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- Richard P. Lewis, MD, FACC, President⁎
- ↵⁎Address for correspondence: Dr. Richard P. Lewis, Ohio State University, 1654 Upham Drive, Room 643, Columbus, Ohio 43210-1250.
The results of the 1995 Managed Care Survey of the ACC membership are published in this issue of the Journal (1). This survey confirms the findings of the original survey of 1993 (2). A large majority of the membership are involved with managed care and have adjusted their practices by merging, networking, installing clinical pathways and instituting continuous quality improvement programs. It is clear that most do not like managed care, particularly the limitations on access to cardiovascular specialists and other restrictions, which are perceived to reduce the quality of care (and raise ethical dilemmas). There is a strong sentiment that physicians must now proactively respond to these changes.
The United States spends more on its health care system than any other nation (>$1 trillion). Unlike other nations, one-half of our system is not directly funded by the government. It appears that we have enough doctors and facilities to provide optimal care, although they are not optimally distributed or universally available. Since 1960, health care costs have consistently exceeded the rate of inflation. By the 1970s, the private sector was embracing the managed care concept, concluding that the fee-for-service system needed to be altered to eliminate incentives to provide “more” care.
The growth of the managed care industry in the past 10 years has been truly remarkable. Extensive mergers and acquisitions have been allowed by the government (shades of the 1890s?), while attempts by physician groups to organize have been suppressed by rules from the Federal Trade Commission. Obtaining the lowest cost, regardless of quality (even when quality measures are available) has been the driving force of managed care up to now. Physicians, as well as other health professionals who viewed this with alarm, were ignored. Only recently has evidence appeared that a strictly cost-based health care system produces bad outcomes (3,4). This is especially true for patients with chronic cardiovascular disease and patients on Medicare.
Despite claims to the contrary, managed care by both private insurers and Medicare has not slowed the growth of total health care costs. Indeed, the inexorable increase in health care costs is a worldwide problem, reflecting new technology for diagnosis and therapy, a high percentage of costs due to health care worker salaries (more than half the total cost) and the successful application of new technologyto the older population.
The failure to control costs is also related to a major characteristic of medicine, that of “marginal decisions,” which is poorly understood by business (5). Marginal decisions, in an economic sense, are those for which there is little clear scientific basis and are thus very difficult to make (and no one wants to make them). As doctors, we make these decisions every day (we call this “clinical judgment”), and this process has proved hard for managed care to control.
Despite the tremendous growth of the managed care industry, it is still very much a work in progress (6). The optimal arrangement among physicians, their patients and payers is still not clear. The dominant model today (i.e., for-profit managed care) may not be so in 5 to 10 years. Furthermore, as Ginsberg (7) points out, the “market solution” applies onlyto one-halfof the health care system. The majority of hospitals are nonprofit, with a mission for charity care. The competitive market cannot provide for the poor or change the public's bad health habits. Thus, eventually health system reform requires that the interests of both the private and public sectors be addressed.
In the past year, two important changes have occurred that will be helpful for the preservation of high quality cardiovascular care. First, our patients have called Congress, the managed care industry and the media about the adverse effects of restricting specialty care. As a result, Congress, the President and many business leaders now accept this concept. Second, the Federal Trade Commission released new rules that make it far easier for physician-led networks to enter the market and compete on quality (as well as cost). Until now, physicians have been largely excluded from planning health care system change, but their inclusion now appears possible.
Cardiovascular medicine is a critical component of planning for the health care system of the future because cardiovascular disease will be even more prevalent as a cause of morbidity and mortality by the year 2010. Indeed, some project a shortage of cardiovascular specialists at that time, particularly as the number of current trainees continues to decline (8,9). Our specialty is particularly well positioned to participate in the development of the new health care system because we have well established, cost-effective disease management strategies for nearly all types of heart disease (prevention, ischemic heart disease, valvular disease, congestive heart failure, arrhythmias, hypertension).
Rather than accepting a “dumbed down” purely cost-control reform strategy, we need to advocate a system in which quality at a good price (value) is the objective. This means that cardiovascular specialists first must eliminate the unnecessary costs that we generate. we have already done much in this arena. Economic efficiency in caring for patients in the hospital has doubled in the past 10 years (sicker patients cared for in half the time at half the professional fee). There has been continuous improvement in the efficiency of our laboratory procedures. Unfortunately, new technology (usually with a better outcome) has obscured this. But we can do better, and we must develop strategies using our ACC/AHA guidelines to further decrease costs without compromising care.
As quality and value rather than cost control become the paradigm for the new system, cardiovascular specialists, with leadership from the American College of Cardiology, can proactively enter the health care system reform debate. The ACC/AHA practice guidelines are a critical component of this effort because these guidelines are nationally accepted as advocating the highest quality care. However, the guidelines need to be kept current, to be expanded and, most important, made more user friendly. The College must collaborate with the government, business, managed care and other interested physician groups to accept the guidelines and develop methods to implement them in daily practice. This will require new approaches, which were extensively discussed at the October Bethesda Conference on Practice Guidelines and the Quality of Care.
The ACC data base has been substantially altered to provide a meaningful and unbiased national benchmark. All of us must participate to provide information on the state of the practice of cardiovascular medicine. This outcome data base is far superior to charge-based data bases widely used by government and managed care. Our data base will help us to develop data-driven guidelines. Methods are being explored to combine guidelines and other evidence-based medicine into computer-based systems that simultaneously provide outcome data to our data base and recommendations for and documentation of clinical care.
A better understanding of cost-effectiveness and other economic concepts is essential to the development of new practice guidelines. The ACC economic summit, planned for February 1997, will be a start, and it will then be possible to incorporate this knowledge into our various CME programs, and, most important, our practice guidelines.
In the managed care setting, patients must assume more responsibility for their own care. This requires more effective patient education, which will be feasible once the ACC web site is underway.
There is one vitally important caveat with regard to the implementation of the ACC/AHA clinical practice guidelines. The guidelines, in reality, are only a matrix for experienced players. They assume considerable knowledge of cardiovascular medicine as well as clinical experience in caring for patients with cardiovascular disease. There are still many class II indications that require that marginal decisions be made. In one sense, guidelines make decision making easier by providing expert consensus opinion, but, paradoxically, their very presence increases the complexity of the decision making. Thus, we must be sure there are adequate numbers of clinical cardiologists available to care for the increased number of patients in the future, especially because only half of such patients are currently seen by a cardiologist.
In the traditional fee-for-service system, the major problem was too much care. In the new paradigm, it will be too little care. Thus, as part of the College's role to advocate optimal quality and value, it must also speak out about too little care when such exists.
Einstein once noted that in the middle of every difficulty there lies an opportunity. The current system is in a state of flux. The time is now for cardiovascular specialists, with the leadership of the ACC, to actively participate in the development of a new health care system, where quality care, value and accountability are the major features. If we are successful, I foresee that organized physician and payer groups will eventually develop quality patient care systems by direct negotiation, with insurers once again serving only as underwriters.
- American College of Cardiology
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- 9.↵Centers for Disease Control U.S. Department of Health and Human Services Advance Data 1993;226(Mar 4):4.