SAN FRANCISCO—“Will physicians' input be included in the healthcare delivery reform movement? If that’s just a dream, how can we as physicians turn it into a reality?” Thomas Lewandowski, MD, of Appleton Cardiology ThedaCare in Appleton, Wis., asked these questions at a March 9 session at the American College of Cardiology (ACC) scientific session.

Healthcare is “a huge business in the U.S., at roughly one-third of the economy or $2.8 trillion,” he said. “That size of an industry will not change course quickly unless there is a major disruptive force or a lot of pressure, which is why insurers haven’t moved on healthcare delivery reform.” However, hospitals are starting to participate in accountable care organizations while maintaining fee-for-service. “Hospitals are keeping a foot in both canoes, as they try to figure out how to navigate the system.” As the third component of the healthcare delivery rung, healthcare professionals, and physicians in particular, think about healthcare in terms of quality.

Yet, Lewandowski said that physicians need to start thinking about healthcare in terms of value, as opposed to simply quality. In addition to quality, the term "value" in healthcare includes consumer satisfaction and some assessment of how well physicians manage resources that are distributed for a particular position.

“Unfortunately, if we don’t do a better job assessing ourselves, there are plenty of organizations out there that will be very [willing] to determine what should be the quality of care or value that we provide,” he said. “Is it acceptable for other organizations to define quality of care and dictate how can it be assessed?”

Lewandowski also spoke to the problem of the business community using claims data to assess value and to create metrics to come up with a definition of value. Claims data does not address patient outcomes, nor if a procedure was clinically necessary. “As a physician, there is nothing in this claims dataset that better directs care,” he said. “Also, [due to] the way in which procedures are coded, it is difficult to assess if it was performed by a physician’s assistant, a nurse practitioner or a physician.”

To better inform practices, nine U.S. states are participating in the Quality Resource Utilization Review (QRUR), whereby physicians receive reports about how they are performing compared with their peers both clinically and economically.

As an example, Lewandowski showed one of his QRUR reports, which compared costs ranked nationally:

• Total for whom physicians filed any claim: 17,195 vs. 19,098;
• Patients whose care physician directed: 15,366 vs. 10,159; and
• Patients whose care physicians influenced: $2,607 vs. $9,359.

He pointed out that some costs, such as those associated with imaging tests, are ordered by the primary care physician (PCP), but they are attributed to the cardiologist because they submit the bill. In Wisconsin, for instance, 50 percent of the imaging studies are ordered by the PCPs, but those studies are not attributed to them.  

A value-based purchasing model needs to combine each quality measure into a quality composite and each cost measure into a cost composite, according to Lewandowski. The QRUR report takes metrics within cardiology to show the cardiologist how he or she is comparatively performing nationally.

“In cardiology, we are blessed by having information provided through such means as the NCDR [National Cardiovascular Data Registry],” he said. “There are trends, there are variations. Giving feedback to the cardiologists will change their behaviors. Let’s redefine a different way to do data that properly assesses the clinical community, and allows us to change from within.”