Value-Based Cardiology

Value-based care in simple terms is providing high quality service at a lower cost, thereby creating value for individuals and the population in general. The reimbursement for physicians and health care organizations is tied to quality and health outcomes instead of quantity of services delivered.

Medicare Advantage is one such platform for value-based health care. It is divided into parts A, B and D. Let's deep-dive into how value can be created for Part A, B and D – especially in cardiovascular medicine – as cardiac costs and cardiac mortality are among the highest of all disease and comorbid conditions.

Part A

Ideally, most value can be created by preventing hospitalizations, but inadvertently there will be some hospitalizations even with the best services. Once a patient is in the hospital, physicians should avoid doing a battery of tests or obvious conditions. A simple phone call to the primary care provider can give a great insight into a patient's current condition and the intercommunicability of electronic medical records will reduce unnecessary repeat testing. Clinical skills are dying – a confident and clinically competent physician can save a ton of unnecessary imaging and blood tests and focus on the relevant ones. Having standardized protocols for common conditions like pulmonary embolism, STEMI and atrial fibrillation can reduce errors and improve quality of care. Hospitals should invest in having a swift, reliable and accountable communication infrastructure platform to ensure quick communication between physicians, specialists, nurses and patients.

Part B

Health care in general is shifting towards outpatient settings. This shift a good trend since preventative, high-quality and one-on-one services can be better provided in an outpatient setting. It is important to nurture the patient-physician relationship by increasing the physician-patient direct interaction time. Trust is also extremely important in this setting. An outpatient cardiologist should be proactive and able to identify high-risk patients, as well as follow up on them frequently. Understanding the background psychosocial structure is also crucial as it is often the key driver of many somatic illnesses. Physicians should empower patients and the patients' family members. They should be encouraged to understand and know more about their cardiac condition. Another important aspect of cardiovascular Part B cost is referral to subspecialists like interventional cardiology and electrophysiology. A well-coordinated referral will save unnecessary repeat testing and trips to other clinics for the patient. An outpatient general cardiologist should have a strong network and a Preferred Provider List so he can get timely updates about his referrals and care coordination is at its best.

Part D

Cost of cardiovascular drugs are sky-rocketing, but there are equally effective generic options available in most cases. In recent years, direct acting oral anticoagulants (DOACS) have been rapidly expanding market share and indications. A significant portion of cardiovascular Part D costs can be attributed to DOACs. There is real-world data to show that DOACS are cost-effective, but there is no large randomized trial to prove its cost-effectiveness. There is no head-to-head comparison trial between DOACs, so in most cases it boils down to physician preference. Most other cardiovascular drugs are generic, along with most secondary prevention drugs for myocardial infarction, heart failure and atrial fibrillation. Entresto and PCSK9 inhibitors are relatively newer, more expensive cardiac drugs. They are highly effective and should be used selectively in patients whom are truly indicated. Again, the cost-effectiveness data is out there but on a small sample size. It is important to follow up on the "real world data" for these newer expensive medications.

Value-based cardiology is the need of the hour. Some of the key buzzwords which can add value to the current cardiovascular health care system are building trust, providing clear communication channels and accountability, reducing errors, using appropriate use criteria, judiciously prescribing expensive medications, empowering patients and improving care coordination.

This article was authored by Kunal U. Gurav, MD, FACC, an early career cardiologist at JenCare in Atlanta, GA.