March/April 2017

2017 brought a new reality to the U.S. healthcare community. The Medicare Access and CHIP Reimbursement Act, or MACRA, is no longer just the law that repealed the sustainable growth rate. With its Quality Payment Program that defines complex new payment models, MACRA is the machine that is nudging clinicians and practices away from fee-for-service and into value-based healthcare.As the transition begins, many clinicians feel confused as they straddle two payment systems in healthcare delivery. Paul N. Casale, MD, MPH, hosted a Cardiovascular Business roundtable discussion, where participants voiced questions on the minds of many, brainstormed answers and identified new opportunities for the cardiovascular community to lead.

About one year ago, FIRE AND ICE trial investigators reported that cryoballoon ablation (cryo) performed as well as radiofrequency ablation (RF) as a treatment for patients with drug-refractory paroxysmal atrial fibrillation. But is “as good as” good enough to change practice? The answer may be emerging just now.

To prevent the risk of patients developing heart failure from chemotherapy agents in cancer care, patients are typically have their left ventricular ejection fraction (LVEF) or myocardial strain monitored using either echocardiography or equilibrium radionuclide angiography/multigated acquisition (ERNA/MUGA). If cardiac damager occurs, the treatment is discontinue or pause treatment. Cardiac imaging to assess chemotherapy-induced cardiotoxicity using strain echo.

Treating today’s cancer patient no longer means simply targeting the cancer. Given the known cardiotoxicities of some established chemotherapies and the possibility that newer approaches may damage the heart, oncologists, cardiologists and imaging specialists now work together to detect and minimize the risk of treatment-induced heart failure.

Every day, cardiologists make hundreds, if not thousands, of mouse clicks, encounter countless notifications and manage a steady stream of alerts that pop up on their computer and device screens. Some say these demands of the electronic health record (EHR) are distracting clinicians from patient care and contributing to physician burnout. Yet there are workarounds that can help cardiologists handle the digital data deluge.

Electronic health records (EHRs) have transformed the way clinical care is recorded and reimbursed, and now their promise for reaching across large populations is making them a key resource for cardiovascular research.  

As a growing body of evidence links palliative care to improved quality of life and better healthcare utilization for patients with heart failure, some in the medical community are advocating a shift from the traditionalist, acute care model to one more in tune with the psychological and physical needs of people with advanced cardiovascular disease.

 Bundling is premised on viewing healthcare as a continuum, but most of today’s healthcare systems use electronic medical records (EMRs) developed for episodic fee-for-service billing. While many in the cardiovascular community are at the beginning of this experiment, some health systems participated in the earlier Bundled Payments for Care Improvement (BPCI) Initiative and have insights to share.    

Policymakers from the FDA and CMS have been invited to participate in ACC.17, says Jeffrey T. Kuvin, MD, ACC.17 chair and chief of Cardiovascular Medicine at the Heart & Vascular Center of Dartmouth-Hitchcock Medical Center in Lebanon, N.H. “This year, we’ll be able to draw on local  expertise, which also happens to be our nation’s expertise—people who can help us understand important, timely issues in cardiovascular medicine and in the world of medicine,” he says.

Don’t underestimate the importance of scheduling in running a successful cardiovascular practice. 

 Effective patient education leads to improved informed consent, decreased preoperative anxiety and better postoperative pain management. Whether allocating office and hospital resources for patient education results in more cost-effective medicine is a more complicated issue.  

The American Heart Association and American Stroke Association say that palliative care should be integrated into the care of all patients with advanced cardiovascular disease and stroke as a means to relieve symptoms, improve patients’ satisfaction with their care, reduce costs and extend survival (Circulation 2016;134[11]: e198-225). Yet, according to 2015 data from the National Palliative Care Registry, only 13 percent of palliative care patients had a cardiac diagnosis. This finding signals the need for both increased referrals to palliative care and more training for cardiovascular specialists in core palliative care skills.

With the launch of the Merit-based Incentive Payment System (MIPS), hundreds of thousands of U.S. clinicians will face new reporting requirements. Participation in a registry, a familiar quality improvement activity for many cardiology programs, could provide a solution.     

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