Former ACC Presidents Jim Dove, M.D., M.A.C.C., and Doug Weaver, M.D., M.A.C.C., and I recently co-authored a piece for Cardiovascular Business magazine on a hot topic in health care reform: accountable care organizations (ACOs). We write:

The problem, however, is that outside already established integrated systems, government regulations have made it difficult or even illegal for practices and hospitals to coordinate care and quality. Since most of the care is delivered by small groups of physicians that are not connected, the challenge is to allow trials of ACOs that are not legal large partnerships or entities.

This is complicated, and the ACC believes clinicians, patients and payors should have input about the design and function of this new structure. The ACC, for example, believes an ACO should reward providers for reducing unnecessary and discretionary services but not denying necessary care. ACO members also should not be at risk for costs they can’t control.

For today's Friday Poll, I want to know what you think about ACOs and their role in delivery system reform.

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.

HHS Secretary Kathleen Sebelius, along with Vermont Gov. Jim Douglas (R), last week announced a new pilot designed to promote the medical home. The three-year program is based on a program in Vermont and will provide financial incentives for primary care doctors to spend more time with patients with chronic conditions, keeping them healthy and coordinating their specialist care, in the hopes that it will cut down costly emergency department visits.

Any effort that could help us cut health spending and simultaneously improve quality is a good one. According to a Health Affairs analysis this week, if the growth rate in U.S. health care spending continues, it’s going to eat up personal income and economic resources.

Heck, it might eat up everything.  Even if the growth rate slowed to a pace of just 1 percent faster than per capita growth in GDP, more than half of any increase in personal income would go to health care over the next 75 years. Sobering. We’ll have to commute to work in ambulances.

"Forty years ago this week, man first stepped onto the moon. It was an undertaking that took vision, commitment and sacrifice. It will take the same vision, commitment and sacrifice for this nation to meaningfully reform our health care system.

"President Obama has called on Congress to undertake this enormous task which is just as daunting as putting a man on the moon. We applaud President Obama’s leadership and we share his goal of health care reform, but we can’t settle for legislation that lacks the teeth to deliver real and necessary quality and payment reforms.

"The American people need health care reform that addresses the causes of our health care problems and not the symptoms. Hacking blindly away at costs and then claiming to have saved the system money is dangerous and punishes the very people that our health care system is meant to serve: the patients. When talking about reducing overall costs to the Federal budget during the campaign, then candidate Obama suggested taking a scalpel instead of an axe to reform, and that’s precisely how we should be reforming the health care system now.

"We must look at how we pay physicians and other care givers, and develop a payment system that incentivizes quality and positive patient outcomes. Until we completely change the way the U.S. payment system is structured, we’ll never be able to bend the cost curve of health care spending.

"Without payment reform that leads to quality improvement, health information technology adoption, and reduced disparity and variation, we will produce a noble increase in access, but without slowing cost increases. That is a formula for disaster.

"Some have proposed as a way to save money is to cut Medicare Part B reimbursements to specialists such as oncologists and cardiologists. Not only does that not achieve enough savings to be of any use, cutting reimbursement will lead to less access to vital services for people in rural areas and in underserved communities. But it really just shifts costs as the cuts to specialists will be offset by increases to primary care physicians.

"What we need are reforms that allow for the adoption of health information technology, coordination of care so that we can reduce heart failure related hospital readmissions, and the use of evidenced-based guidelines and appropriate use criteria to stop unnecessary medical procedures. And we need incentives to promote partnerships between primary care and specialists in order to better coordinate care for most expensive and complicated chronically ill patients.

"This is, as then candidate Obama suggested, a targeted approach that can achieve real reform with real results and measurable outcomes." 

Earlier today, CMS updated its Hospital Compare Web site to include data about 30-day hospital readmission rates for acute myocardial infarction, heart failure and pneumonia. The site already provides information about 30-day mortality measures for the same groups. The site is intended both as a resource to patients – who can search by hospital to find out how their hospital compares to other hospitals – and to hospitals looking to improve their performance.

Making this data publicly available is a positive first step toward improving quality, simply in that it lets hospitals know how they’re doing. The way our current health care system is structured, it’s completely possible that they have no idea – which means there is no incentive to improve. However, given the dire straights our health system is in, we all need to take part in reducing costs to make the system viable in the long-term. In the CV world, ACC data show that reducing high-cost heart failure readmissions by 20 percent could save $265 million. That kind of savings is nothing to laugh at.

What You Can Do
First, start by reviewing the data. Once you’ve done that, ACT. The ACC is encouraging hospitals to enroll in our new Hospital to Home (H2H) initiative, which aims to reduce cardiovascular readmissions by 20 percent by 2012 by improving the transition from hospital to “home.” This is a lofty goal, but by providing evidenced-based strategies for reducing readmissions along with technical assistance to implement the strategies, we can make the reduction a reality.

Other Considerations
Although we value the opportunity for improvement Hospital Compare offers, it’s equally important that the data used is both fair and valid – and that our response as a community always places the best interests of the patients in the forefront of our efforts. The ACC will work with CMS and others to use the release of this data to strengthen the Medicare program and help ensure that Medicare beneficiaries receive high-quality CV care. Because at the end of the day, high-quality CV care for patients is the most important goal.

Additional Coverage:

• Baylor hospital leads way to lower heart failure readmission rates. USA Today.
  
  
• 'Double failure' at USA's hospitals. USA Today. 

The Senate Committee on Health, Education, Labor and Pensions (HELP) last week outlined its broad goals for reforming the American health care system. Among the top goals: improving the delivery system; enhancing prevention and wellness; reducing fraud and abuse in public and private health systems; and establishing shared responsibility for financing of reform efforts. Nobody can argue with the goals, but how the heck do we get there? We’ll need more details and some HELP.

The Committee appropriately suggests that health care reform legislation should encourage adoption and use of health IT; promote evidence-based medicine; facilitate health literacy; and include strategies for tackling preventable medical errors and hospital readmissions. It also proposes better managing chronic conditions through care coordination, medical homes and community health teams. Again—we agree. I mean, duh.  But, how do we systematically do that? ACC is working with leaders in the Senate and House as they continue to flesh out these and other proposals and develop overarching health reform legislation. For the latest information on health reform, visit http://qualityfirst.acc.org.

Meanwhile, President Obama met this week with key Democratic Senators Baucus and Kennedy and reaffirmed his support for the creation of a government-sponsored “public plan” health insurance option — the issue that invokes the most angst and opposition from Republicans who might otherwise support some kind of overarching health reform legislation (as an alternative to national bankruptcy?). Read more in the New York Times and The Washington Post. 

For me, it’s what is not in these articles and stories that is most concerning. Consider the following:

IF the SGRrr payments are flat for ten years as projected, how do we prevent tens of thousands of doctors from just throwing in the towel, exacerbating the access problem? If we move the delivery system toward integrated groups, and transform payment from fee-for-service to bundling or episodes of care (or capitation) to align payment incentives with quality improvement, who receives and distributes the payment bundles?  Hospitals? New entities?  If the money goes to hospitals to dole out to doctors, should doctors all be employees of hospitals to be able to share in the huge profits hospitals make from? Or could bundles go directly to doctor groups? If so, how would they be organized if not already in integrated systems? And, if any of this is going to work in terms of payment incentives, gainsharing, and new potential relationships between physician specialties and hospitals, isn’t some anti-trust relief going to be needed? Is that part of the reform plan?

And, where is the med-mal relief plan that we will need to reduce defensive medicine costs? And, what if a new public plan is created that pays less than what it costs for some doctors to produce the required care? In the current Medicare program, it is illegal to balance bill patients to cover costs. Will a future potential Medicare-for-all concept of Medicaid, the new ‘public plan,’ and Medicare allow doctors to opt out--or will we be forced into a kind of pseudo-public employment? If the new public system were to become untenable and unfair in terms of reimbursement (let’s say the government has some budgetary problems in the future?), would doctors be prohibited from opting out of the program and still seeing patients who were willing to pay them directly?

And what about EMTALA? If health reform achieves universality, is EMTALA to be sunsetted? Do on-call stipends go away? Why or why not?

None of these ‘details,’ among many, many others, are currently included in the emerging principles of reform discussions. It’s a little scary. We really need to think about these details. It seems to me that after we pass whatever we pass this year, we’re going to have a year or two of very messy details and divisive issues to deal with.   

The Senate Health, Education, Labor and Pensions (HELP) Committee held a hearing on health care delivery reform and the roles of primary and specialty care in new delivery models last week. Senator Sherrod Brown (D-Ohio) chaired the hearing and inquired about design and implementation of the patient-centered medical home and whether a primary care physician should be sole provider under this model.

Primary, Specialty Care Partnerships
ACC is lobbying to ensure that patients choose where they feel the safest and most comfortable — whether that is a specialty medical home or a primary medical home. In either case, the receiving practice needs to be willing to coordinate all the care and ensure that the patient is getting the most affordably delivered high quality care from wherever necessary. I’m not sure this hearing shed much light on that. I was hoping for more emphasis on the importance of team practice and the needed future importance of partnerships among physicians, nurses, pharmacists, and others to achieve quality, adherence and effectiveness goals.

Steven Schlossberg, a urologist with Sentara Medical Group, did assure the committee that the best outcomes for patients stem from a cooperative partnership of primary and specialty care. He specifically mentioned that Congress should not use Budget Neutrality as a way to strengthen primary care as it would weaken specialty services. Dr. Schlossberg asked for stable and fair reimbursement across the board. 

Reimbursement Issues
ACC has argued that increasing reimbursement for E&M codes across all specialties is critical (Evaluation and Management codes — cognitive doctor visits in the outpatient setting — are very much under-reimbursed). General cardiology, geriatric cardiology and outpatient care across all CV subspecialties is threatened in the same way that primary care suffers if E&M codes are not increased for ALL. This would help primaries the most, but access is a complicated issue.

Witnesses also discussed reducing hospital re-admissions, present and looming physician shortages in the United States, the need to focus on guidelines and reduce waste and the need to implement health IT (duh).

*** Image from Flickr (Brittany G). ***

Kaiser Permanente has substantially improved the heart attack survival rate for its members in Colorado through an innovative program that links coronary artery disease patients and teams of pharmacists, nurses, primary care doctors and cardiologists, with an electronic health record (EHR) and advanced clinical care registry.

George Halvorson, CEO of Kaiser, underscored that technology and treatment innovations alone are not enough.  

“It was not newer or more expensive treatments, but an integrated approach to deliver the right care at the right time. Maximizing information for the clinician means optimizing care for the patient."

The Kaiser pilot integrated front-line nursing and pharmacy teams that worked with cardiovascular patients and their physicians. The program achieved the following results:

• Patients had an 88 percent reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program;
  
  
• The number of patients meeting their cholesterol goal went from 26 percent to 73 percent, and;
  
  
• The number of patients screened for cholesterol went from 55 percent to 97 percent.

Proof positive that technology and coordinated team-based care can make a change for the better in the quality of cardiovascular care.

One of five Medicare beneficiaries discharged from the hospital is readmitted within 30 days, according to the Commonwealth Fund. Half of patients admitted for reasons other than surgery are readmitted without having seen a doctor in follow-up. The study appeared in the latest issue of the New England Journal of Medicine and shows these hospital readmissions cost Medicare $17.4 billion in 2004. Wow.

Heart failure readmissions account for the biggest chunk of that. Our new Hospital-to-Home (H2H) initiative with the Institute for Healthcare Improvement (IHI) could mean savings on a massive scale for heart failure and coronary artery disease. H2H aims to reduce preventable readmissions by 20 percent by 2012 for HF and CAD. We’ll give hospitals and physicians tools and strategies to help educate patients and ensure they follow up with physicians, adhere to medications and improve outcomes in the outpatient setting.

H2H got major media attention at ACC.09, resulting in great early coverage:

• Wall Street Journal: "Cardiologists Set Heart-Failure Treatment Program"
  
  
• MedPage Today: "ACC: Cardiologists Plan to Cut Heart Failure Hospital Readmits by 20%"

Yesterday, the ACC said goodbye to one wonderful president, Douglas Weaver, M.D., M.A.C.C., and welcomed a new one, Alfred Bove, M.D., F.A.C.C. Dr. Weaver has contributed so much to the College, leading ACC health care reform efforts, representing the College at various events, including at the White House, and supporting the College’s mission. It is sad to see him go – but I am sure he will remain active, especially with national health care reform efforts moving full steam ahead.

But, as the saying goes, when one door closes another opens ... I’m thrilled to have Fred Bove as our new president because he has so much to bring to the table on so many subjects.

As he said in his opening remarks last night, his presidency will be centered on bringing the focus back to the patient, as part of a very exciting initiative, dubbed “The Year of the Patient” (Watch a CVN interview with Dr. Bove on the initiative here). He said it best in his recent post to this blog, the emphasis of the Year of the Patient is "not only on respecting the cardiologist who provides continuous cardiac care to keep patients active and symptom free, but also in bringing patients into the care team and empowering them to participate in their care decisions."

The theme will resonate throughout national leadership and into our state chapters not only in 2009, but as a long-term theme for the College. Programming will be held that will strengthen the patient-physician relationship with both short- and long-term strategies, including greater promotion of our patient portal, CardioSmart.org. The College also will work with lawmakers to implement policies that encourage patient empowerment.

The College believes that the pathway to quality is through the patient. If we make sure that patients remain the focus during health care reform efforts, high-quality care will be the natural result.

This post comes from ACC President-elect Alfred Bove, M.D., Ph.D., F.A.C.C. Dr. Bove, who will take over for current ACC President Douglas Weaver, M.D., F.A.C.C., later this month, is a professor emeritus, medicine, at Temple University School of Medicine. As president, Dr. Bove will usher in "The Year of the Patient," in which the needs of patients will be at the forefront of all the College’s efforts.

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The world of cardiology is replete with new technology. There are advanced imaging techniques, new implanted devices that measure heart failure status, exercise levels, that pace the heart in complex algorithms and ICDs to prevent sudden cardiac death.  We have a plethora of new medications for the variety of acute syndromes, and have developed life saving programs, like D2B: An Alliance for Quality, that have helped reduce the risk of serious myocardial damage after an acute MI.

However, even in our technology-laden world, the great majority of cardiology patients still come to the outpatient office for the day-to-day maintenance of their condition. It is in the outpatient setting where patients are evaluated for their cardiac problems, receive therapy for their disorder, get advice about minimizing cardiovascular disease risk and learn about the detrimental effects of a chronic cardiac condition.

We live in a reimbursement world that encourages testing and procedures, but does not support the cardiologist who follows a patient for years, maintaining a state of reasonable health, avoiding progression to overt symptoms, and allowing the patient to experience a reasonable quality of life with chronic heart disease.

It is this commitment to good patient care that the ACC wishes to emphasize in the Year of the Patient.  The emphasis is not only on respecting the cardiologist who provides continuous cardiac care to keep patients active and symptom free, but also in bringing patients into the care team and empowering them to participate in their care decisions. ACC’s health care reform goals are to provide reimbursement for the coordination of care that often requires care management time spent beyond the actual office visit, and to recognize quality as a component of reimbursement. 

The movement toward a “Patient-Centered Medical Home” seeks to reward the primary care physician with added reimbursement to integrate care, provide continuity and manage chronic disease.  However, we as cardiologists perform the same duties with our heart patients and should consider developing a Cardiac Medical Home for patients with chronic heart disease.  This concept embodies our goals of patient empowerment, improved quality, adoption of electronic health records and the incorporation of non-physician providers (nurses, nurse practitioners, physician assistants) into a single entity that will optimize care of patients with chronic heart disease.

This team approach, with the patient as part of the care team, is the future of our practices. We will soon find demand for our care increasing to unmanageable proportions due to the aging population and a shortage of both physicians and nurses who can provide cardiac care.  Information technology and a team approach will allow us to manage a large number of patients with heart disorders.

For the next year and beyond, the ACC will emphasize the care team consisting of physicians, nurses, nurse practitioners, physician assistants and the patient, with the hope that we will succeed in increasing reimbursement for continuous cardiac care, and begin a movement that recognizes the cardiologist who chooses to emphasize continuous patient care.

- By Alfred Bove, M.D., Ph.D., F.A.C.C., ACC president-elect

* Dr. Bove's post is the fifth in a new monthly series of guest posts by ACC leadership. Check back next month to see which ACC leader is sharing his or her thoughts on health care reform!