By Rick McGuire

One year ago, our cover story looked at NAVIGATING 'THE VALLEY OF DEATH,' based on the "creative destruction" sweeping through health care. As William Zoghbi, MD, then ACC president, put it: "This change is mammoth, it is historic, and it affects everyone's life involved in health care." Like last year's cover story, we returned once again in January to the ACCF Cardiovascular Summit: Solutions for Thriving in a Time of Change. Once again, whether you thrive—or survive—may mean the difference between steering a strategic course focused on solutions versus wandering the desolate valley of shifting expectations and accountability.

Some days it may seem more like the Road to Perdition, but—at least compared to this time last year—signs suggest it’s more a Road to Recovery. Still, it largely remains under construction so expect plenty of delays and obstacles ahead.

The problem continues, as it has for several years now, that everything is happening at once. Suzette Jaskie, MBA, president and chief executive officer of MedAxiom Consulting, points to a convergence of critical changes occurring across the health care industry:

• changing payment paradigms
• industry consolidation
• rise of the consumer (e.g., demand for transparency)
• the data revolution (driving performance)
• looming physician shortages

One example of these changes: Despite an aging population, hospitals are experiencing a drop in volume, from 123.2 inpatient stays per 1,000 population in 1991 to 111.8 in 2011. Their response? Jobs cuts in an effort to be more efficient and more effective; some hospitals have even closed their doors altogether. An accumulated total of 275,000 lost jobs are projected by 2022, according to the American Hospital Association.

Ms. Jaskie said, "Physicians not only have to be ready to respond to these changes but also lead us through these changes and retain control of your industry."

She added, "What's happening inside hospitals is a reaction to the economics. Cost-cutting has primarily been tactical—meaning we’re reducing staff and trying to cut supplies—but we’re not doing the hard work, yet, of re-engineering the way we work." Importantly, she emphasized the word "yet" because clearly she thinks re-engineering is inevitable—and coming soon.

One doesn't have to travel far to understand why re-engineering will be coming soon to a hospital near you. Cost transparency, for example, is driven by data, such as the fact that a pacemaker implanted in Livingston, New Jersey, costs $70,712, while 22 miles away in Rahway, New Jersey, implanting the same pacemaker system racks up a bill of $101,945. Recently the Centers for Medicare and Medicaid Services (CMS) released common procedure cost data and states have started requiring transparency of commonly billed procedures, with North Carolina hospitals tracking 140 most common procedures and Arizona the top 50. Some health systems are voluntarily posting cost estimators and common pricing. Knowledge equals power, and this puts the power of the dollar into clinician and consumer hands.

Stuck in the Middle

The convergence of all of these factors has set off a pitched battle between insurers and providers for the health care dollar, with physicians caught in the middle taking broadsides form both sides. It has certainly been a blow to the wallet: while physician practice costs have increased nearly 30% since 2001, Medicare payments to physicians have been below inflation for more than a decade. And for half that time, payments to physicians have seen zero growth or were actually in negative territory. Even in the best 2 years (2011 and 2012), cumulative Medicare payment updates have been just shy of 5% annually, compared to an increase in inflation of 20% since 2001. On the other hand, payment to hospitals have certainly increased, never missing a year of growth—as of 2012 they were up nearly 40% since 2001.

These payment update data were compiled by the Center for Healthcare Quality and Payment Reform, whose president and CEO, Harold D. Miller, presented the CV Summit’s Keynote Address. Some of the blame, he said, rests with physicians who:

• have not defined solutions to control health care costs without rationing;
• are seen as the drivers of higher costs;
• have not defined payment models that will support lower-cost, higher-quality care and maintain financial viability for physician practices; and
• have not organized to manage and deliver high-value population health care to purchasers and patients.

Besides this avalanche of blame, physicians must navigate a rocky road of change throughout health care. As Toby Cosgrove, MD, CEO of the Cleveland Clinic, has put it, "Whether providers like it or not, health care is evolving from a proficiency–based art to a data-driven science, from a freelance physician to hospital-employed physicians, from one-size-fits-all community hospitals to vast hospital networks organized around centers of excellence."

So, is there any place at all anymore for the small practice? Absolutely, according to David C. May, MD, PhD, president of Cardiovascular Specialists in Lewisville, Texas. "The idea that private practice is dead is a bit premature. The majority of us remain in small private practice and the message for those practices is to recognize that they do have to do some things like the larger groups, particularly things like data acquisition for benchmarking, quality improvement efforts, and paying attention to appropriate use criteria metrics and incorporating them into their practice Those things are the language that the larger systems and payers understand and listen to."

Another big advantage to small practices: "The small practice has a tremendously viable, rapid, and adaptive change capacity that no large system can match," stressed Dr. May. "So if you combine knowing your data, improving your data, and that adaptability, I think that not only will we survive but we’ll thrive in the next several years."

Quality is Job One

Large or small, quality matters. Howard T. Walpole Jr, MD, MBA, is chief medical officer of Okyanos Heart Institute in Freeport, the Bahamas, and course director of the CV Summit. As he puts it, "We started out practicing traditional medicine, doing something because 'that’s the way we do it.' Several years ago we entered an era of quality, now we are moving to value, realizing that as a profession we have to look at quality and cost, which was a foreign concept to most clinicians until the last few years. Now we are going through a culture change towards improvement of quality and cost. Not just doing it once but getting your entire organization into a culture where every day you are trying to continually improve what you are doing."

This emphasis on quality and value is illustrated by news from the Cleveland Clinic. Each physician there receives a flat salary fora 1-year appointment. This allows physicians to re-negotiate each year, so if a physician has a highly productive year that may result in a higher salary. Annual performance reviews are based on five to seven quality metrics. Like everywhere, said Joseph G. Cacchione, MD, an interventional cardiologist and chairman of operations and strategy, "there are leaders, laggards, and followers," but something is changing in 2014. For the first time since the Cleveland Clinic was established in 1921, he said, there will be physicians whose salaries will be cut or physicians terminated if they are in that bottom 10% of some aggregation of those quality metrics.

According to Matthew Phillips, MD, president of Austin Heart PLLC in Texas, what drives quality is culture. "We sit down and have an interventional group that says we’re going to meet all the [appropriate use criteria]. We have metrics, we track it, and we make sure if we don’t meet all the AUC, then we are accountable with the outliers." One big change at Austin Heart this year: Dr. Phillips asked all clinicians who do heart catheterizations, but not interventions, to stop doing heart caths. "It doesn’t work anymore, especially in big cities where I have 11 or 12 board-certified interventionalists. In our system, they did not like doing it, but they did it, and I think it’s better patient care."

Texas colleague Dr. May agrees: "All of us need to manage hypertension, but not all of us need to do percutaneous aortic valve replacement. Not all of us need to do transplant or advanced heart failure. And until we come to grips with that reality, we’re going to continue to have this competitive environment in which the 8-person group and the 150-person group and the academic medical center all envision themselves competing for the same population of people."

With everything happening at once, there is a paradigm shift–load of change and one critical element for every center will be managing the pace and rhythm of that change. William F. Martin, PsyD, MPH, director and associate professor, DePaul University, Chicago, reminded CV Summit attendees that human short-term memory is estimated to hold 7±2 bytes of information. Trying to remember and juggle 20 or 30 major change initiatives in a facility is too overwhelming. “An organization is an accumulation of individuals, so think about picking three or four initiatives and then once adopted, pick another three or four initiatives—but be aware of the bandwidth required of those changes. And once through one bump, give them a little time to recuperate so they can get some energy, and then get ready for the next one. Otherwise, people get burned out, affecting efficiency, safety, and quality for sure."

Small Practice: Not Dead Yet Size can be an advantage for small practices assuming the practice: Engages all providers Uses a flat, rapid decision-making tree Vests and engages participatory employees Incorporates multiple models/similar practices with which to engage in best practices Understands that physicians are being measured now on cost and quality (cost is an advantage in small groups) Makes professional help readily available/inexpensive Source: David C. May, MD, PhD, President Cardiovascular Specialists, Lewisville, Texas

Forget the Carrot, It’s All Stick Now

In an effort to facilitate change, CMS used a carrot-and-stick approach, for a while. However, if you missed the carrot, you will now feel the stick as payment “adjustments” kick in for the major quality programs of CMS. As Cathleen Biga, RN, MSN, president and CEO of Cardiovascular Management of Illinois in Woodridge, noted, the conversation of e-prescribing has ended; it is required as of 2014 and embedded in meaningful use criteria. All eligible professionals who did not participate in 2013 will receive a 2% penalty in 2014.

The physician fee schedule now focuses heavily on quality, with CMS beginning to implement the physician value-based payment modifier (VBM) involving an assessment of both the quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule. Beginning in 2015, all practices with 10 or more physicians will feel the impact of the VBM, with completion scheduled for 2017.

"They are moving us into a value-based world as quickly as possible," said Ms. Biga, with strong disincentives for inaction. "I get in trouble all the time when I call them 'penalties;' we're supposed to call them ‘payment adjustments.' Whatever you call them, it means you’re losing money."

These changes bring some good news: the various methodologies used for non-Medicare patients have been a huge administration burden. As CMS begins applying VBM, both cost and quality data will be included in calculating payments for physicians and “Physician Value-Based Performance,” as it’s called, will sunset all existing payment programs and would apply to physicians in 2017. While not finalized, the proposal includes:

• requiring the ordering professional to consult the AUC prior to ordering “advanced imaging”
• require use of clinical decision support tools
• may require prior authorization for individual practitioners determined to be outliers

These tools are already available through the ACC and Ms. Biga recommends clinicians get used to using them.

Given penalty dates that are still a year or more out, you may be tempted to think you have time and don’t have to deal with this yet. In fact, procrastination is a lousy option. Ms. Biga says there are sizable data lags and you can pretty much bet that those penalties will be based on what you do this year and next. This is not new: what you are being penalized for this year is what you were doing a couple years ago. For example, when CEOs and CFOs focused on the 2% readmission penalty on October 1, 2013, that are now kicking in for 2014, it was based on data from 2012. That’s a significant lag but underscores why physicians must be paying attention now.

The Whole Enchilada

Physicians look at the broad range of clinical processes and patient experiences that go into assessing quality for reimbursement purchases and ask how they can impact patient experiences across an entire hospital. Yet, with physician leadership, clinicians really can impact how a whole hospital functions. You cannot underestimate how important cardiologists are to care of patients.

Consider the case of acute MI readmissions, which have been overlooked in some centers who have been concentrating more on heart failure readmits. What can be done to prevent the scenario of an MI patient discharged after 4 days who returns a week later with some atypical pain, goes to the ER, and is readmitted. In this example, the clinician seems to have no control yet can get dinged due to a readmit that may very well have been unnecessary. Ms. Biga suggests taking a page form the ACC’s Hospital to Home (H2H) program.

"We try to mandate that all our discharged patients are seen within 48 hours of discharge, including our MI patients," said Ms. Biga. "It has helped immensely and not just with our Medicare patients. We’re finding that while our patients tend to be very literate many are 45-, 50-, or even 60-years-old and are not very med literate because they have never had to take a drug; so, they get confused."

In that early office visit post-discharge, make sure medication instructions are understood and patients get referred for cardiac rehab. For patients in a nursing home or other skilled facility, she says, patient navigation policies are “enormously successful” but must be very organized. "If a patient is being discharged at 7 or 8 o’clock at night you must have a mechanism in place to make those post-discharge appointments. And please, if family members say they are too busy to take their mom, dad, or granny back to the hospital, make the appointment anyway because cancelling it takes an active effort; having them call up and make an appointment is much more difficult."

Embracing quality that improves care—and doing it via physician leadership—should be viewed positively. Ms. Biga notes, "Don’t get depressed. This is the opportunity you have been waiting to embrace."

Finally, Optimism?

In this third year of the CV Summit, Pamela S. Douglas, MD, Duke University School of Medicine, Durham, NC, returned as course co-director. She recalled how in the first year, attendees seemed to be asking ‘what’s going on here?’ and feeling blind-sided, while 2013 attendees appeared to have some denial about whether changes applied to them. In 2014, she said, the conversations in the hallways and during breaks have shifted. "The woe-is-me feeling of previous meetings has been replaced this year with people saying 'I can use that piece of information' or 'some variation of that might work for me.' It is a much more optimistic, forward-thinking, solution-grabbing feeling to me—and that is an unbelievably important change in our approach to our future."

Charles L. Brown III, MD, chief of cardiovascular services at Piedmont Heart and Piedmont Healthcare Atlanta, said he’s encouraged because the changes are working. "Last year, we left this meeting with a better understanding of the importance of appropriate use criteria, printing out all the AUCs and giving them to all our individual centers of excellence. We put in AUC checks and balances in the cath lab and the nuke lab giving our guys all the device criteria."

Dr. David May is not surprised it’s working. He used the ACC’s Practice Innovation and Clinical Excellence (PINNACLE) Registry to assess how such data can influence an individual private practice center. "We simply took our data, which comes back from PINNACLE, and at our monthly doctors’ meeting we gave our physicians the actual reports: we did not talk about their data, I did not engage in berating them or giving plaudits, I simply placed (the reports) on the table. And a year later, we analyzed our data and we discovered that essentially every quality metric improved significantly." This included metrics such as initial laboratory tests for patients with newly diagnosed heart failure, documentation of an advanced care plan, and cardiac rehabilitation referral from an outpatient setting.

There are several lessons here, explained Dr. May. Physicians really are paying attention to what you are presenting to them. It suggests clinicians like seeing their data and they fix their procedures in a hurry once they see their data. Also, he said, "It points out that the things that are thought mundane—Did you measure the blood pressure? Did you do a lipid profile in the appropriate patient?—are things in which we are deficit certainly by national quality metric standards, but by simply measuring it, we improve."

Does it get any simpler than this? Dr. May said, "It’s not expensive to do, not terribly sexy to do, doesn’t require a randomized trial to do, but it does in fact make a difference. I believe that the widespread adoption of those types of technologies—registry systems that are easy to use—will make a dramatic improvement in our metrics for quality as we normally think of them."

At the conclusion of the 2014 CV Summit, Dr. Walpole said, "Speaking as one clinician, I am more optimistic about our profession now than I have been in a number of years. I think we can take the reins of this thing and turn it around."

Keywords: Patient Care, Medicine, Traditional, Insurance Carriers, Private Practice, Documentation, Cardiac Catheterization, Referral and Consultation, Centers for Medicare and Medicaid Services, U.S., Health Care Costs, Patient Discharge, Registries, Quality Improvement, Salaries and Fringe Benefits, Safety, Delivery of Health Care, Fee Schedules, Patient Navigation, Electronic Prescribing, Medicare, Office Visits, Leadership, ACC Publications, CardioSource WorldNews

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