Thriving as a Cardiologist in the Post-reform Era

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 - Eric C. Stecker, MD, MPH, FACC
Eric C. Stecker, MD, MPH, FACC

The Supreme Court’s decision to uphold most elements of the Patient Protection and Affordable Care Act ensured that major structural changes in healthcare will continue to rapidly evolve. Most discussions of reform have centered on access to coverage, access to care and potential mechanisms of cost savings. But this is only half of the story. 

A critical factor differentiating the current round of healthcare reforms from the managed-care reforms of the 1990s is an emphasis on “value” across the spectrum of approaches. High-value medical services maximize quality while minimizing cost.   

As healthcare reforms are implemented at the national, state and local levels, responsibility for managing quality will fall on cardiologists working with hospital and clinic administrators. In the past, cardiologists added significant monetary value for health systems by generating large patient encounter volumes with only crude measures of quality in a fee-for-service environment. In the future, individual cardiologist’s importance for an organization will be defined using sophisticated measures of quality balanced with revenues and costs in a global payment (capitated) environment. To achieve this, cardiologists must identify which organizations can succeed and work in leadership roles to help those organizations adapt as reform evolves. 

Anyone who has experience with Medicare’s Meaningful Use might be skeptical about the accuracy and impact of quality improvement efforts. Healthcare’s quality efforts remain in their infancy and are being rolled out across a fragmented industry that often has 1990s-era IT infrastructure and entrenched organizational siloes. But other industries have successfully approached quality improvement and some healthcare institutions have already gained traction and efficiency.

It is no longer sufficient to say we provide high-quality care; we must demonstrate it objectively. Quality metrics remain imperfect but will improve over time and provide important information for patients and policymakers. Patients who see cardiologists participating in programs like ACC’s Imaging in FOCUS, and using registries such as those that fall under the ACC’s National Cardiovascular Data Registry umbrella, can be assured the appropriateness and quality of their inpatient and outpatient care is being monitored and in most cases continuously improved. The ACC’s clinical publications, including practice guidelines, consensus documents, appropriate use criteria, data standards and health policy statements are also excellent resources when it comes to guiding the most appropriate, evidence-based care.

Medicare has initiated value-based purchasing programs to incentivize healthcare systems to improve quality. These programs could expand considerably if proven successful. Individual health systems and insurers have experimented for many years with various financial programs to incentivize physicians to improve quality metrics or outcomes. The impact of these pay-for-performance programs has been mixed, but as pointed out by Andrew Ryan, PhD, and Jan Blustein, MD, PhD, appropriately targeted and scaled monetary incentives are likely to have an impact (N Engl J Med 2012;366:1557-1559). Programs that incentivize patients by lowering or eliminating copayments (value-based insurance design) have proven very effective and are critical to aligning both the “supply” and “demand” of high-value care.

Physicians are accustomed to caring for individual patients who engage them in the clinic, emergency department or procedural suite. However, by necessity the measure of a population’s health is made at the population level, not the individual level. Federal, state and local governments as well as employers have become more motivated to track aggregate health measures. As a result, cardiologists will become increasingly responsible for reporting and improving the health of all the patients in their practice as a whole. It will be important for cardiologists to gain the familiarity and skill to manage populations, but also retain sensitivity to issues that could harm individual patients so that policies and metrics can be modified accordingly.

If healthcare reform efforts are appropriately structured, cardiologists can thrive by focusing on efficient provision of high-quality care for individuals and populations. This will be best achieved when cardiologists align with and attain leadership roles in health systems that focus on and incentivize