Value-based Reimbursement Is Here to Stay & Other Lessons from Cath Lab Leadership Boot Camp

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Arnold H. Seto, MD, MPA and Robert J. Applegate, MD

The business of cardiology was at the forefront of discussion at the Society for Cardiovascular Angiography and Interventions (SCAI) Cath Lab Leadership Boot Camp in May. Speakers focused on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), bundled payment models and value-based reimbursement. Here are a few of the lessons attendees took back to their practices.

Start preparing for financial risk; it’s inevitable

Sixty-seven percent of healthcare organizations expect more than half of their contracts will be value-based by 2018, but only 4 percent feel ready for the transition, according to MedAxiom presenters featured at SCAI’s boot camp. Another 25 percent are still investigating how to achieve the transition while 35 percent are running pilot efforts.

Meanwhile, the average MedAxiom member organization expects half of its contracts to be at least partially population-based or capitated by 2020. This shift will increase providers’ financial risk and require more coordination across pre-hospitalization, inpatient and post-discharge settings. Succeeding in risk-based contracts will require several competencies:

  • Governance: Leadership, broad participation, accountability and coordination
  • Systems-based thinking: Breaking down institutional barriers to make optimal decisions for the entire organization instead of an individual unit or division
  • Effective strategy deployment
  • Aligning incentives: Providers and managers must have their financial incentives aligned with those of their organizations. A pure fee-for-service productivity model cannot exist within an accountable care organization that is even partly responsible for the costs of care.
  • Data collection: Accurate system data on costs (quality resource and use reports), quality (Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]) and variability. Clinicians in hospitals participating in episodic payment models need to know not only their own postacute care costs but also those of their partner facilities.

Mandatory episodic (bundled) payment models were scheduled to begin for both coronary artery bypass graft surgery and acute myocardial infarction in 2018. However, the Centers for Medicare & Medicaid Services (CMS) recently canceled implementation after receiving numerous public comments from providers and facilities. CMS reported, “Many providers are currently engaged in voluntary initiatives with CMS, and we expect to continue to offer opportunities for providers to participate in voluntary initiatives, including episode-based payment models.” Thus, while mandatory bundled payments are off the table for now, the incentives within MACRA that favor either alternative payment models (5 percent bonus) or cost-efficient care through the incentive payment system scoring system (where 30 percent of the score is resource use) remain.

Learn to make the business case for care

Clinicians aren’t the only ones whose value will be under scrutiny. More than ever, device manufacturers and pharmaceutical companies will need to demonstrate their value and justify their prices. SCAI made value a focus at its scientific sessions with a session titled, “Make the Business Case,” where speakers debated the need for new technologies, such as transcatheter valves, left atrial appendage occluders and chronic total occlusion (CTO) revascularization strategies.

Even at a high-volume center such as Cedars-Sinai Medical Center in Los Angeles, transcatheter aortic valve replacement (TAVR) reimbursement is of marginal benefit, according to Timothy Henry, MD, director of the hospital’s cardiology division. Rather, Henry said, the benefit of the TAVR program has come from increased overall clinical activity, particularly with imaging. The business case for CTO revascularization is similar, David Kandzari, MD, told boot camp attendees. CTO PCI may be burdened with increased catheter and time costs, but the associated growth in PCI referrals made CTO PCI financially beneficial at Piedmont Heart Institute in Atlanta, where Kandzari is director of interventional cardiology and chief scientific officer.

Whether such increased intensity of services will be penalized in the era of value-based reimbursement remains to be seen, but in a fee-for-service model, such procedures are financially viable for facilities.

Prioritize optimal cath lab operations & protect cath lab staff

With the proportion of elective PCI cases declining from 80 percent to 40 percent in the past decade, flexible scheduling of staff, procedures and operators will continue to be important. Cath lab leaders should develop skills at managing and motivating staff, aligning physician and hospital incentives, and managing outlier clinicians. Manesh Patel, MD, chief of cardiology at Duke University Medical Center in Raleigh-Durham, N.C., detailed his effort to “drive care improvement by reducing practice variation” by physician operators. Along with standardized order sets, Duke was able to reduce waste by 57 percent from 2015 to 2016 by employing a dashboard to accurately monitor and report time and supply use by individual providers.

Protecting physicians and staff from the occupational hazards of radiation exposure and orthopedic injuries was the exclusive focus of one SCAI session. New technologies including robotic PCI, weightless radiation protection shields and real-time radiation exposure monitors will enable concerned operators to protect themselves, at some cost. The most beneficial practices—the basics of time, distance and shielding—are inexpensive or even free, according to Ryan Reeves, MD, of the University of California at San Diego. Additional protection from fluoroscopy system upgrades, which can cost $100,000, could be justified in high-volume labs, he said. Robotic PCI is expensive but addresses both radiation exposure and orthopedic injury.

Burnout affects 50 percent of physicians, according to the American Medical Association, with the top contributors including clerical demands, overwork, underpayment, loss of professionalism and excessive scrutiny. James Goldstein, MD, of Beaumont Health System in southeast Michigan, recommended stress management techniques, such as exercise, good posture, eating well, life balance and getting enough sleep.

Embrace clinical pathways & quality tools

Clinical pathways and quality tools can help operators reduce waste before, during and after procedures as well as reduce complications and costs—in some cases even more so than new technological breakthroughs. To be effective though, they need to be disseminated widely and applied broadly. MedAxiom presenters and Jordan Safirstein, MD, of Morristown Medical Center in New Jersey, discussed how same-day PCI discharge pathways led to an effort to change the now-obsolete SCAI guidelines on length of stay after PCI. Over time, many centers have transitioned from the high-cost traditional TAVR pathway to a minimalist approach characterized by avoiding general anesthesia, surgical cut-downs, extended lengths of stay and prolonged bedrest, explained Mauricio Cohen, MD, of the University of Miami.

Interventional cardiology has no shortage of proven, evidence-based tools for improving quality, as several boot camp presenters noted. The field’s operators are positioned to reduce inappropriate PCIs by committing to better documentation and limit contrast-induced nephropathy and bleeding complications by championing risk assessments linked to fluid management, anticoagulation and vascular access choices.

The next several years are poised to bring the most dramatic changes in healthcare reimbursement seen in decades. One thing is certain: Value-based reimbursement is here to stay, and all of us—physicians, hospitals and insurers—need to move swiftly to prepare for the shift.

Arnold H. Seto, MD, MPA, and Robert J. Applegate, MD, are interventional cardiologists at the Long Beach Veterans Affairs Medical Center in California and the Wake Forest Baptist Medical Center in Winston-Salem, N.C., respectively. Seto directed SCAI’s 2017 Cath Lab Leadership Boot Camp while Applegate was the scientific sessions program chair.