🏥 Is cardiology the cleanest VBC specialty?

Blake Madden

Sep 15th, 2026

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Hey Hospitalogists,

Today I'm sharing a conversation I had with Emily Rash, COO, and Dr. Neil Gheewala, CMO of VBC, at US Heart and Vascular, one of the multi-state cardiology platforms quietly building out while dermatology and GI hogged the PE headlines. We got into the Ares thesis, the integration grind, governance, the 36-week wait time, why cardiology may be the cleanest VBC fit in specialty, and Neil's RFK Jr. pitch on what he's calling a Level 6 reimbursement category.

Quick note before we get into it, I hope to see you at one of these events:

9/23: Happy Hour at Vizient → The Venetian in Las Vegas. First round's on me. Can you make it?

9/30: Building the VBC Playbook for 2027 and Beyond → Join me for a virtual event with Navina. We’re going to show you where AI can give your team back time for patients, not paperwork. Bring your questions.

11/2-11/3: Hospitalogy AI Retreat → Travel is covered. Our speaker lineup includes Dr. Tom Lee. Will you be there?

11/15: Happy Hour at HLTH → Open bar, tasty bites, and the people steering financial performance in healthcare. Free to attend.

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Inside US Heart and Vascular: Cardiology's Independent Integration Play, and When Private Equity Works

Cardiology private equity has been having a moment. While dermatology rollups grabbed headlines and GI consolidated under PE's loving embrace, multi-state cardiology platforms have been building out: Cardiovascular Logistics, Cardiovascular Associates of America, US Heart and Vascular. Different sponsors, different theses, different bets on what specialty consolidation is truly for.

On a recent episode of Claims Denied, I sat down with Emily Rash, COO, and Dr. Neil Gheewala, CMO of VBC, of US Heart and Vascular to discuss cardiology’s independent integration play. There’s plenty to get into. Let's break it down.

Why Ares (and why Rubicon, too)

USHV came together in late 2020 / early 2021 when several capital partners were circling the cardiology consolidation opportunity. Neil and his Tucson group ended up choosing Ares Management and officially formed the company in December 2021 as founding members. Four and a half years in.

What's interesting, and didn't get nearly enough attention in the press cycle, is that USHV doesn't just have Ares. They also brought in Rubicon Founders specifically for VBC capability. Rubicon contributes actuarial staff, contracting expertise, and operating partners who have built risk-bearing entities before. Ares brings the platform-building muscle: talent, org design, value creation plan execution, growth capital for ASCs and advanced imaging.

That dual capital structure is the cleanest specialty-VBC sponsor pairing I've seen. Most PE-backed specialty rollups are pretty good at the rollup math: multiple expansion, ASC arbitrage, central services, comp model rationalization. They are generally not good at risk contracting because nobody on the cap table has ever priced an MLR. Rubicon fixes that gap. If more specialty platforms had paired this way out of the gate, the Medicare 2030 VBC mandate wouldn't feel like a five-alarm fire for so many of them.

Cultural integration is key

When I asked Neil what's been hardest the past four and a half years, his answer was integration, specifically cultural integration. Not the tech stack, not the multiple expansion model, not the ASC build-out. Cultural integration, where you take multiple practices that have all been highly successful in their own communities and find common ways of operating without flattening what made each of them work locally.

The truth that’s almost never shared: Integration is a 5-year grind across competing physician compensation models, different staffing ratios, different referral patterns, different EMRs (we'll get to that), and different cultures around access and after-hours coverage. Get it wrong and you have a holding company, not a platform.

USHV's recipe, per Emily: one central tech stack (eClinicalWorks, with AI tools layered around it including the Suno ambient scribe), a daily management system where every practice huddles on key metrics, an operating cadence that allows for cross-region best-practice sharing, and centralized support functions like the 24/7 "call us first" line and the Integrated Care Clinic.

I asked her how you evaluate cultural fit when bringing in a new partner practice. Her answer: USHV puts existing physician partners directly in front of prospects so they can decide whether they want to practice alongside this group of doctors, plus a value creation plan they walk through transparently. Translation: you don't get acquired by USHV without first doing the cultural diligence in both directions. That feels right, and refreshingly different from some of the financial-only diligence I've watched go sideways elsewhere in PE-backed physician services.

AIR: Autonomy, Independence, Representative governance

Neil cited an acronym from his colleague Rick Schneider: AIR. Autonomy. Independence. Representative governance. He argued the third leg is the one independent physicians care about most and the one most rollup pitches gloss over.

Here's how it works at USHV. Every market has its own clinical governance board with multiple voting members. Local decisions (office locations, staffing, day-to-day operations) get made locally. There's a national clinical governance board (led by Dr. Robert Yoe out of Birmingham) handling platform-wide questions like EMR selection, MIPS adherence, and clinical tech standards. Three physicians sit on the USHV board of directors. There's a chief physician executive. A physician-led committee runs VBC strategy.

I asked Emily how USHV keeps the local boards from getting steamrolled by corporate when a tough call comes up. Her answer was layered: yes, certain rights are written into the governance documents, but the more honest answer is that running over local physician authority would freeze the business. You don't get integration through fiat. You get it by partnering with people who already share the vision, then collaborating in good faith. (Tip O'Neill: “All politics is local.”)

I think this is the part of the USHV pitch that resonates most with cardiology groups still on the fence about a PE partner. The AIR framing is honestly a better starter than half the slide decks circulating in physician M&A right now. Free strategic gift to anyone competing for cardiology rollup deals: steal it.

36 weeks is the moat

Here's the stat that should make every cardiology incumbent uncomfortable: national average wait to see a cardiologist is 36 weeks. Nine months. For a CHF patient or someone with concerning chest pain, that's not access; that's a referral into the void.

USHV's response is the Integrated Care Clinic, or ICC. Launched in Plano in 2024, now with 400+ enrolled patients (mostly heart failure, expanding into AFib), and a version in Houston and Tucson. The ICC operates as an immediate-access clinic where patients can walk in for IV diuretics, oral diuretic titration, or whatever ambulatory intervention keeps them out of the hospital.

Neil told the story of a young military patient who drove two hours from a satellite area to see him at the Tucson clinic. Patient called Wednesday. Saw Neil Thursday. Stress test in office that day was profoundly positive. Cath the next morning revealed left main coronary artery disease. Bypass on Monday. From phone call to bypass: five days. The kicker was Neil's framing: he was less proud of his own clinical decision-making and more proud of his front-desk staff for empowering the squeeze-in. Culture shows up in the call center.

This is a story that's only possible if your tech stack, governance, and culture all line up. None of it works in a holding-company model. In cardiology, the 36-week wait is the entire moat. If USHV can compress it consistently across markets, the rest of the rollup math takes care of itself.

Why cardiology may be the cleanest VBC specialty

Emily's argument: cardiology has structural alignment between fee-for-service economics and VBC economics that most other specialties, and especially hospitals, don't have.

Three levers drive value in cardiology VBC: side of service shift to ASCs, hospitalization avoidance, and proactive multi-comorbidity management. Each of those three things ALSO drives value in fee-for-service cardiology. ASCs are higher-margin per case. Avoiding hospitalizations protects long-term patient relationships and downstream procedure volume. Proactive management drives appropriate utilization. There is no structural tension in the model.

Now compare that to a hospital system. Hospitals carry billions in fixed assets (beds, ORs, cath labs, ED capacity) that have to run hot to stay solvent. Telling a hospital system to keep CHF patients out of the inpatient ward is asking them to walk away from one of their highest-margin DRG buckets. Economics fight the mission. In an independent cardiology rollup, they don't.

USHV is taking what Emily called a "ramp to risk" approach with Humana and United on the payor side. Upside-only or shared savings to start, escalate as performance proves out. Specialty VBC has been a graveyard for groups that jumped to global cap before they had the operations to support it. If you don't have the immediate-access infrastructure, the 24/7 call line, and the side-of-service options stood up, downside risk will eat you alive in year one.

I'd also flag the LEAD model and CARA specialist contracting as the next frontier. Emily said USHV is interested in CARA specifically as a specialist contracting mechanism, a structurally cleaner way to participate alongside value-based primary care groups than what existed under REACH. Worth watching how that conversation evolves.

Pitching a Level 6 category to RFK Jr.

Prior to our conversation, Neil sat at a roundtable in Tucson with Secretary Kennedy and a group of local health system CEOs. He was the only independent physician executive in the room. (Tells you something on its own about how rare large independent specialty platforms with this kind of representation still are.)

His pitch to the Secretary: create a "Level 6" reimbursement category for ambulatory immediate-access visits, specifically the in-office IV diuretic, IV metoprolol, IV Lasix encounter that an ICC can deliver to a CHF patient who calls in decompensating. Today, that visit either doesn't get reimbursed adequately or the patient gets routed to the ED, generates a five-figure facility bill, and clogs an already-flooded ER.

This is exactly the kind of fee-for-service hack CMMI should be moving on. Yes, full-risk VBC eventually solves this. Risk-bearing groups will figure out the economics of in-office IV diuretics on their own. But the country isn't going to be in full risk by Tuesday. A reimbursement bridge that pays appropriately for the ambulatory equivalent of an ED visit would compress utilization before VBC fully matures. CMMI loves a good model. Go take it.

I'll also note Neil made the price transparency pitch directly to the Secretary, and this administration has been louder on price transparency than its predecessors. We'll see if anything moves on either front. Healthcare policy is famously a place where good ideas die.

Looking ahead 5 years

I asked both of them what cardiology looks like in five years. Neil's answer: bifurcation. Outpatient-centric groups handling immediate access and ASC procedures, hospital-based groups handling acute care. Young fellows in training will increasingly have to pick a path (outpatient or inpatient) earlier in their careers. That migration is already happening and will continue.

Emily layered in the policy backdrop. CMS has signaled all Medicare patients should be in a VBC arrangement by 2030. If cardiology doesn't have an answer for that, the answer will get written for the specialty by people who don't practice it. USHV is positioning to make sure the answer comes from operators.

Here's my take: Bifurcation is real and inevitable. What's less certain is whether the independent platform model wins or whether health systems claw back share through employed cardiology and integrated network plays. My current bet is on the platform model in markets where capital is patient and governance is real — which is, frankly, a smaller set of platforms than the press releases would suggest. USHV passes that bar based on this conversation. Time will tell whether the next vintage of cardiology PE deals does.

Philips Future Health Index 2026

The Philips' Future Health Index 2026 surveyed 2,000+ clinicians and 20,000+ patients across 10 countries, and the data backs up what we've been saying: AI is delivering real dividends. Clinicians report saving 132+ hours a year, seeing a median of 5 more patients per week, and catching potential medical errors with AI. In addition, nearly 1 in 3 healthcare leaders are already seeing budget savings. But the survey also found healthcare's infrastructure hasn't caught up, with 77% of clinicians saying AI training is inconsistent or nonexistent, and 72% turning to their own personal AI tools when their organization's options fall short. Worth the click if you're trying to figure out where your own organization sits on that adoption-vs-readiness curve.

Source: Philips Future Health Index 2026

National Survey of Employer-Sponsored Health Plans

According to the latest National Survey of Employer-Sponsored Health Plans from Marsh (formerly Mercer), health benefit costs per employee are expected to jump 8.2% on average in 2027. This is the highest increase since 2003, “even after accounting for planned cost-reduction measures. Employers said that the cost of their current plans would increase by 11%, on average, if they took no action to lower it.

ON YOUR RADAR

Read: Which health systems have strong finances? Becker’s Hospital Review shares a list of 71 systems compiled from credit rating reports.
Resource: What keeps hospital CMIOs up at night? Roughly 50% of specialty referrals never turn into a completed visit. In this article, Regard’s CMO shares how to solve this at scale.*
Breakdown: Vizient/Kaufman Hall has released the National Hospital Flash Report: July 2026 Data.

*This read is brought to you by one of my brand partners who help make this newsletter possible!

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— Blake

@Blake Madden

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🏥 Is cardiology the cleanest VBC specialty?