Author + information
- James T. Dove, MD, FACC, ACC President⁎
- ↵⁎Address correspondence to:
James T. Dove, MD, FACC, American College of Cardiology, c/o Padmini G. Rajagopal-Moorehead, 2400 N Street NW, Washington, DC 20037
The drums are beating louder for health care reform. Every presidential candidate has raised concerns about the uninsured and proposed a plan to extend coverage to them. Beyond that, details are sparse; the plans focus more on cost and volume control and are sprinkled with points about quality and waste.
Unfortunately, the candidates’ proposals contain most of the same flawed policies found in the “reforms” imposed on our health care system during the past 15 years. Those policies failed before and they will fail again because patients and physicians have been told what to do—not asked what needs to be done. For positive health care reform to happen, that has to change. The most important participants must be at the table. Patients have seen a progressive erosion of choice and have experienced controlled access while physicians have been increasingly strangled by regulations and perverse incentives. Cost controls have been thinly veiled as quality measures.
Our Responsibility as Stewards
Many health care professionals have taken advantage of opportunities to improve quality and coordination of care and to decrease over-utilization and duplication of services. They have responded with better adherence to guidelines and performance measures, use of registries, and acceptance and implementation of work plans such as D2B and appropriateness criteria. However, there is much more that can be done through care team development with prevention and acute and chronic care coordination. We have not been the best stewards of medical resources. We see wide variations in the use of procedures and medical testing. All health care professionals must be better stewards and accept the challenge to use these resources more wisely.
We should, however, not lose sight of the many extraordinary accomplishments of medical care. Mortality for acute heart attack has decreased over the past 30 years from >30% to <5%. Mortality for all cardiovascular disease declined 26% between 1999 and 2005. Stroke mortality decreased by 24% during that same period. Medical care is more evidence-based, and the delivery of quality is better than it has ever been in the history of medicine. These successes and many others are something of which to be proud. However, we also know and have the tools to do better. We need to focus on quality appropriate care in a timely, safe, effective, and efficient manner.
Reaching the goal of quality appropriate care for all patients will require a system redesign that makes full use of electronic health records, interconnectivity, collaboration, and team-based care. Patients, physicians, and other members of the health care team are best equipped to accomplish this. It will be difficult to do, particularly in our current system, which currently stifles innovation and fails to support quality system development.
ACC Health Care Reform Summit
On February 1 and 2, 2008, the American College of Cardiology sponsored a Health Care Reform Summit to gain a better understanding of the perspectives of patients, labor unions, seniors, economists, government, and other medical societies. Before this summit met, a Blue Ribbon Panel (BRP) of Fellows of the American College of Cardiology and members of other medical organizations discussed the current state of health care, barriers to reform, system redesign, and payment reform to support the redesign.
The principles developed by the BRP focus on a system redesign that promotes care coordination, evidence-based medicine, guideline adherence and appropriate quality care. The redesign also requires a connected information technology (IT) infrastructure—which will not happen one practice at a time and most likely will require a mandate for interconnectivity. Government and payers will need to fund and promote the adoption of electronic systems. Health care in the U.S. is often faulted for failing to adopt information technology. Many countries with government-funded health care have IT systems paid for by the government. In our country, the continuous ratcheting down of physician reimbursement over the past 15 years and increases in overhead costs have made it impossible for many practices to invest in IT infrastructure.
Coordinated care will save money; however, the savings achieved with system development need to be reinvested into further infrastructure improvements that promote developing evidence-based care, preventive care, and acute and chronic care models. That has not been the pattern for savings achieved in the past several years. Instead, we have seen excess profits leaving health care and not benefiting patient care or system redesign. John Tooker, executive vice president and chief executive officer (CEO) of the American College of Physicians, suggests that physicians and patients have a poor understanding of the economic interests of the other players in the medical marketplace.
Considering a Proposed System Design
The output of the BRP was presented for all of the participants at the summit to serve as a critique sounding board. Summit attendees were asked to comment on the basic principles of health care reform with patients and physicians at the center of the BRP redesign. The response was a resounding “yes” to the design and a “yes” to the important role that patients, physicians, and care team members should play in creating that design. There was unanimous agreement that universal coverage and access to care were necessary in any system.
It is easy to respond, “What are the details?” Obviously, an overall structure is needed on which to build. Health care has many regional variations in patient and physician preferences. One size will not fit all. We heard at the summit that there are 168,000 medical practices in the U.S. comprising 1 to 4 physicians. Forcing them into a single structure would be a nightmare and counterproductive. A better strategy would be to design several possible templates that can be further adjusted and adopted based on regional and local preferences.
Jerry Shea, assistant to the president for governmental affairs of the American Federation of Labor-Congress of Industrial Organizations, commented that 76% of their members have insurance coverage. Likewise, 76% want health care reform. They are concerned about the uninsured, but they fear more losing what they have.
We physicians also fear the unknown and are concerned that the replacement might be worse than the present. These fears are justified for both patients and physicians because that is exactly what has happened over the last 15 years.
The time has come to build a coalition of patients and physicians from multiple organizations and medical societies to lead change. We must be at the table because, as John C. (Jack) Lewin, CEO of ACC, has said, “You are either at the table or on the menu.”
Will we have health care reform based on quality appropriate care or a continuation of the cost of volume controls that have failed so far? We need to guide the path to designing a system of best care around which financing has to mold rather than molding a care system around financing priorities. That doesn’t mean ignoring costs, but it does place quality care as the top priority.
The question for ACC members now is: should we accept more of the same or proactively lead the change? The answer seems obvious.
- American College of Cardiology Foundation