In the final wrap up session for the 2009 Health System Reform Summit, ACC’s current presidential team commented on the findings of three break out sessions held throughout the Summit. ACC Vice President Ralph Brindis, M.D., F.A.C.C., stressed the importance of showing our willingness to work with CMS on appropriate use and our openness to conducting comparative effectiveness research by using real-time registries. In particular, we need to mature our ambulatory registry efforts, as conducted through our IC3 Quality efforts, so that quality can be measured in all places where care is provided, Ralph said.  

Attendees also used the final hour to clarify essential issues for the College, the issues and concerns we must focus on in the near future to reach consensus and better define. 

Current President Doug Weaver, M.D., F.A.C.C., gave final comments. If this conference shows anything, he said, it is that there is no shortage of ideas and there is a sense of urgency. We need to provide an imperative – although it’s unclear what that should be – for hospitals and CV professionals to use registries. If registries were used in both hospitals and practices for even just a sample of all patients, the result would be more educated members, and would serve to put quality at the front of our minds. None of this is easy, Doug said, but if we can do it convincingly, we will be ready for when patients want to know more; we will be on our way to improving quality, and we will be role models for other specialties. If we can do this, no one will stand in our way in the future.

Our last presentation before wrapping up the 2009 Health System Reform Summit discussed access and patient partnerships, featuring presentations from Darren Willcox of the Coalition to Advance Health Care Reform, Bill Novelli, CEO of AARP, and Helen Darling from the National Business Group on Health. All the speakers supported patients taking more responsibility and becoming more involved in their health and health decisions -- and the increasing trend of this actually happening.

Willcox discussed Safeway’s efforts to get its employees to improve their health through support networks, like a 24-hour hotline, 100 percent coverage for preventive care and lifestyle management programs. Safeway’s efforts paid off – they have been able to stabilize health care costs at the 2005 level. 

Novelli talked about AARP’s health care reform campaign with SEIU and NFIB, called Divided We Fail. This campaign focuses heavily on the patient, stressing that in order for care to be considered “patient-centered,” it must involve the patient in care decisions. This means that patients need to know more about the resources they consume and there must be incentives for physicians and patients to work together to efficiently use health care resources. 

Darling gave statistics from two surveys her group has conducted recently of employees. The survey found that employees want health communications targeted to their needs; employees want to reduce their costs and get more value out of their care; and employees are trying to live healthier. People are more and more willing to take personal responsibility for their health. 

All three of the speakers responded to two controversial issues that they were asked about in the Q & A session. More...

ACC Vice President Ralph Brindis, M.D., F.A.C.C., kicked off this morning’s first session on defining quality and value at the 2009 Health System Reform Summit. The speakers – Douglas Wood, M.D., F.A.C.C., of Mayo Clinic, Glenn Steele, president and CEO of Geisinger Health System, and Francois de Brantes, CEO of Bridges to Excellence – all agreed that we need to seek value, and by pursuing quality we will get toward the ability to reduce costs. This is the opposite of the discussions in the political world – where the #1 priority is reducing costs, followed by quality.

Wood and de Brantes agreed that value is the best combination of quality and price. Wood argued for a formula for value, where: 

VALUE = QUALITY (Outcomes, Safety and Service)
            -------------------------------------------------------
            COST (Unit price X Use rate) 

By assigning numbers to these positions, you can determine the value of any given procedure, he said. This system has the potential to be implemented right away, and could be improved over time, according to Wood. Wood also made the point that quality should be the first focus of reform, and by improving quality, costs will be reduced over time.  

Steele talked about his Geisinger's efforts to improve care and reduce costs through chronic disease care optimization and acute episodic care; patient engagement; transitions of care; and the advanced medical home. For example, through its advanced medical home program (ProvenHealth Navigator), which uses partnerships between physicians (albeit mostly in larger practices and with health IT) and hospitals, Geisinger decreased medical costs by 4 percent and dropped readmission rates by 5 percent. Readmission rates for heart failure dropped by 40 percent. 

The bottom line: Efforts like this need to continue so we can brainstorm better ways of providing care. Value in care is not discussed nearly enough. If we are going to reform the health care system, the combination of quality and price MUST be part of the discussion, if not the whole discussion. The ACC knows that – increasing patient value is the #1 principle of ACC’s health care reform campaign and the #1 purpose of the application of registries, in particular the IC3 quality efforts  ... and the value principle was crafted LAST year at the 2008 Health System Reform Summit. Let’s hope value in care moves to the forefront in future discussions on reform. 

Just finished up with the “Models for Payment Reform” panel at ACC’s 2009 Health System Reform Summit, featuring ACC Senior VP of Quality and Science Janet Wright, M.D., F.A.C.C., Bob Berenson, senior fellow at the Urban Institute, and Gail Wilensky, senior fellow at Project HOPE and a former CMS administrator. 

Janet spoke about reaching out to other specialties to form quality networks in order to improve care. I wonder: How do we move physicians into these quality networks? This will require a business case, which doesn’t exist currently.  

Berenson spoke about the different payment systems currently in place and the payment systems that have been talked about for the future, including pay-for-performance, paying for episodes of care or bundled episodes of care. He concluded that given the heterogeneity of payment systems and the readiness of many physicians to try new systems, the country may no longer need a one-size-fits-all solution like the SGRrrr. However, there must be incentives to move physicians into these new payment systems.

Wilensky called the payment system the “most broken screwed up” part of Medicare, claiming that the current system of the SGR and RBRVS (Resource-Based Relative Value Scale, which assigns payment based on the resource cost of providing a service) can’t work because there is a basic disconnect between payment incentives and the physician – meaning that nothing the physician does will influence total spending. However, she warned that doing away with the SGRrrr is never going to happen, so we need to either have an SGR closer to the practice level or move the system toward bundling payments. p.s. I’m not sure I buy that. We need more innovative concepts that aren’t even on the table yet, like using our registries to reduce disparities and variations, or gainsharing between payers and physicians and patients, which could bring down the overall costs. We need to think of new solutions.

What do you think: What’s the best way to reform the payment system?

Today is the first day of the College’s 2009 Health System Reform Summit. Over 100 leaders from within the College have gathered to talk health care reform, brainstorm solutions, and find ways to get our voice heard. Over lunch, economist Len Nichols, Ph.D., director of the health policy program at the New America Foundation, gave a presentation titled, “The Cost of Health Reform (and of Doing Nothing).” Nichols made some great points right on target with the points the ACC has been trying to make with its Quality First campaign.

Nichols gave these as the underlying realities of the health care system:

• The system’s incentive structure is “deeply flawed” – and some profit from the flawed structure
• Behavioral choices affect health and health costs
• The system cannot afford “business as usual” trajectories
• Change is impossible but necessary (he intended you to smile here)

The incentive structure is deeply flawed. I’ve been talking about payment reform on this blog since it launched – since I started as CEO at ACC -- and I can assure you, it’s the top thing on the minds of our members. Physicians are NOT compensated for providing the right care the first time -- they are compensated for the VOLUME and COMPLEXITY of tests they perform. This has to change. Changing the payment structure to reward high performance could have a dramatic impact on controlling costs and improving care.

Payment reform was one of three investments Nichols said we could use to create efficiencies to pay for reform. The remaining two: health IT and comparative effectiveness research. The ACC is highly supportive of health IT. We think it can improve efficiencies and reduce medical errors. Cardiology has one of the higher rates of health IT adoption of any of the specialties, but it’s not nearly high enough. We need to use the stimulus dollars to implement INTEROPERABLE health IT. Because we need to use it to adhere to guidelines, outcomes effectiveness and value. Comparative effectiveness is a little trickier – it must be done right to truly work.

Here’s what he says are solutions to “breaking the chain” of inaction: pursue bi-partisan reform and reform ourselves. Cardiologists can do this. We already are – look at our registries (National Cardiovascular Data Registry and its many sub-registries); look at our guidelines, appropriate use criteria, performance measures and other clinical documents, helping CV professionals translate science into everyday practice. We need other specialties to follow, and we need Congress and the President to listen.