HRS: Experts debate doc involvement, quality measures in healthcare reform

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Former U.S. Senator Tom Daschle
Image source: Center for American Progress
DENVER—The six-week-old healthcare reform legislation aroused a heated debate between former Sen. Tom Daschle, D-S.D., NPR journalist Juan Williams and physicians Harlan M. Krumholz, MD, and Richard I. Fogel, MD, who discussed government involvement and the questions that remain about quality measures within clinical practice, during the opening plenary session of the 31st annual conference of the Heart Rhythm Society (HRS) on May 13.

“The most important thing is to define our goals,” Daschle said. Drawing on a football analogy, he said: “Enactment only got us to the 30-yard line, so we still have 70 yards to go, and along the way there will be problems.

“In the healthcare reform package, the easiest aspect to figure out is the insurance reform component, as it is spelled out with great granularity and timelines,” Daschle said. But, he acknowledged there is far less clarity about the incentives and achievable goals for practitioners.

In examining healthcare reform through the lens of the political and sociological landscape, Williams said, “This bill is still pretty politically unpopular, especially among the elderly. Most Americans believe the bill will drive up the deficit and taxes, and question who will benefit from the bill.”

Speaking to the audience of approximately 4,000 HRS attendees, Williams pointed out that “doctors need to be convinced that they can trust the government” because they are “concerned” the government will tell them how to practice and unknowingly establish rates and reimbursements.

However, Krumholz, a professor of cardiology, epidemiology and public health at the Yale University School of Medicine in New Haven, Conn., said there are many “aspirational qualities of the bill, and there are still details to be ironed out, but the opportunities lie in its commitment to quality.”

Krumholz said the challenge will be in its implementation. He references CMS’ Center for Innovation and the potential CMS demonstration projects as opportunities. “One of the central challenges is how to move these pilot projects into the general healthcare system,” he said.

“Although the law has set out these aspirations with some timelines, the details are still being formulated. Therefore, the professional medical societies should engage and help formulate and integrate these ideas,” he said. “We need to funnel in the expertise of the various physician specialties. The future has not been set yet. The parameters and the investment have been made, but specifics about quality and practice management are yet to be determined.”

However, Fogel, who is CEO of the Care Group in Indianapolis, said: “The opportunities are how we respond to the challenges.” He noted that it has yet to be seen how the U.S. will improve access to healthcare, while simultaneously improving its quality. “In actuality, [the bill] improves access at the primary care level, but not at the specialty and subspecialty care level,” said Fogel, who more particularly questioned how quality is defined and achieved in the specialty of electrophysiology.

Noting that the U.S. is shifting to value-based purchasing, or payment-for-quality model, Fogel said: “If we are going to pay for quality, we better be able to define it well. I’m concerned that we do not currently have the metrics to properly define quality, especially dealing with the nebulous nature of atrial fibrillation.”
 
Fogel also questioned the government involvement with physician treatment of their patients, especially in light of the constant delays with the SGR cut.

“The next five years will be formative years—after which we may lose some momentum for real change—and the five following years will launch the implementation process,” Daschle said. “I hope there will be a lot more transparency [in the next 10 years], and a far greater degree of health IT adoption, which is only at 15 percent currently. We ought to be 100 percent integrated in 10 years.”

Ten years from now, Krumholz said there “isn’t any question” that there will be greater integration of healthcare, especially among formerly siloed specialties. He added that the patient doesn’t observe the individual practitioner or specialty, but rather he or she observes the care received as a whole, which the patient then uses as a basis to evaluate the whole healthcare system.

“The policymakers get ahead of us, because we think we’re much better at measuring quality than we actually are, and ultimately, part of that quality equation has to include how we involve those caretakers around us—not just how our little piece moves,” Krumholz said.

Williams also spoke to the general distrust of government among the U.S. public, which he defined as a “really strong anger…in terms of the discussion about healthcare.” However, he predicted a higher degree of technology in the hospital setting and a greater proliferation of boutique healthcare in the next 10 years.

“We’re at the cusp of an incredible paradigm shift in how American medicine is practiced,” said Fogel, noting the proliferation of hospital and private practice mergers. “Two years ago, 30 percent were hospital employees, last year, it was 50 percent and this year, it’s 70 percent. The next 10 years will mark the end of private practice cardiology.”

“The [healthcare reform] bill is clearly focused toward primary care, which is a ‘gate keeper.’ I am concerned about what criteria will be developed to allow patients to see specialists,” said Fogel.

For instance, the bill called for the creation of an independent Medicare advisory commission. “These are appointed individuals, not elected, but accountable to the public. Other specialists and I have the fear that this board will be making decisions that could potentially limit access to care,” Fogel said. “You wouldn’t want a group of non-cardiologists making decisions about who receives atrial fibrillation ablation.”

Krumholz responded: “We really need guidance. Ideally, the professional societies will step up to provide legitimate, sensible guidance based on strong evidence. The notion that we’re going to start putting some boundaries on what is permissible is not unreasonable.”

In referencing the flawed SGR payments, Daschle noted that these types of groups, who will solely focus on medical decisions, might be an improvement on Congress.