Between Two Worlds: Straddling the Past and a Still-forming Future
Orlando, Florida – Two years ago, our cover story on the 2013 ACC Cardiovascular Summit was headlined NAVIGATING ‘THE VALLEY OF DEATH,’ based on the creative destruction roiling healthcare at every level. At this year’s meeting, the continuing transition of the healthcare system is leaving physicians straddling the gap between what was and what will be. Cardiologists may feel like the volume-based train ran over them on its way out of town, and now the value-based express is bearing down on them.
The next business day after the CV Summit concluded, Health & Human Services Secretary Sylvia M. Burwell made what she called a historic announcement, setting clear goals and a timeline for shifting Medicare reimbursements from volume to value. The goals:
- Switching 30% of traditional (fee-for-service) Medicare payments to quality- or value-based payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements, by the end of 2016.
- Tying 50% of payments to these models by the end of 2018.
- Moving 85% of all traditional Medicare payments to quality or value by 2016.
- By 2018, moving 90% of these payments through programs such as the Hospital Value-Based Purchasing or Hospital Readmissions Reduction Programs.
It’s the first time HHS has set explicit goals for alternative payment models that steer away from paying a flat fee for each service to value-based payments.
Putting some dollars to those goal numbers, in 2011 Medicare made almost no payments to providers through alternative payment models; today, such payments represent approximately 20% of Medicare payments or more than $70 billion. (This is based on 2014, when Medicare fee-for-service payments were $362 billion.) Thus, the goal is to have such payments increase to about $110 billion by the end of 2016 and to about $181 billion 2 years later.
It’s just part of an overhaul in healthcare that started long before the Affordable Care Act. To succeed, physicians need to better understand everything they did not learn in medical school. According to Pamela S. Douglas, MD, CV Summit course co-director and professor at Duke University School of Medicine, “We go to medical school and we have no courses on how to be a leader, how to manage business practices, finances, government regulations. [Yet], as good as you can possibly be about listening to murmurs or dilating lesions, the rest of how you deliver healthcare is incredibly dependent upon non-clinical skills.”
It used to be easier. In the old fee-for-service world, quality was not rewarded, pay was for volume, there was fragmented care, an acute hospital focus, and stand-alone providers thrived. Now, revenue is dropping, volume is decreasing, and there is minimal reward for quality. Practitioners are straddling between the old world and the still-forming new world of value payments, required continuity of care, systems of care, provider payment that is at risk, technology-driven information, and physician alignment.
While time is a necessary structure to keep everything from happening at once, that structure has been failing physicians in recent years as everything seems to be happening at once. The Physicians Foundation recently listed critical areas that healthcare analysts, lawmakers, physicians, patients, and the public need to closely watch this year.
Consolidation Hits the Gas Pedal
Clinical autonomy is threatened with increasing consolidation among hospitals and health systems that continues to drive smaller, independent medical practices into larger systems. Hospitals and physicians must work together to ensure that clinical decisions are being made independent of any bureaucratic or organizational pressures that could potentially affect the integrity of medical decision-making.
At the 2012 CV Summit, Suzette Jaskie, MBA, president and chief executive officer of MedAxiom Consulting, discussed the three stages of integration—and with the announcement by HHS, we have hit the last stage. The transaction stage takes 1 to 2 years and, she said, it can be “painful, long, and emotional.” At the end of that phase, you still don’t get to flip a switch and suddenly have one organization. Cultural integration requires another 1 to 3 years. Only then do you reach stage three: creating value.
Value creation is being fast-tracked now. In 2014, 33 federal programs asked providers to submit data on 1,675 quality measures, with state, local and private health plans requiring data on hundreds more—and little overlap with reporting requirements in federal programs. Soon after the announcement by HHS, the National Quality Forum submitted recommendations on 199 performance measures for Health and Human Services to consider in 20 federal programs.
This year, many of the federal pay-for-performance programs carry financial penalties. Hospitals and doctors stand to lose millions in Medicare payments for missing filing deadlines or improvement benchmarks in programs that track hospital-acquired infections, readmissions, and electronic-record use.
In looking at compensation, for the first time in about a decade, overall compensation for cardiologists fell 8.5% in 2013, with integrated providers showing less of a decline (6.9%) than independent practitioners (8.9%) for a total difference in median compensation of 29.3% ($548,630 for employed vs. $424,380 for independent cardiologists), according to the 2014 MedAxiom Provider Compensation & Production Survey.
External Pressures Strain the Physician/Patient Relationship
This rising emphasis on valued-based payment models is increasing the strain on the physician/patient relationship. Factors such as more non-clinical paperwork and rising administrative and regulatory pressures (measurement fatigue) threaten to erode the quality face-time physicians are able to spend with their patients.
Demands relating to electronic health records (EHRs) remain a hot-button issue for doctors. Tyler Gluckman, MD, Providence St. Vincent Heart Clinic, in Portland, told CSWN: Interventions that EHRs continue to be “the pain point” for clinicians: “This is the bane of their existence, in part because really it encapsulates everything we do.”
Record keeping is critical because, more and more, it will drive reimbursement. Cathleen Biga, RN, MSN, President, Chief Executive Officer of Cardiovascular Management of Illinois in Woodbridge, emphasized that the carrot phase used to facilitate adoption of EHRs is over and now we are deep into the penalty phase: “Physicians have so much to worry about, including the alphabet soup of PQRS (Physician Quality Reporting System), e-prescribing, and QRUR (Quality Resource Use Reports), their eyes glaze over but they are starting to realize that their compensation is going to be directly impacted by (the collected data). The penalties are always 2 years after the data collection, so the 2015 data collection period we are in right now will impact their pay in 2017.”
For example, 2015 is the first year of PQRS penalty (-1.5%) and that’s for 2013 failure or non-participation. Next year, the penalty increases (-2.0%) for not being successful or non-participation in 2014. If you treat one CMS patient, she said, report it. There are 18 measures, Ms. Biga added, and it “helps illustrate that Medicare wants providers to perform certain actions—such as checking a patient’s body mass index—during every in-person encounter.”
She said the big component of physician value-based purchasing is the value modifier and, simply explained, that is cost and quality at the group level. Physicians are used to individual report cards, but this is a report card on their entire practice. “They and their partners need to understand what this is and how it will impact their compensation,” said Ms. Biga. In brief, she said, it’s really simple: It is here to stay and confusing as—let’s say heck. There is no more incentive money and the demands will seem like a bottomless pit.
Impact of ICD-10 on Physician
ICD-10 is causing severe administrative problems in about half of all physician practices and 75% of survey respondents say ICD-10 will unnecessarily complicate coding. Although the feds delayed implementation to October 1, 2015, physicians and providers cannot afford to delay planning and engagement, or they risk major cash flow disruption and lost revenue.
Nichole Knight CPC, CCS-P, Director of Revenue Cycle Solutions, MedAxiom Inc., and Linda Gates-Striby CCS-P, ACS-CA, St. Vincent’s Medical Group, Indianapolis, said clinicians should prepare now for the fall start date, and continue efforts on clinical documentation improvement, which will pay off for more than ICD-10. Clinical documentation matters as it is the basis for: compliance, payment, quality/cost efficiency measures, payer quality/cost programs, Appropriate Use Criteria adherence, medical liability defense, and (of course) clinical information for patient care.
The difference between poor and optimal documentation is not great, but it is important. To illustrate, they gave this example of coronary artery disease (CAD)/angina diagnostic statements:
- Poor: CAD
- Better: CAD of LAD
- Best: CAD of LAD with unstable angina
- Extra Credit: CAD of LAD and of SVG to LAD with unstable angina
One starting point: get into the habit now of documenting tobacco status and body mass index on every patient. Also, Ms. Knight said that now is the time to “clean up” problem lists: every listed condition will eventually have to be converted to ICD-10. Review how you are using ICD-9 now, including current documentation to see if it would support ICD-10 now or if changes are needed. (They also warned that counting on another delay is NOT an implementation strategy.)
“That costs how much?” While that question has been asked for years, often the clinician could not answer the question. The lack of transparency and seemingly arbitrary nature of medical costs/billing practices has led to understandable frustration. As cited in a white paper published by The Physicians Foundation, The Wall Street Journal noted one example where a Nevada patient’s echocardiogram bill was $373 before a merger with the local hospital system—and $1,605 after.
According to C. Michael Valentine, MD, Co-director of the ACC Cardiovascular Summit, transparency should be everyone’s default setting. He told CSWN: Interventions, “Whether sharing data with physicians and the public or the transparency of finance between the hospital and physicians, everywhere you improve transparency, you improve buy-in, team-work, quality of care and you improve the quality metrics that you are trying to achieve. Look at Fortune 500 companies, they rate transparency as one of the most important avenues for employee satisfaction. We should look at it the same way in medicine: as long as there is a lack of transparency there is lack of trust and a lack of team work. And the last thing we need right now in health care is more lack of trust and team work.” Yet, Dr. Valentine adds, “We’re shocked to find a number of hospitals and physicians groups throughout the country that don’t have this transparency. And it’s very difficult for them to work together with administrators to improve care and quality metrics without the data and without the transparency.”
Access to Physician Care
Based on the Physician Foundation’s 2014 Biennial Physician Survey, 44% of physicians planned to take steps that would reduce access to their services, including cutting back on patients, retiring, working part-time, closing their practices to new patients, or seeking non-clinical jobs. As millions of new patients are insured through the Affordable Care Act, the growing scarcity of access to physician care presents a formidable challenge to the healthcare system in 2015 and beyond. The age of the workforce today may mean access issues tomorrow. According to Joel Sauer, MBA, Vice President at MedAxiom Inc., in Ft. Wayne, Indiana, about one third of the cardiology workforce is 59 years-of-age or older (32%) with the oldest group being the interventionalists (37% are 59 or older, including 7% who are 71 or older). He said, “We’re going to see some significant turnover in the next 10 years in cardiology.” What we don’t know is whether we’ll have the number of cardiologists required coming into practice.
It Takes a Team
From the demands of the Affordable Care Act to recent clinical practice guidelines, clinicians must place more of an emphasis on team-based care. “We have to become more efficient in all aspects of how we deliver medicine to our patients,” according to John D. Baker, MD, Director of Invasive/Interventional Cardiology and Cardiac Catheterization Laboratories at the Anaheim Regional Medical Center, Irvine, California. To be more efficient will require team-based care, he told CSWN: Interventions. “Unfortunately a single person, a physician, managing every aspect of outpatient care doesn’t work. When you train your staff, not only do you create a team around you that wants to be involved, your staff will step up to the plate, do more education, will learn how to do more, you’ll have better employees, longer-lasting employees, and an overall improved work life.”
What makes a good team? Dr. Baker said communication is probably number one: communication between team members so everyone is not working in a silo. Number two: every person working to the extent of their licensure and their education. “If you hire a physician assistant and you only have them do treadmills,” he said, “that is probably not the top of their licensure. Lots of your team can do so much more.” Third: a good sense of “we’re doing this together.” A cohesive team is one in which everyone knows their roles and expectations. “Those three things are paramount at creating a good team,” said Dr. Baker.
Why the strong reluctance to share responsibility? William F. Martin, PsyD, MPH, Director of the Health Sector Management MBA program at DePaul University in Chicago, said the big issue is the fear that it will not be done right. Plus, “It can be contentious, because if you share responsibility people may feel you are dumping on them.” Conversely, if you do not share responsibility what happens to you as a leader? Dr. Martin said, “You get all the burden. You get more work. You may lose influence. There are a lot of people in your organization who want to have an impact and who want to grow and develop. So look at it from a workload perspective, from a participation perspective, and as a tool for development, whether you are developing physicians or other leaders in your organization. These are the benefits from sharing responsibility.”
Importantly, evidence suggests it works. Dr. Valentine stated: “It’s really impressive to see heart failure readmissions drop because of team-based care, to see quality metrics improve in hospitals, to see patients being able to be seen faster based on better timing and better communications with team-based care.”
HF is a particularly good example given that in the fiscal years of 2013 and 2014, hospitals with higher-than-expected readmissions rates have or will experience decreased payments for all Medicare discharges. There are a number of variables known to impact HF readmission: HF disease management programs, comprehensive discharge planning, patient education, and early follow-up.
Mary Norine Walsh, MD, Medical Director of heart failure and cardiac transplantation at St. Vincent Heart Center of Indiana, suggested specific strategies to reduce readmissions:
- Identify persons with HF while they are in the hospital, even if HF was not the primary admitting diagnosis.
- Provide patients with education and a plan for action prior to discharge.
- Send patients home with a follow-up appointment scheduled within a week of discharge.
- Refer patients to a multidisciplinary HF disease management program.
- Consider hospice for appropriate patients.
Putting some dollars to all of this, consider an effort to reduce LOS for all cardiac surgery patients by 0.5 days at Piedmont Atlanta Hospital. Joshua Roberts, MD, Senior Director at Piedmont Heart and Piedmont Healthcare in Atlanta, reported a study of isolated CABG patients who underwent defined multi-disciplinary review with a goal of developing an open heart surgery pathway that would decrease variation in patient care. The multidisciplinary discharge planning process included a daily huddle where patients were evaluated by all members of the care team, including ancillary areas, ensuring that patients were on track for a timely discharge.
The impact: $3.4 million saved, including 1,690 patient days from August 2013—December 2014. (For another look at how such efforts can improve care and reduce costs, see the sidebar: 700 Hospital Days.)
EHR Efficiency: Not an Oxymoron
Electronic health records continue to be a key element of system transformation and a hurdle for many centers. Ty Gluckman, MD, said of EHRs, “We have come some distance but there is still tremendous work to do to improve things: How to engage more of the care team in this process, whether it relates to procedural documentation—even some of your day-to-day note documentation—your evaluation, and management services. How do you fundamentally leverage other people who traditionally haven’t been a part of the process?”
In the case of reporting a stress ECG, for example, get the techs and the nurses who supervise these tests to help conceptualize the note. According to Dr. Gluckman, care team optimization requires working with your coding and compliance team, developing policies and procedures, auditing for compliance, and performing periodic reviews and modifications. Overall, he said:
- Standardize your workflows,
- Regularly evaluate which providers and staff are struggling with your EHR,
- Identify which tools/shortcuts can be used to help you generate notes more efficiently (e.g., macros, dictation, and/or scribes to generate notes; do chart abstraction in advance to preload problem lists), and
- Leverage your staff to help simplify your evaluation and documentation (Teach MA’s and RN’s to work at the top of their license; utilize rooming staff to enter the chief complaint, review history, and update medication and problem lists).
One way to solve some of the new-world data demands is through the NCDR (National Cardiovascular Data Registry—see the accompanying table). Ralph Brindis, MD, MPH, the NCDR Senior Medical Officer, and ACC Past President joined Kathleen Hewitt, MSN, RN, ACC Associate Vice President, Science and Quality, in a session on NCDR 101: Start with the Basics and Develop a Champion.
NCDR data can be used to fulfill the reporting requirements of regulators, payors, corporate systems, and even fulfilling, in some cases, public reporting requirements. They advised: be aware of the changing landscape. You can run, but you can’t hide—sticking your head in the sand will not work. Understand that this will affect your practice and how you are paid in the future. Now is the time to get involved with your data. If you’re not at the table, you’re on the menu.
Here is one example of how AUC will continue driving evidence-based, appropriate use. An act of Congress, passed in the summer of 2014, requires consultation of AUC prior to the ordering of advanced diagnostic imaging (CT, MRI, nuclear medicine, and PET) in the physician office, hospital outpatient, and emergency department settings (emergency use will be exempt). This is an effort to reduce duplicate and/or unnecessary scanning and associated costs while ensuring that the appropriate studies are done for the right reason on the right patient.
Compliance will rely on clinical decision-support (CDS) software that analyzes and ranks the appropriateness of a physician’s order for a diagnostic imaging test. Payment will be made if claims for reimbursement confirm that the AUC were consulted, which CDS mechanism was used, and whether the imaging test ordered adhered or did not adhere to an acceptable CDS rating. (Physicians ordering advanced diagnostic imaging services will not have to adhere to the AUC, but they must confirm that the guidelines were consulted.)
- 2015 – Appropriate use standards selected
- 2016 – Eligible vendor selection, including a basic free portal
- 2017 – Implementation for Medicare patients—no payment for imaging without decision support number
- 2020 – Outliers must use prior authorization
Regarding self-regulation and the role of appropriate use criteria, Dr. Brindis said, “Although this sounds onerous, is it not better for us to impose these controls on ourselves than what is done currently by payers to control costs and procedures?”
While some clinicians see all the changes and are heading for the door, Richard A. Chazal, MD, Medical Director of the Heart and Vascular Institute, Lee Memorial Health System, Florida and Vice President of the American College of Cardiology, is not one of them. “I think we can always do better. I haven’t found any system yet that I felt was perfect and that’s part of the mindset of most cardiologists: if I think I’m really good at what I’m doing, there’s a tremendous opportunity to get better tomorrow. That’s one of the exciting things about being in cardiovascular medicine now. Tomorrow is a new day and you have an opportunity to do things a little bit differently and a little bit better and there’s no reason to ever get bored.”
The overarching theme today is how to develop systems of care that utilize the cardiovascular care team to improve quality and efficiency in the transition from volume to value. One of the best examples of the heart-team approach in action is a chest pain center. Richard A. Chazal, MD, is Medical Director of the Heart and Vascular Institute for the 4 hospital Lee Memorial Health System in Florida and Vice President of the American College of Cardiology.
Dr. Chazal and colleagues set out to improve the care of patients who arrive in the emergency department with chest pain but are not clearly having a myocardial infarction. Of course, high-risk patients with a TIMI score of 5 to 7 who were troponin positive or showed ischemic changes on their electrocardiogram (ECG) were admitted for definitive treatment. For moderate- (TIMI score of 3 or 4) or low-risk patients (TIMI score 0 to 2 and, in both groups, an ECG that is normal or unchanged and initially normal cardiac biomarkers), they were placed in a clinical decision unit for observation.
Physician assistants or nurse practitioners initiated protocols (including determination of TIMI score). All along the way, patients were given information regarding what was next. For example, they were told that additional blood draw for troponins would be made at 3 and 6 hours, and a second ECG would be performed at 6 hours. If they developed elevated cardiac enzymes, recurrent chest pain, or ECG changes consistent with ischemia, they would be admitted for care. If not, a cardiologist might perform a stress test, or the patient would be discharged and an outpatient stress test scheduled within 72 hours. Rather than be left with little information, they would be told when to expect to be discharged if their condition did not change.
Stress Levels Drop
Dr. Chazal noted that the first big difference is the greatly reduced patient stress level; with standard care, patients may spend hours with little information regarding the timeline, and no idea what to expect or when they might be released. “This is one of the places where, as a clinician, I like length of stay as a metric,” he said, “because we’re accomplishing the same care within a shortened framework which, for the patient, is terrific because he or she is spending less time NPO, not eating and hungry, and scared quite frankly before there is a definitive diagnosis made and then they can move on.”
For the hospital, of course, the bottom line is more concrete—this approach frees up beds. Specifically, compared to standard patient management, the three hospitals participating in this study saw 696 total days saved across a period of about 9 months, with 174 beds made available.
“We believe that that increased utilization of this guideline-derived protocol abbreviated some of the wasted time that we had before,” said Dr. Chazal.
Interestingly, length of stay for both groups dropped. It dropped more for the group that was in the cohort cared for by the advanced care provider, but the group that received more standard care benefited from an apparent halo effect as the guideline-directed methods became more widely used for all chest-pain patients arriving in the emergency department.
“The data I showed you today are not good enough,” he said. “All of us have room for improvement in care, and look for those gaps. Looking at data is how you begin this process. Our initial dataset showed that we had an excess number of patients who arrived in the emergency department who had nuclear stress tests who ended up being negative. And we saw that there was an opportunity there for more appropriate utilization of resources, reduction in radionuclide exposure for patients, just better care.”
New Core Competencies for Physicians (As of January 2015)
Paul H. Keckley, PhD, Managing Director, Navigant Center for Healthcare Research and Policy Analysis (Washington DC/Chicago)
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Heart Transplant, Interventions and Coronary Artery Disease
Keywords: CardioSource WorldNews Interventions, ACC Publications, Angina Pectoris, Angina, Unstable, Body Mass Index, Cardiac Catheterization, Cardiac Surgical Procedures, Centers for Medicare and Medicaid Services (U.S.), Clinical Coding, Clinical Competence, Continuity of Patient Care, Coronary Artery Disease, Cost of Illness, Data Collection, Daucus carota, Electrocardiography, Electronic Health Records, Electronic Prescribing, Government Regulation, Heart Failure, Heart Transplantation, Liability, Legal, Medicare, Patient Protection and Affordable Care Act, Patient Readmission, Registries, National Cardiovascular Data Registries, Reimbursement, Incentive, Value-Based Purchasing, Patient Discharge
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