By: Judy Tingley, MPH, RN, member of the ACC’s Clinical Quality Committee.

The Centers for Medicare and Medicaid Services (CMS) readmission payment penalties went into effect on Oct. 1.  Mandated by the Patient Protection and Affordable Care Act, this quality improvement initiative imposes financial penalties on more than 2,200 hospitals with Medicare readmission rates above the national averages.  The unintended consequence of these penalties is yet to be determined.

This new crackdown will have the greatest impact on the “safety net” hospitals that treat our poorest patients.  Current studies demonstrate that much of the variance in readmissions is due to factors beyond the hospital's control.  Many of these community hospitals have limited resources, antiquated medical records systems, serve late presenting and/or underinsured clients, and are at greatest risk for financially failing.  This reality reaffirms that quality metrics identification and measuring outcomes has never been more important.  As we move toward data driven reimbursement models, it is critical that the implementation of “patient centric quality metrics” does not get lost in the quagmire of financial and regulatory demands.  Quality needs to remain the focus of “quality metrics.” 

Of late, safety measure techniques used by the airline industry have been meaningfully translated to health care delivery systems.  Pre-operative checklists (modeled after pre-flight checklists) have significantly improved patient safety.  Just as regular and consistent communication between the crew and air traffic control helps thwart potential problems and keep the skies friendly, so should regulators, payers, hospitals, patients and practitioners communicate to keep patient safety at the forefront.  If not, we should brace for the impact of the unintended consequences of making worse a system that is very much in need of patient centric reform.  

Our population is changing and if you’ve seen one patient, you’ve seen one patient.  There will never be a one-size-fits-all model to eliminate readmission.  Therefore, the impact of demographic characteristics, co-morbidities, socioeconomic parameters, post-discharge environmental factors and regional health care delivery disparities all must be considered in strategically planning meaningful cost efficient care.  As our patient population ages the economic impact of this reality is yet to be seen:

• Half of older women 75+ live alone
• Persons reaching age 65 have an average life expectancy of 18.1 additional years
• The 85+ population is projected to increase to 9.6 million in 2030
  

Improved efficiency and reduction in avoidable readmissions is imperative.  Methods to better identify patients at risk for readmission, reduction of hospital complications, improvement in transitional care and overall communication between providers and patients are important ways of improving quality care.

There remains much work to be done in order to transform today’s health care into the efficient quality centric delivery system needed for the future.  The ACC has taken the lead in providing tools to help practitioners review and provide a transition of care plan.  Specifically, Hospital to Home (H2H) is a national quality improvement initiative developed to help hospitals reduce all-cause readmissions among patients with heart failure or acute myocardial infarction.  As health care providers, we must continue striving toward a coordinated multi-disciplinary strategy to effectively address improving quality of care in a fiscally responsible way.  If we fail, brace for impact!

A new post on the New York Times Blog provides an interesting glimpse at the challenges we face as health care providers when it comes to involving patients in their own care decisions – a key tenet of patient-centered care.

“For over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment,” writes Pauline Chen, MD, for the Times. “Numerous research papers, conferences and advocacy organizations have been devoted to this topic of “shared decision-making,” and even politicians have clambered aboard the train … But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient’s perspective.”

Chen cites a new article published in the latest issue of Health Affairs that explores the patient perspective. The article, which highlights the results of six focus-group sessions with 48 people in the San Francisco area, indicates that while the majority of people have a strong desire to engage in shared decision making, there are several obstacles that inhibit the ability to move from concept to reality. Key among these obstacles is the perception of physicians as authoritarian and fears of being categorized as a “difficult” patient. “This fear of retribution seemed related to both potential immediate and delayed effects,” the article notes. “A challenge to authority might modify treatment decisions as well as negatively influence the nature of the physician-patient relationship.”

Other findings from the focus groups, include the large amount of time spent by patients in conducting their own research regarding their disease state and/or treatment options, as well as the desire by patients to bring family, friends or other care providers with them to help compensate for any “social challenges” and time pressures “inherent in clinical consultations.”

Interestingly, these findings underscore the need for implementation of many of the elements identified as essential in the College’s recent health policy statement on patient-centered care. For example, focused education and training around patient–clinician communication incorporated as part of medical school and continuing education curricula could help providers learn how to best avoid the authoritarian perception. The health policy statement also calls for the development of easy-to-use decision aids that provide information about diseases, as well as risks and benefits of treatment or screening options. These have been shown to improve knowledge, reduce decisional conflict due to feeling uninformed or unclear about personal values, increase active participation in decision-making, and reduce indecision.

There is no denying that shared decision making poses challenges on both the physician and patient fronts. Chen is absolutely correct when she notes that “care organizations and doctors’ practices must be restructured to allow more in-depth conversations; clinicians need to be reimbursed for the time required for more meaningful conversations; and health care systems must adopt rigorous quality standards that measure and value real patient engagement in decisions.” However, there is also no denying the benefits to patients and to the health care system as a whole if we are successful. Cardiovascular disease is particularly well-suited as a testing ground for the concept, given the number of treatment options that exist for which small or no differences in outcomes exist. This allows for patients’ values and perspectives to play larger roles in the decision making process.

At the end of the day, the College is fully committed to patient-centered care. Our task is to learn from studies like the one in Health Affairs and continue to chart a course that ensures the needs of each patient and his/her family are met in the most appropriate, high quality and cost-effective fashion possible.  After all, a patient shouldn’t be afraid to speak up at the doctor’s office!

This post was authored by William J Oetgen, MD, MBA, FACC, ACC's senior vice president of Science and Quality and Jim Fasules, MD, FACC, ACC’s senior vice president of Advocacy.

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Today the ACC released a list of “Five Things Physicians and Patients Should Question” in cardiology as part of the Choosing Wisely® campaign, led by the ABIM Foundation with eight other medical specialty societies. The list identifies five targeted, evidence-based recommendations that can support physicians and patients in making wise choices about their care.

The ACC list details the following five recommendations:
• Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
• Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
• Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
• Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.
• Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).

The ACC’s list was developed over the last several months, with the College asking its standing clinical councils to recommend between three and five procedures that should not be performed
or should be performed more rarely and only in specific circumstances. ACC staff took the councils’ recommendations and compared them to the ACC’s existing appropriate use criteria (AUC) and guidelines, choosing items for the five things list that had the most consistent inappropriate score in the AUCs and were Class III recommendations in the guidelines. The ACC’s Advocacy Steering Committee and Clinical Quality Committee each then reviewed the five items before sending it to the ACC Executive Committee for final review and approval.

The ACC joined Choosing Wisely because we recognize that physicians have a professional, moral and ethical responsibility to take the lead in addressing these challenges. Through the campaign and the publication of this list, the College is kick starting a conversation between its members and patients about the need – or lack thereof – for many frequently requested and/or ordered tests or treatments.

The facts driving the Choosing Wisely effort are well known: The current way we deliver health care in America contains too much waste in the form of inappropriate tests or procedures that do not benefit patients, and may cause harm. Some experts say that as much as 30 percent health care delivered in the United States may not improve people’s health. Providers and economists agree that this is unsustainable and threatens America’s ability to provide the highest quality of care possible to all patients.

While the ACC has taken a bold step in identifying and developing the list, the work doesn’t stop here. Over the coming months and years, we will be working with the ABIM Foundation, Consumer Reports and a variety of Choosing Wisely campaign stakeholders, including the American Society of Nuclear Cardiology and the American Society of Echocardiography, to raise awareness of these lists and make them accessible to patients and the public.

Learn more about Choosing Wisely and read all nine lists released at www.ChoosingWisely.org.

Today the Bipartisan Policy Center’s Task Force on Delivery System Reform and Health Information Technology (IT) released an important report, Transforming Health Care: The Role of Health IT, which outlines recommendations for the most effective use of health IT to achieve the triple aim through new models of care delivery and payment reform. I am a member of the task force – we’ve been working on this plan for over a year.

Following the authorization of up to $30 billion to support health IT under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the report was created to identify real-world examples and best practices that facilitate coordinated, accountable and patient-centered care; and to make recommendations for ensuring that current health IT efforts support delivery system and payment models shown to improve quality and reduce costs in health care, in ways that best utilize scarce public and private resources.

I joined the Bipartisan Policy Center’s co-chairs, former Senators Tom Daschle (D-S.D.) and Bill Frist, MD (R-Tenn.), and former Governors Ted Strickland and John Engler, at a policy briefing featuring prominent leaders in the field to release the report and discuss how to make it happen.

The report identifies key gaps and barriers to achieving widespread adoption of health IT, including: misaligned incentives; a lack of health information exchange; limited level of consumer engagement using electronic tools; limited levels of Electronic Health Record (EHR) adoption; privacy and security concerns; and multiple federal priorities that all require focus and attention.

The task force also identified several goals and recommendations to overcome these barriers including: aligning incentives and payment with higher quality, more cost-effective health care, accelerating health information exchange efforts, accelerating and supporting engagement of consumers using electronic tools, expanding education and implementation assistance, addressing concerns about privacy and security, and further aligning federal health care and health IT programs. Incidentally, the task force has had a kind of brilliant idea on how to get beyond the unique patient identifier controversy – which is politically stalled. We suggest developing “patient tracking” systems to manage patients securely over the continuum.

After the press event was over I had lunch with Daschle, Frist, Strickland, and Engler to talk further about implementation ideas and how the ACC can help move this. The good news is most of the field of cardiology and the ACC with its quality tools and programs are already working to implement most of these recommendations, but as the health care landscape changes and the cost of health care increases, it is important now more than ever to adopt new models of care delivery.

For more information, visit www.CardioSource.org/HealthIT.

A recent article in Health Affairs examined the supply and distribution of the cardiology workforce across the country given “a sufficient cardiology workforce is necessary to ensure access to cardiovascular care. Specifically, access to cardiologists is important in the management and treatment of chronic cardiovascular disease.”  The paper was co-authored by Harlan Krumholz, MD, FACC, a member of the ACC Board of Trustees and professor of medicine and epidemiology and public health at Yale University School of Medicine.

The results showed that there has been a modest increase in the cardiology workforce over the past 12 years, whereas the primary care physician and entire physician workforce shortages are more pronounced. But there’s also a big disparity in the geographic distribution of cardiologists across the country, specifically in rural and socioeconomically disadvantaged areas.

As the U.S. “baby boomer” population becomes older, it is clear we will need to rely on team-based practice models to deal with the cardiovascular demands on the U.S. health care system that are certain to increase. A team-based model will enable delivery system and quality of care improvements as it offers solutions to the workforce shortage, and will expanded physician productivity, and improve job satisfaction by reducing workloads and preventing burnout.

According to the CDC, since 1950, age-adjusted death rates from cardiovascular disease have declined 60 percent, representing one of the most important public health achievements of the 20th century. Despite this huge reduction in morbidity and mortality, just imagine what we can accomplish when we work together in a team-based setting using NCDR^® and PINNACLE Registry^® data to systematically improve patient outcomes, and simultaneously improve efficiency and value.

We still have a long way to go in fighting the leading cause of death in the U.S., so let’s get to it!

The ACC has joined the ABIM Foundation’s Choosing Wisely^TM campaign along with eight other leading medical specialty societies and Consumer Reports to help physicians, patients and other health care stakeholders think and talk about overuse or misuse of health care resources in the U.S.

According to the Organization for Economic Co-operation and Development, decade after decade the U.S. spends more money per capita on health care than any other developed country with little progress in quality or value to show for it. The Congressional Budget Office estimates that up to 30 percent of care delivered in the U.S. goes toward unnecessary tests, procedures, medical appointments, hospital stays and other services that may not improve health. Coupled with the fact that the Centers for Medicare & Medicaid Services estimates U.S. health care spending will reach $4.3 trillion by 2019, it is clear that our current health care system is unsustainable and in need of an intervention.

As part of our longstanding effort to play an active role in addressing the quality of care, the College is joining the campaign to encourage open communication about the risks, costs and benefits of tests and treatments so that our patients can be informed partners when making important decisions about their care. We believe that partnerships between patients and health care providers are crucial to achieving better outcomes and lowering health care costs. From our CardioSmart^TM National Care Initiative, aimed at helping patients better understand and/or prevent heart disease, to our state-of-art educational programing and decision-support tools that place evidence-based guidelines at a clinician’s fingertips, we have been and will continue to be committed to ensuring the most appropriate, cost-effective care.

Over the course of the multi-year campaign, we will be working with the ABIM Foundation to identify and reduce waste in the health care system. With the medications, devices and imaging technology available to cardiologists today, we can save and improve the lives of patients who would not have had a chance just 15 years ago, but we also have a responsibility to use these powerful tools effectively and make sure we are choosing wisely.

To learn more about the Choosing Wisely campaign visit, www.ChoosingWisely.org.

KevinMD had a great guest post recently by Mary Pat Whaley on the time associated with a patient visit. I think the title sums up the blog well: “Your 10-Minute Office Visit Needs 8 People and 45 Minutes of Work.”

As Whaley notes, even the shortest of office visits have a lot of work behind-the-scenes that needs to be done; seeing the patient is just a small part of the overall visit.  And, I would submit that far more than 8 people and much more than 45 minutes is required.   Health care is a regulation- and administration-heavy field, and this requires time to make sure the regulatory and administrative rules are followed. For example, HIPAA requires privacy forms to be filled out prior to the patient being seen. Verifying someone’s insurance information is time-intensive. Not to mention ensuring that we charge the patient the right co-pay based on their insurer and insurance plan. On top of that, pay-for-performance programs require time- and technology-intensive data collection during and after the visit. All of this, and more, makes up one “10-minute office visit.”

Whaley concludes: “The practice, the patients and the overseers of health care want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable.  It’s what we all want.  And it ain’t cheap.”

I have to agree with her. The complexity of the American health care system is incredible. And, the layers of complexity account for much of the cost. Our system has been built by accretion.  We “reform” the system by adding on layers of regulation, of bureaucracy, of administration.  As you look behind the eight people figured in this visit, the cost if not the time includes coders, compliance workers, claims specialists, re-claim specialists, computer network and now electronic health record experts,  lawyers, front office personnel, and even standard maintenance personnel for the  building.

As the regulation and administrative burdens add on, the cost of practicing gets greater and it is harder to cover these expenses with income.  Add to that more and more cuts to cardiology, and it’s no wonder that a large number of private cardiology practices are integrating with hospitals. Last year, the ACC reported the results of a survey of ACC members that found nearly 40 percent of private group practices were currently integrating with hospitals or merging with other practices. An additional 13 percent of all cardiovascular practices were considering hospital integration or a merger in the next three years to help stem the financial burden.

These are uncertain times for cardiology and for the House of Medicine in general.  To be clear, the ACC supports the triple aim of better health, better health care, and at less cost. But to get there, we will have to deal with the repercussions of massive changes, and may I say probably the accretion of more layers, to our health care system. In my opinion, “dealing” with the repercussions will not be enough – we need to shape the discussions if we want to be pleased with the health care system structure of the future.  And, maybe we can even help peal away some of the layers.

Shift happens. That’s what a lot of worried hospitals, physicians, insurers (and probably patients) are thinking as they contemplate the uncertainties of health care reform. It’s like we’re all going to reform school together. Recently I pointed out that clinging to the status quo was going to take the nation down a black hole of rising national debt, unaffordable premiums for individuals and small businesses, and an unsustainable world of hurt.

As physicians, we’re already feeling that in all the price controls being slapped on the practice of medicine by all public and private payers happened before reform passed. The SGRrrr debate about whether or not to cut physicians another 21 percent in Medicare is a poignant and decade-long example of that.

With its warts and all, the PPACA (Patient Protection and Affordable Care Act) forces us into an environment of forced change. I hear a lot of grousing about it, but it’s here and it’s not going away. There are quite a few things we don’t like in the bill; and quite a few needed elements not included, but things have to change to expand access, to increase overall quality, and to align increasing costs to more closely track GDP.

Even if we don’t yet know precisely how that needed change should manifest to best accomplish those things, we still need to get at it. Importantly, as reform progresses we also need to make sure that we protect health research, science and innovation, which are significant contributors to the health of the American economy we can’t afford to undermine.

It’s all very tricky, and as I've stated before, there will be winners and losers. My question to each of you is: Do you know which you want to be? (Duh)

Hospitals are scrambling faster than doctors at present to build networks and prepare for integration. Not suffering apparently from ‘mural dyslexia,’ hospitals see the ‘handwriting on the wall’ as a need to change their game to prevent their bottom line from being slashed. PricewaterhouseCoopers broadly advised hospitals this week to prepare to promote continuous quality improvement strategies or risk severe upcoming penalties. PWC said appropriate hospital admissions, hospital-acquired conditions and payments tied to value-based care will be three key areas of focus on to remain profitable for both public and private care. 

Our own ACC cardiologist colleagues are already engrossed in a migration to hospital employment or contractual integration. Cardiologists are smart folks, and I do not see this as a migration of lemmings. But it may be an intermediary step leading toward different future structures. In California, for example, big news last week was that more than 20 major hospitals of Southern California have formed a foundation (with physician officers on the board) to bypass California’s “Corporate Bar on the Practice of Medicine” in order to create the equivalent of employed doctor networks. The Corporate Bar in California prevents hospitals from hiring doctors directly, so the new foundation model will hire doctors who will then exclusively contract with the organizing hospitals to provide care across the Los Angeles and Orange County region.

Wall Street investors believe that some of these changes were bound to occur with or without the PPACA and health reform. Medical students are not graduating aspiring to enter private practices, and would clearly prefer to be employed in groups or networks that minimize on-call, handle the administrative hassles, produce the flow of patients they will treat, and offer more control of their lifestyles. Meanwhile, hospitals and insurance companies, according to Wall Street, need to consolidate to reduce administrative costs and improve efficiencies. Thus, physicians will also need to consolidate or network to effectively negotiate with consolidated hospitals and payers. Health reform is just going to speed these processes up. A lot of these kinds of changes already have occurred in other industries. All of us recognize that such dynamic changes always produce winners and losers. 

Believe me, I recognize how difficult all this is to swallow for people out there who are taking care of patients, participating in reducing morbidity and mortality by 30 percent over the last decade, and working very, very hard to produce high-quality care now. You have to be asking, why do we have to endure this crazy process of massive change at the same time? There’s no easy answer. Change is tough, and unfortunately health care in this country, to be sustainable, has to change.

Hopefully we can make the changes necessary to ferret out the waste and ineffective aspects of the system and still produce the desired ongoing progress in science, quality, patient-centered clinical improvement and practice vitality. The risks really are enormous. The College has to be there as a partner with all of you as we go through these significant times of transition. But the opportunities are enormous as well.

*** Image from Flickr (worldsislandinfo.com). ***

HHS and the Office of the National Coordinator for Health IT (David Blumenthal and his team) reported last week that in the latest year they could measure accurately -- 2007 -- 34.8% of private practices had an EHR. That’s a 91% increase in use since 2001. However, only 3.8% of practices had “fully functional” interoperable, clinical decision support capable, e-Rx capacities. But, they surveyed the practices then that said they were definitely going to move ahead and install an EHR. If most actually did, ONC estimates that over 50% of practices will have an EHR (not fully functional) this year. We’re getting there.

The ACC was lucky enough to have health IT experts speak at our Health IT Spotlight Session at ACC.10, including Blumenthal, US CTO Aneesh Chopra and Marc Overhage of the Indiana Health Exchange. Check out the two video below for interesting interviews on the future of health IT with Chopra and Overhage.

I spoke with the New York Times "Prescriptions" blog contributor Anne Underwood this week about physician payment reform. Here's an excerpt, but visit the NYT's blog for the full interview:

Q. What’s wrong with the way physicians’ pay is structured now?
A. We have built our system on a payment model that rewards volume. Doctors get rewarded for more tests, more volume, more hospital admissions, more visits. There are no incentives for quality of care or administrative efficiency. That’s part of why our system is more expensive than other nations.

The good news — and the reason why I’m excited about health care reform — is that the best health care in this country often tends to be very affordable. The whole discussion about bending the cost curve can be resolved by setting new incentives in payment that reward better outcomes with evidence-based medicine.

Q. The Cleveland Clinic and Mayo Clinic pay doctors a salary rather than fee-for-service. Is that what you mean?

A. At the Mayo Clinic, Cleveland Clinic, Kaiser Permanente and other integrated systems, doctors are salaried to improve quality. They’re unfettered from having to deal with the dizzyingly complicated current payment systems. And they can do it precisely because they have an integrated system.

But about 85 percent of the U.S. health care system is not integrated. Instead, it’s divided between small practices and community hospitals that aren’t linked together with incentives to coordinate care. In the hand-offs that occur between hospital care and outpatient treatment, patients sort of get lost in the shuffle. That’s one reason why 27 percent of patients with heart failure are back in the hospital one month later. They often don’t have the medications right or in hand, or they don’t understand what they need to do to help take care of themselves.

Even between the internist or family physician who generally manages a heart patient and the cardiologist who occasionally consults on the patient, you don’t have the coordination that should occur — unless you’re in one of those integrated systems, with electronic health records and incentives for coordination and quality.