foramen ovales, and ablation of triggers for atrial fibrillation, and cardiologists moving into the fields of neurology and vascular surgery.

The barbarian thesis is the brainchild of DrRich, Richard Fogoros, MD, a former professor of medicine in the fields of cardiology and electrophysiology. In a The Health Care Blog, in a piece called "Atilla, the Cardiologist, " DrRich opines at some length about “the Great Cardiology Migration," into heart-related problems as responsible for transient ischemic attacks, strokes, migraines, and even Alzheimers.

The editors of The Health Care Blog asked me to comment on Dr. Rich’s thesis.

Here was my response.

What Doctor Rich is explaining in 2835 words is the balloon effect of medical economics.

If you press down on the top of cardiologists' main financial balloon, as the CMS is doing on by slashing cardiology fees for stents and implantable pacemakers, secondary balloons begin to pop out below as cardiologists expand their interests to other organ systems in order the maintain the overall volume of the balloon.

There are three morals to this tale:

• One, the heart supplies all other organs, therefore the entire body falls and diseases of all organ systems falls within cardiologist’s balloon. The cardiologist is no buffoon.

• Two, broad minded cardiologists do not suffer from hardening of the categories. They do not restrict their attention to hardening of the arteries.

• Three, old cardiologists never die, they just resort to coronary bypass procedures.

And here was the comment of Brian Klepper, PhD, an imminent health care analyst, and a friend of mine, who observes.

DrRich writes an entertaining post, but the day of the barbarian cardiologist is drawing to a close. Specialists of all types, manipulating the payment system to advantage through an unholy alliance between the AMA’s RUC and CMS, have exhausted our ability to pay without limit. The mauraders may arrive, but the corn is gone, and there is no plunder left. It’s a bummer when there’s nothing to pillage.

DrRich fantasizes a plain of endless FFS, where the riches never end. That’s the world of 2000, not 2015. The pendulum is swinging the other way now. Purchasers can use data to see who is over-reaching. A few may escape notice for a while longer, but for the most part, they’re toast, an anachronism that will be annihilated by the progress of a more evolved, smarter market.
In other words, DrRich, as bombastic as he is verbose, doesn’t have a clue that the conditions that allowed plunder in the past have changed. The cardiologists’ days of excess, like Mubarek’s, is over.

Cardiologists Cornered by Data and Codes

Doctor Klepper may be right. When the government has enough data, cardiologists will no longer have anywhere else to hide from federal authorities and other payers. And when the Reimbursement Update Committee and CMS narrow the coding gap between subspecialists like cardiologist and primary care and “endless FFS” fades into history, there will be no more “plunder.”

I am not as confident or as judgmental as Brian, I would characterize many of the new things cardiologists are doing as innovative.

The Law of Health Reform Thermodynamics

Besides, I am a believer in the Law of Health Reform Thermodynamics - For Every Federal Action Decreasing Specialist Fees, there is an Equal Reaction among Patients and Physicians.

This Law is shown at work in a today’s lead article in USA Today, which reports that costs of Medicare and Medicaid advanced by an unprecedented 10% in the second quarter, in reaction of the new Health Reform Law, designed to cut the costs of care by decreasing specialty fees. Patients reacted by seeking more care while the getting was good, and specialists were happy to supply the care.