This post was authored by Thomas J. Lewandowski, MD, FACC, governor of the ACC Wisconsin Chapter.

Like it or not, the way in which society determines the value medical specialists provide has permanently changed.  We have fought valiantly to dispel the misbelief that we act not in the patient’s best interest, but our own.  Years of increased debt and financial hardship caused through the use of our “Pens” has resulted in an environment which is unsustainable and likely to cripple our economy.  Resulting market pressures for change have impacted all practice environments, including academic centers and more recently, fellowship training.  While many now define value as the cost of care relative to its quality, there is an appropriate concern that a disproportionate emphasis is being placed on the cost.  Without a proper balance, standards of care will be defined by the lowest cost with rewards designed to ensure they remain low.

To succeed in the future, clinicians will need to demonstrate they provide greater quality at a lower price. Unfortunately, current systems are not designed to demonstrate differences, in what we would consider true or meaningful quality, neither at a system or provider level.  However, the tools and data we need to effectively provide a better balance already exist.  Because of great courage and foresight shown by our predecessors, we as a College sit upon a wealth of knowledge that no other specialty possesses.  The critical data needed and sought by so many is contained within our registries, guidelines, appropriate use criteria, and the tools being developed to make this knowledge available at the patient’s bedside.  As more of our members become employed by large systems and are paid on a per-member/per-month basis, our advocacy will become less about specific reimbursement rates for procedures and more about integration in practice of our tools and use of our data within systems of measures or assignment of value.  More meaningful assessment of quality will not only be tied to adherence to scientifically based standards, but also increasingly tied to a documented improvement in outcomes and quality of life.

In states such as Wisconsin and Florida, detractors have argued against using a more robust method, because no other specialty can presently replicate our work. Others have said this would result in a complex, expensive system with an unproven return on investment. This does not mean it doesn’t need to be done. Unspoken is the fact that with accurate, actionable, and consistent data, clinicians will be able to effectively reverse policies designed with only cost in mind. In order to protect the integrity of our profession and the safety of our patients, we must advocate for moving from measuring what we can, to measuring what we need.

Recent work by the ACC’s advocacy and legislative groups has been crucial to setting the stage for this to become a reality.  Inclusion of registries in the Physician Quality Reporting System (PQRS) process opens the door for the ACC to effectively impact the method of quality assessment.  However, we have a lot of work ahead.  We must ensure that our registries contain the correct, relevant information that is truly reflective of the care we provide. We must not only be able to demonstrate that we followed guidelines, had optimal outcomes, doing so at a lower cost, but also with superior clinical judgment.  We will need to be able to better identify underuse of imaging, testing and treatments, while doing it in a way, which is integrated into our workflow.  Data must be collected as we treat patients without increasing the burden on the clinician.  Let us not move to yet another system of “checking the box,” or relying on generic best practice alerts.

If we can demonstrate how this may be effectively done, we will not only begin to allow our registries and clinical guidelines to work in support of our members, but we will show others a better way forward.  Current legislation to repeal the Sustainable Growth Rate passed by the House contains many provisions that will allow specialty societies, such as the ACC, to more effectively lead this change. However, as we have already learned, we must not allow our work to be misdirected, resulting in unintended consequences.  By remaining actively involved in the design and implementation process, we will maintain the greatest ability to minimize this likelihood.  Our path will not be easy or quick, but more likely associated with rough patches and at times divergent opinions.  For our profession and patients, we must fight for the ability to define quality, and thus value.  We must not allow the unit of measure to mostly reflect something green in color.

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