Why risk-taking is integral to increasing value in cardiology

Medicine is, and has been for years now, trending toward a more value-based payment system. But what exactly does that mean, and where does cardiology fit in?

“Value” is a concept that’s increasingly hard to define in the healthcare landscape, Tim Attebery, DSc, MBA, CEO of the American College of Cardiology, said at MedAxiom’s Fall CV Transforum in Dana Point, Calif., Oct. 23. Warren Buffet famously described the idea in less than 10 words—“Price is what you pay; value is what you get”—but it’s not that straightforward in medicine.

The most bare-bones definition of value in healthcare is that it’s the product of benefits minus costs. Strategy expert Michael Porter, PhD, brought quality into the equation, making value equal to quality divided by cost, and in 2013 Utah radiologist Vivian Lee, MD, expanded the definition to include service as a variable.

It’s hard to pin down a concept that’s always in flux, Attebery said, but he summed up value as the output of outcomes like quality, safety, access and equity divided by total payment. In this case, he said, payment is society’s cost.

“We’re going to define value by what is provided by what you do for society,” he said, addressing clinicians. “For patients, not stakeholders.”

Attebery’s expanded equation also considered risk and time, where value was equal to outcomes over price times some risk. Risk can be positive or negative depending on how much responsibility a practice wants to claim for its outcomes, but the CEO argued that physicians who refuse to take risks will actually lose value in the long-term.

“If you say, I don’t want to take any risk and I just want to be paid the guaranteed payment, and someone else can take the risk on the outcome, then I would submit to you that you’re going to end up generating less value,” he said. “The more risk you take, I posit you’re adding more value.”

Risk pays off

There’s great economic value to taking risks in healthcare, Attebery said, insisting it’s a “very important point for all of us to embrace” in 2019. There are a whole host of elements of risk, including risk for outcomes, total costs, coordination of post-discharge care, and risks for specific populations with certain conditions. Again, it’s a term that suffers from a lack of a standardized definition.

Whether or not to take risks in cardiology—and therefore push the field forward—should be a carefully calculated decision, Attebery said. But while choosing to not take risks is a rational decision, he doesn’t necessarily recommend playing it safe.

“If you say you don’t want to take risks, essentially what you’re doing is paying somebody else to take a risk,” he said. “You’re giving up some of your potential income to someone else who is taking risks. So I would say you’re leaving money on the table.”

And that’s not the only place cardiologists are missing out, Attebery said. Conservative estimates in the U.S. suggest some 20% of CVD spending is avoidable or unwarranted, translating to $60 billion in lost income per year. Medicare payments to cardiologists in 2016 totaled $14 billion—a sum Attebery argued could be funneled into cardiology departments to improve their quality of care.

Practices can also attempt to cut costs by reducing the number of avoidable events like repeat surgeries or hospital readmissions, minimizing clinical errors and lowering external costs.

Increasing value in cardiology will be a challenge, Attebery said, but it’s possible through risk-taking, improved outcomes, reduced prices and utilization of resources. Terms like “value” and “risk” also need to be standardized, which he said will likely take a long time without some initiative.

“We should lead this dialogue,” he said. “We shouldn’t wait for the insurance companies, or for Seema Verma, or for whoever the president is or whoever’s in charge of Congress, to come to us with a definition. We should be leading that definition.”