With all the focus on primary care and its role in care coordination and controlling spending, specialists get lost in the shuffle. But they of course, do have unique knowledge about how to treat very complex and expensive conditions. A study in the journal Circulation looks at what happens to spending and quality when cardiologists participate in accountable care organizations treating Medicare patients. (Circulation Article) The authors examined ACOs with and without cardiologist participation from the period 2008 to 2015. The care of patients who had cardiovascular disease and were attributed to ACOs was analyzed for spending trends and results on cardiology quality measures. Cardiovascular disease is very common among Medicare beneficiaries and some of these diseases are quite expensive, such as heart failure. Primary care doctors have a limited ability to effectively manage those diseases. Nonetheless, many ACOs have few or no cardiologists, or other specialists, as participants, in fact 20% had no cardiologists in their network. The researchers looked at total spending and spending by category. The quality measures were admissions for heart failure patients, all-cause readmissions and ER visits.
For Medicare beneficiaries with cardiovascular disease, being assigned to any ACO led to a modest but statistically significant reduction in annual spending, with the average being about $300. If the ACO had cardiologist participation, there was an additional savings of about $225. ACOs with cardiologists had more outpatient facility fee spending, but lower skilled nursing, evaluation and management, procedural care and testing spending. The greater the ratio of cardiologists to beneficiaries in the ACO, the more significant the spending reductions were. There was no difference in the quality measure results. The outcome of the study shouldn’t be surprising. Whatever the virtues of effective primary care, when a patient has a serious medical condition, a specialist is needed and is more likely to provide care that over the long run avoids unnecessary hospitalizations and other care. In fact, it would be worth considering whether patients whose medical needs are dominated by one disease, like congestive heart failure, wouldn’t be better off with a cardiologist or other relevant specialist as their primary care physician. As long as the specialist is following appropriate care guidelines, they might create lower spending with no negative effect on quality, as this study found.