The ACC Corner: Linking Providers with Payors Helps Navigate Healthcare Reform

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William R. Lewis, MD, FACC

As Congress and other policymakers seek to lower costs, improve access and ensure quality in the U.S. healthcare system, there are increasing opportunities for collaboration between healthcare providers and payors.

Over the last several years, the American College of Cardiology’s (ACC) Medical Director’s Institute (MDI) has sought to identify these opportunities in which cardiovascular specialists, medical directors from national and local private health plans, and other industry stakeholders can partner to improve efficiency and quality of care.

In attempting to bring about change and collaboratively develop systems of care, partnerships and programs have grown out of past MDI meetings, such as working with payors like UnitedHealthcare to pilot test the ACC’s Appropriate Use Criteria (AUC) as a clinical decision support tool. Currently, discussions are underway with several health plans around adoption of an ACC-sponsored alternative to radiology benefit managers, based on the AUC and tied to quality improvement and education tools.

Discussions also continue with payors on the use of registries, like the PINNACLE Registry, as a means of measuring and reporting quality that does not rely solely on claims data. In an era of transparency, the ACC and other organizations are committed to the collection of accurate data and the provision of information to members and patients to assist in shared decision making. However, it is essential that quality be measured the right way using the best data.

When it comes to performance assessment, it’s critical that physicians lead the process. Physician groups and health plans must work together to develop the right incentives to support and encourage participation. The college’s Cardiovascular Practice Improvement Pathway—a byproduct of past MDI discussions on how to define a quality cardiovascular practice—is nearing completion. The pathway is designed to help practices establish quality goals and targets the creation of a roadmap to guide performance improvement activities. Also, it is intended to bring consistency by standardizing the methodology for how cardiovascular practices are assessed and recognized.  

These topics, as well as payment reform, care coordination and the role of payors and providers in quality improvement and cost containment, were on the agenda for the most recent MDI meeting in October. This conference was a forum to discuss how various payment models could establish care management processes, improve quality and fairly distribute cost savings and decision making. Participants also discussed what competencies need to be in place for each stakeholder to succeed both financially and in terms of quality improvement.

MDI participants heard from health plans, such as Horizon Blue Cross and Blue Shield, on ways they are working to coordinate care, share patient data and assign performance metrics across sites of service. Participants were able to discuss the role of specialists in achieving targets and outcomes, and the ways that cost savings can be distributed to participants. In addition, patient-centric models, such as shared decision making and care management, were explored. This forum provided an opportunity for participants to learn more about leadership and management structures needed to be in place to enhance coordinated care.

As the U.S. moves forward with implementing healthcare reform, collaboration between health professionals and health plans is key to ensuring the most effective implementation and the greatest value and support for cardiovascular professionals and their patients.

Dr. Lewis is chair of the 2010 ACC Medical Director’s Institute and chief of clinical cardiology at MetroHealth Medical Center in Cleveland.