Yesterday I presented to ACC’s Board of Governors about the health reform and its likely effects on payment models. There is a wide array of pressures affecting the health care system right now. For one, we’re hearing more and more talk about cost containment and remaining competitive in a global economy. Health care eats up 17% of the country’s gross domestic product and is growing at a faster rate than the GDP. Meanwhile, the rising cost of health care premiums (the ACC’s premiums for its employees are going up 18%) puts a strain on U.S. businesses to compete with other global businesses that do not have to pay for their employees’ health care, enabling them to cut costs.

To get costs down, a variety of changes have been proposed. This includes the integration and consolidation of physicians, hospitals and insurers to reduce overhead and duplicative services. There’s also purchasing power in large integrated systems. Some ways we might see this play out in the future is through the creation of more integrated systems (or accountable care organizations?). Integration can be horizontal (physicians aligning themselves with a hospital but not being employed by it) or vertical (where the physician is an employee of the hospital).

While either model could work out positively, the ACC and I would much prefer a future of horizontal integration of physician groups, independent practice associations, and other physician managed entities contractually aligned with insurers and hospitals. This protects physician autonomy, the patient-physician relationship and could even be ultimately a better strategy for hospitals and insurers than having them try to manage physicians as employees. The ACC continues to work hard to protect those physicians who choose to remain in solo or small group practice. These practices are more viable in some regions of the country than in others but, given that the vast majority of fellows seem to prefer employment at larger group venues, the movement toward integration is significantly driven by physician choice not health reform pressures externally.

There’s also the growing use of PATIENT incentives to keep down costs. Employers are increasing the burden of growing premiums by transferring costs to employees. Patients receive cheaper copays for visiting a primary care physician than visiting a specialist. Insurers are offering cheaper premium rates for staying within a “preferred” network of physicians.

Related to cost, there’s the problem of payment. See ACC SVP of Advocacy Jim Fasules’ write up earlier today about the SGR and its very expensive problems. Clearly, it’s not working. Because of this, we’re seeing a pressure to move away from fee-for-service reimbursement and toward models like the patient-centered medical homes and performance-based incentive programs. It remains to be seen what the best way of doing this is, but we know we need to find some way to pay for high-quality, patient-centered care.

The system is clearly struggling to implement delivery system reform. Never before have we seen such a pressure to implement electronic health records in a nationwide fashion. These systems enable better and easier care coordination, which can improve the patient experience by reducing duplicative testing and transferring of paper files. With widespread adoption of EHRs and care coordination, we could see a dramatic shift in how care is delivered. We’re also seeing a shift to focus on prevention, although much remains to be done on this front, in particular for cardiology.

The health reform law, or the discussions around it, is in large part responsible for bringing some of these changes to fruition. Whether or not you agree with the changes it’s bringing, they are here in large part to stay, even though ACC is working with other societies on “clean up” legislation should look. Cardiology must bring ideas to the table to portray ourselves as a specialty that the White House and Congress can come to for advice when finalizing the details over the next few years.