ACC Corner: Payment Reform Key to Triple Aim of Healthcare
In the debate over how to achieve the "triple aim" of better healthcare, improved quality and lower costs, payment system reform emerges as one of the central issues needing to be addressed. While most would agree that any new payment system needs to reward value instead of volume, how best to achieve these ends remains the question.

To date, no single payment model has been proven effective for all care settings, and it is likely that different models will be effective in different practice settings. In general, the American College of Cardiology (ACC) supports payment reforms aimed at improving coordination of care, team-based care delivery, the appropriate use of tests and procedures and medication adherence. The ACC also is supportive of incentives for care providers—and patients themselves—to improve quality, efficiency, outcomes and value of care while reducing overuse or underuse of tests and technologies.

To help shape the debate, the ACC is developing several payment models for cardiovascular care that could be broadened to the larger healthcare arena if successful. One proposed model would bundle payments for a variety of providers over an episode of chronic disease, such as stable ischemic heart disease. The bundling may cover an entire episode of care or be broken into smaller bundles that reflect patient preferences for care. This model has the potential to help eliminate unnecessary procedures, reduce administrative burdens related to documentation and the pre-authorization of individual services. This would facilitate adherence to guidelines and appropriate use criteria, as well as encourage registry participation.

The college is looking to systematize more effective patient care transitions with the goal of reducing the costs related to hospital readmissions. Nearly 20 percent of Medicare patients are readmitted to the hospital within 30 days of discharge and heart failure is the most common reason for readmission. In 2004 alone, the total cost of heart failure readmissions was $17.4 billion—a failure of the care continuum. Through a partnership with the Institute for Healthcare Improvement, the ACC 's Hospital to Home initiative aims to find ways to improve patient transitions from hospital to "home" and reduce unnecessary readmissions.

Finally, the college is investigating population health management, or "comprehensive care" payment models, for patients who receive primary care from specialists such as cardiologists. While recent accountable care organization (ACO) regulations have focused on primary care, some patients with significant illness such as congestive heart failure receive comprehensive care from a cardiologist. Feasibility of the medical home model and the ACO model for a medically complex patient will be tested for application in specialty practices.

In the U.S., these and other pilot programs at the state and national level over the next several years could contribute toward a better understanding of what types of incentives are needed for improved care coordination, as well as what various-sized practices might need in terms of health IT, and workflow redesign to ensure all patients are receiving the quality of care they deserve. To be truly effective, medical societies like the ACC, as well as Medicare, private payors, Congress, patients and others, will need to work together to share best practices and identify hurdles. The path ahead will not be easy, but if done properly it will lead to not only cost savings, but improved care delivery.

Dr. Casale is head of the ACC's Payment Reform work group and sits on the editorial board for the new online Community on Payment Innovations, a partnership between the ACC and the American Journal of Managed Care, which will launch later this month on