Every 42 seconds, one American will suffer an acute myocardial infarction, which is among the top ten most expensive hospital principal discharge diagnoses. Data from the National Health and Nutrition Examination Survey showed that 50 million or more Americans have high blood pressure warranting some form of treatment, and cardiovascular expenses have one of the largest portions of current spending—an amount estimated to triple over the next 20 years.
Despite these dire facts, there’s some hope that better treatment and management is ahead. Value-based care programs represent a shift toward focusing on quality measures. Notably, nearly half of the quality measures are related to cardiovascular disease.
Dr. William Borden, director of healthcare delivery transformation at George Washington University, believes that the healthcare system is beginning to build better interactions between cardiac specialists and primary care providers. In addition, they’re beginning to strengthen collaborative ties with public health stakeholders to help keep people healthy and hopefully reduce the number who end up needing cardiovascular care.
Payment reform in cardiology
A JAMA Cardiology article recommends three principles that contribute to VBC success, including strong clinical leadership and substantial investments to successfully redesign care processes, improve quality and decrease costs. These are fair points, as so far, there have been mixed results of VBC programs in hospitals. Dr. Ashish Jha points to the success of hospital readmission reduction programs and compares them to the lack of results for cardiology programs. The British Medical Journal published a comprehensive study which found that little evidence for any impact of VBC on patient outcomes.
According to Dr. Jha, some current programs (including AMI and congestive heart failure) represents none of the key design features needed for VBC success. Meanwhile, the Hospital Readmission Reduction Program, which appears to have been successful, was designed using some of these principles. The incentives for reducing readmissions are relatively large, readmissions are easy to measure and most hospitals can track their readmission rate. Perhaps these same principles could be applied more rigorously to facilitate the success of the VBC program.
Three ways to potentially improve cardiac success
While preparing for the next series of cardiac-related VBC programs (slated for release in 2018), hospital systems can consider these three strategies:
1.Partner with primary care and other community providers with similar goals: Care is going outside the hospital to the community. Hospital systems can capitalize on partnerships with primary care, mental health and wellness providers that seek to reduce obesity and hypertension, and to address depression and other mental health issues, which correlate with AMI and heart failure. As physicians are seeing more complex patients with several comorbidities who are often overweight, arthritic, and/or depressed, the status of the primary care physician is rising. Primary care physicians are now recognized as the professionals who can integrate care and improve outcomes.
2.Strengthen inter-hospital collaborations: Driven by a shared commitment to enhance and broadly extend the scope, quality and value of heart care services for patients throughout Wake County, Duke Health and WakeMed Health & Hospitals have agreed to combine their nationally and regionally renowned heart programs in a single heart service. This collaboration was initiated March 1, 2017, so keep a close watch to learn from their progress.
3.Hospital-to-Home care transitions: CMS has publicly reported risk-standardized readmission rates for acute heart failure, pneumonia and myocardial infarction since 2009. Early models, relying primarily on data about co-morbid conditions and not on social or behavioral determinants of health, may have missed the mark in terms of their explanatory value. When planning hospital-to-home transitions, hospitals should focus on patients at higher risk of readmission. These patients may be identified either on the presence of certain characteristics (advanced age, polypharmacy, decreased functional status, etc.) or by using predictive models that quantify the risk of readmission. At present, it is uncertain which of these approaches is superior, but either can provide some stratification for the allocation of resources and attention. Using a structured needs assessment to identify areas of concern and provide focused resources to patients may prove to be an effective way to tailor assistance to patients’ needs.
Although it’s difficult to find examples of easy successes with cardiac VBC programs, in preparation for the next set of cardiac APMs, health systems and hospitals can consider these three approaches to potentially widen the scopes of their programs to improve chances for success.
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