Opting for Outpatient: Specialty Clinics May Emerge as Hubs for Cardiovascular Care

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As the U.S. transitions toward new payment models, healthcare organizations are rethinking how specialized postacute care clinics figure into efforts to improve patients’ outcomes and reduce costs.

Surging demand

Assemble the forecasts of health analysts, associations and government agencies, and the picture that emerges is one of a growing number of patients with multiple chronic conditions whose healthcare needs are likely to strain the U.S. medical workforce and economy. By 2035, the American Heart Association says, nearly half of Americans will have some form of cardiovascular disease and the costs of their care will have soared to $1.1 trillion, up from $555 billion in 2016 (see related figure on page 15). Amidst such projections, the Centers for Medicare & Medicaid Services (CMS) has said it wants 90 percent of traditional Medicare payments tied to quality or value by 2018. CMS is phasing in new reimbursement models, such as the Medicare Quality Payment Program and bundled payments, with the goal of cutting costs in part by holding providers more accountable for patients’ outcomes and satisfaction.

As these and other pressures mount, cardiology practices are developing strategies for staying in better contact with patients, especially in the vulnerable period after hospital discharge. Some practices are expanding the range and number of specialized outpatient cardiovascular clinics they offer for patients with common or hard-to-manage conditions, such as heart failure, hypertrophic cardiomyopathy, atrial fibrillation (Afib), hypertension, hyperlipidemia or valvular heart disease.

Source: American Heart Association. 2017. Cardiovascular Disease: A Costly Burden for America— Projections Through 2035; reprinted with permission.
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The more-clinics tactic was highlighted in January at the American College of Cardiology Cardiovascular Summit, where speakers addressed questions about how to improve patients’ access to care, deploy advanced practice providers (APPs), support practice growth and reduce the number of patients who are readmitted or treated in emergency departments.

Randomized clinical trial data would be needed to confirm whether specialized cardiology clinics enhance the quality of care, says Paul Heidenreich, MD, professor of medicine at Stanford University and a cardiologist at the Veterans Affairs Palo Alto Health Care System in California. “Still, most people would agree that patients with cardiovascular issues are best managed in specialty clinics.”

Ginger Biesbrock, PA-C, MPh, MedAxiom Consulting
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Matching populations with resources

Specialized clinics may contribute to the goal of improved clinical outcomes at reduced costs because the setting is suited for matching patient populations with resources that patients with specific conditions tend to need. These clinics succeed because they assemble multidisciplinary teams with strong “content expertise,” says Ginger Biesbrock, PA-C, MPh, vice president at MedAxiom Consulting. “If I’m working with only hypertrophic cardiomyopathy or only heart failure patients, I’m going to get very good in these areas. These clinics allow providers to manage patients who are very complex.”

Heart failure patients, for example, benefit from a variety of resources, and it can be “hard for a cardiologist to offer that kind of access, such as [to] social work, pharmacy, dietary and education, in their typical models, where they’re managing patients with highly critical issues,” Biesbrock says. “[By] pulling out these patients and managing them as a specific entity, we’re able to offer a level of resources greater than we could at the regular office.”

Specialized clinics also may represent an opportunity to increase satisfaction for both patients and healthcare professionals. When physicians, APPs, pharmacists, dietitians, social workers and other health professionals work closely together in a clinic they may be better able to understand the population and have a positive impact on workflow and patient management. These strengths may translate into benefits patients appreciate, such as timely or same-day appointments, improved cross-specialty coordination for patients who have co-morbidities and tackling problems that might otherwise lead to readmissions.

The specialized clinic also may be a setting where physician assistants and nurse practitioners can work “at the top of their license,” which can increase productivity for the practice and satisfaction for the APPs, says Vicky Wild, NP-C, chronic cardiac disease programs manager at the Heart and Vascular Institute Clinic at Memorial Health University Medical Center in Savannah, Ga. Staff efficiency and greater attention to patient management and care also can help reduce costs.

Paul Heidenreich, MD, Veterans Affairs Palo Alto Health Care System
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Planning & monitoring

With the plan to launch Medicare’s cardiac episode, or bundled, payment models in 2018 (see related article on page 18), there’s “great interest in good outpatient care,” especially in the 90 days after discharge for myocardial infarction or coronary artery bypass graft surgery, Heidenreich says.

Practices may be tempted to roll out a variety of new clinics quickly, but a better strategy, he suggests, is to take small steps, including reaching out to other practices in the area to learn from their experiences with specialty clinics. “Ideally, find another clinic in your area that’s up and running,” Heidenreich says.

It’s also crucial, Biesbrock stresses, to have a solid business plan that reflects the practice’s governance and defines the clinical strategy. A successful plan also hinges on deep knowledge of the patient population, including the number of patients with the condition the clinic might serve and their needs.

“You can’t just focus on cardiac,” says Wild. She recommends studying the area’s demographics and considering issues such as homelessness, access to transportation and insurance status. Wild made sure her heart failure clinic was located on the bus route because she anticipated that many patients would not have a car.

Demographic data also help with establishing a systematic approach for identifying and routing patients to the clinics, which Wild and Biesbrock consider essential to the success of a clinic.

“I’ve seen clinics open and close because they failed to establish their patient demographic upfront and have no patients,” Biesbrock explains. “A way to create a steady stream of patients is to automatically refer every heart failure patient to the clinic before discharge.”

Constant monitoring is critical for ensuring a clinic’s survival. Clinic staff should track numbers of new and established patients, their referral sources, retention rates, wait times and requests. If patients are asking for weekend and evening appointments, then restructuring a clinic’s operating hours could help with retention and satisfaction, notes Heidenreich.

He also recommends studying how the clinic team is working. The challenge, he says, is for everyone to be busy, working at their level of expertise and licensing, “with no redundancies and no time wasted.”

The fee-for-service reimbursement model has magnified the challenge because many of the services that clinics should be providing haven’t been reimbursable. “It’s been a struggle,” Biesbrock says, because cardiologists have had to pay social workers, case workers, pharmacists and others out of pocket [in order to staff clinics].”

It may get easier as value-based reimbursement models evolve to cover the work of more providers and as research supporting best practices is conducted. Regardless, the key, according to Biesbrock, is to think of specialty clinics as part of a “larger group of population-based strategies.”