This post is authored by Gary Puckrein, PhD, president and chief executive officer of the National Minority Quality Forum.

Physicians and the medical community have reached a fork in the road: we need to document that quality and reduced costs are related. By doing so, we hope to offer policymakers a new framework in which to measure the value of medicine. The conjectures:

• An avoidable mortality index can be an indicator of unnecessary acute events (disease, hospitalizations, disability and death) in a population. Such an index may have utility in localizing the performance of our health care system, thus enabling the investigation of gaps in outcomes of care. 
• There are signals that avoidable acute events are non-random occurrences. There is a possibility that they manifest at predictable frequencies within clinical and geographic sub-populations, and are sentinels of health care and health status disparities.
• Unnecessary acute events have financial implications. At least one study found that 36% of diabetes-related hospitalizations were avoidable. If that percentage holds true for Medicare beneficiaries, the savings could well be over $10 billion per year.
• By reducing unnecessary acute events, we may be able to establish an association between improved quality and bending the cost curve, thereby offering a counterpoint to those who believe reducing provider reimbursements is a desirable cost savings device.
  

The American College of Cardiology, the National Minority Quality Forum (NMQF), and the American Association of Clinical Endocrinologists have joined forces to put our conjectures to the test and have formed the CardioMetabolic Health Alliance. The objective of the Alliance is to improve cardiometabolic risk factor control in diverse populations, including high blood pressure, elevated fasting blood sugar, dyslipidemia, abdominal obesity (waist circumference) and elevated triglycerides; and to provide more effective and coordinated care for people with established cardiometabolic disorders.

In pursuit of its mission, the Alliance will study the possibility that predictable patterns of unnecessary acute cardiac events occur in communities, and that these patterns are measurable and amenable within the context of current treatment modalities. By using the ACC’s PINNACLE Registry and CathPCI Registry, as well as NMQF’s Cardiovascular Disease Index and U.S. Diabetes Index, the Alliance will explore the possible correlation between cardiometabolic disease and unnecessary emergency room visits and hospitalizations; and how these findings can be used to design predictive models and quality improvement interventions targeted for providers and patients at high risk for an acute cardiovascular episode.

Members of the CardioMetabolic Health Alliance and ACC will be meeting at the 2012 Cardiometabolic Health Congress this week in Boston, Ma. Visit the Alliance’s website for more information www.cardiometabolicha.org. Also read more about CardioMetabolic Syndrome in an article in the July/August issue of Cardiology magazine.

New survey data released by the ACC provides an important first-look at cardiology from the viewpoint of hospital administrators, reflecting responses of 300 hospital executives and cardiovascular professionals representing 291 hospitals and medical facilities. 40 percent of these CEO-administrators say their facility had either acquired or had considered acquiring a cardiology practice in the last two years.  Roughly 20 percent indicated they are considering an acquisition in the near future.

Recruitment of cardiologists and other cardiovascular professionals is the top priority in terms of the biggest challenges facing hospital administrators in successfully running a cardiovascular service. The FACC designation was viewed as an important factor when it comes to hiring. According to the survey, 72 percent of administrators said they were somewhat more likely or much more likely to hire a cardiologist with an FACC designation, with more than three-quarters (77 percent) of the administrators indicated that it was extremely or very important for cardiologists to have earned the FACC in general.

The FACC distinction symbolizes a dedication and commitment to the highest quality of cardiovascular care. Fellows are elected to the college based on their credentials, achievements, and contribution to cardiovascular medicine as recommended by faculty and members, and it’s good to see that this distinction is recognized as important in the hospital environment.

On the quality front, the survey found that almost all hospitals participate in cardiovascular quality initiatives, with 83 percent participating in ACC sponsored quality activities like the ICD and CathPCI Registries, and the Door to Balloon (D2B) Alliance.

Bottom line, the data from this survey are extremely important as we move forward with meeting the needs of cardiovascular professionals and administrators in the constantly evolving health care environment. It’s good to know that the College is moving in the right direction with its quality efforts.

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 proposed 2012 Medicare Physician Payment Rule (formally called the Physician Fee Schedule) was issued just before the 4th of July weekend at 4:15 p.m. Friday. Why? So nobody will have time to read it and comment and complain until this week. The 2010 payment rule was devastatingly bad. The 2011 rule was nowhere near as bad as that, and this one for 2012 is not full of apparent surprises. The 2012 rule has the third year of residual cuts that originated in 2010, but the impact next year averages out about negative 1%. The big impact would be the SGR cut of 29.5% if it were not waived -- which it will be for a year at least I presume.

Here are some of the highlights from our initial review (more coming later this week):

• Imaging Payment Reductions: CMS proposes to reduce the payment by 50 percent for the professional component of certain imaging services provided at the same session on the same day by the same physician.
  
  
• Electronic Prescribing Penalty: By law, CMS is required to reduce Medicare payments to those practitioners who do not electronically prescribe and for whom at least 10 percent of their Medicare payments are associated with certain types of office visits. As part of the 2012 proposed rule, CMS is considering providing practitioners with an additional opportunity to avoid the penalty.
  
  
• Potentially Misvalued Services: CMS identifies three cardiology codes for review as potentially misvalued. Data for cardiovascular stress test (93015), extracranial study (93880), and complete electrocardiogram (93000), will be reviewed by the RUC for presentation to CMS before July 2012.
  
  
• Physician Compare and Value-Based Purchasing: CMS proposes another step towards the required implementation of value-based purchasing in 2015. In the proposed rule, CMS includes a series of claims-based measures that will be used to report on physician quality using the new Physician Compare website. In addition, CMS proposes a series of quality measures that will be used to adjust payment based on quality starting in 2015.
  
  
• Physician Quality Reporting System (PQRS) and Maintenance of Certification (MOC): CMS proposes some changes to PQRS but largely keeps intact the registry reporting that is commonly used by cardiologists. Physicians that successfully participate in PQRS in 2012 will receive a 0.5 percent bonus of Medicare payments.
  
  
• Coding: CMS, as expected, continues to move forward with bundling payments for certain services. Specific changes will not be available until November.

Read the full initial review on CardioSource.

Quality of life and length of life are heavily dependent on health care (as well as on genetics and economics). As health care is gradually extended to the poor of the world, and particularly in Asia, they are discovering ways to provide modern care at very low costs, and not just because wages and salaries are less.  Actually in the US, we should recognize that rising employer and family health care premiums are depressing wages and/or disposable income here! In fact, in 2016 the percent of household income spend on health care -- on average across all American families -- will be 45%!

So, anyway, Asian medical innovation will be affecting your practice and/or your doctor sooner than you realize. China and India are revealing how medical costs can be slashed in the US and EU. How? In various ways, including call centers, remote imaging interpretation and medical tourism. Foreign training of medical professionals willing to immigrate here and work for lower salaries (for a while anyway) is also a factor. But, frugal innovators in India and China are also making cheaper medical devices that work effectively. Companies like China’s Mindray and India’s TRS stripped down imaging scanners that cost one-tenth of similar equipment here. ECG machines in Asia cost $500 or less, instead of $5000, for example. A night in a US hospital room costs 25 times as much as a similarly equipped modern hospital room in India or China. GE, Phillips, Medtronic, and other US companies are investing heavily in these countries, and positioning to participate in these markets effectively, and manufacturing cheaper products. Could this reflect Toyota/Honda versus GM and Ford comparisons in the US during the 1980s?

The Economist says two factors keep good but cheaper devices and infrastructures out of the US. First is that we as patients here don’t care about costs much when employers or government is paying the bill -- patients have to contribute out of pocket more for their care in Asia (so will we soon). Second, they say the FDA’s propensity to be risk averse currently prevents introduction of such products, which can’t afford to go through their expensive and lengthy processes.

The New York Times this weekend featured a detailed article on the ongoing investigation into alleged inappropriate use of percutaneous coronary intervention (PCI) and substantial overutilization of stents at St. Joseph Medical Center, in Towson, MD. 

The issue of quality and appropriateness of medical care is not limited to use of stents in the state of Maryland (In fact, the Times article mentions similar cases in Texas and Louisiana), nor is it confined to the field of cardiology. That being said, this current issue provides an opportunity to illustrate how professionals societies, like the ACC, can take a leadership role in ensuring quality care through use of peer-review, accreditation and data management. 

We happen to have over two-thirds of the US angioplasty/stent clinical data in the United States. Applying the currently recognized best evidence for appropriate use to these procedures, our data shows that nearly 70 percent of stents are placed appropriately as life-saving care for persons having heart attacks. Of the 30 percent placed in patients electively, as in the NYT story, we believe about 12 percent may be inappropriate. That's 4 percent of overall stent use, which while not a crisis of mass overuse, is nonetheless unacceptable. The point is: we now have means to give doctors and hospitals continuous data feedback on how their performance compares with best evidence and with their peers. Why don't we use it!

Quality in the outpatient setting seems to be a topic that is getting more and more attention in the specialty arena. Some of my primary care colleagues have been looking at their quality of outpatient care for several years now.

If the recent New York Times article is any indication, it seems to me that the insurers will steer patients to physicians and practices that can demonstrate their quality.  The article discusses the increasing demand for health plans that limit patient options for providers to save on costs. The article states:

One way insurers say they hope to prevent ... consumer backlash is by emphasizing that they are not choosing doctors on price alone. The insurers say they look to see how quickly a doctor’s patients recover from surgery, for example. But how much the insurers emphasize quality remains to be seen.

The problem (or, more accurately, ONE OF the problems) with this is that frequently physicians get assigned “quality” by measures that are not created by doctors, or maybe were created by doctors but use claims data rather than clinical data.

If we’re going to get measured, then we need to be the ones creating the measurement system. That’s why the ACC put together something called the Cardiovascular Practice Recognition Program (CVRP), which is practice-level assessment and recognition program designed specifically to identify quality in cardiovascular practice. The CVRP will establish legitimate goals and targets for cardiovascular specialists and their practices. I think this is a program that holds great promise for quantifying quality in the outpatient arena, and we’re working to refine the program even further. You can learn more about the pilot program on CardioSource.

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.

The Mayo Clinic under the leadership of CEO Dennis Cortese, M.D., has released a payment reform proposal to Congress based on value-based indexing, meaning payment would be based much less on volume of services, and much more on quality and efficiency (Q/C = value).

It’s an interesting payment reform concept (strongly supported by Harvard Business School and various physician-friendly economists) that would require the creation of a value index within the formula used to determine Medicare physician fees.

(For those interested in the related specific policy details, their proposal eliminates the current geographic indexing of the physician work component of the fee schedule, and applies instead a value index to the work component.  It does not change the indexing of practice expense or malpractice expense. While the current fee schedule formula applies the geographic index to 25% of the work component, and there is currently a temporary floor at 1.0, the Mayo proposal applies the value index to the entire work component and there is no floor or ceiling).

While not everybody will like (much less fully understand) this, it could possibly be a way out of the mess we’re in. Of course the devil’s in the details, but in looking through the Mayo proposal, many of the methods proposed involve (real or virtual) integrated systems. The College is exploring “virtual integration” concepts that we would suggest to CMS as “pilots in payment reform.”

But, there is also a “patriotic cause” here in promoting "value" as a pathway to reduce the risk of a bankrupted or much diminished system of rationing in the near future. In addition, I suggest we also consider a potential patient and physician opportunity here, were we able to design and recommend a 'value' approach that both allows a systematic means of improving quality, and also providing a real upside for physician practices.

Present, Past and Future
It ain't easy, but that's because we have for decades been immersed in a frustrating, dizzyingly complicated, and volume-based reimbursement concept that we seem to be clinging to, hoping that we can tweak it to viability. I don’t believe we can. The current payment model needs to be replaced in carefully planned phases. I predict that in the future cardiologists and most physicians will compete on and be paid by market-based salaries (with quality and patient satisfaction incentives). Practice organizations will administratively interact with the payment formulas and models of tomorrow, which will also be freeing doctors to spend more time with their patients, while reducing administration costs enormously. However, administrative “liberation” should not mean that physicians should ignore the responsibility for leadership of their practices in the future. Quite the contrary -- if we had not in the past abrogated such leadership, we wouldn’t be saddled with the dysfunctionality of the current payment system!

I applaud Mayo for suggesting a potential pathway to a better future for doctors, patients, and society. But most of medicine is hardly positioned to participate as easily as Mayo and other integrated systems might. We need to work with ‘non-integrated’ practices to get them ready for the coming changes, not just to survive, but rather to thrive. Nothing is more important for us in my opinion. I think we’re up to the challenge; but we’ll need to work together to educate, experiment, and make such a transition possible for most members.

*** Image from Flickr (alasam) ***