Author + information
- W. Douglas Weaver, MD, FACC, ACC President*
- ↵*Address correspondence to:
W. Douglas Weaver, MD, FACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037
The health care system in our country is broken in many places, and fixing all of it at the same time will be difficult and unlikely to occur. On the other hand, fixing parts of it may have unintended consequences and change one set of perverse incentives into another. With the country currently in economic turmoil and 500,000 people losing jobs each month, will there be the will and energy to engage both the Congress and stakeholders into a meaningful dialogue that will lead to real improvements?
One of my greatest worries is that we could be victims of across-the-board price cuts for today's health care instead of having real reform centered on access and quality. It is estimated that health care costs are one-third or more higher than the value of the service received. Also, possibly as much as two-thirds of the recent increases in cost are due to new technologies such as imaging—the things that cardiologists do every day. Some of the suggested solutions are also difficult, too. For example, can we really “bundle” the professional and hospital costs of some of our expensive and common chronic conditions when most of medical practice is sized at twos and threes?
We live in a country in which primary care physicians are doing nuclear, computed tomography, and magnetic resonance imaging in their offices, yet they have never been formally trained in these procedures. They do it to help keep down the expenses of their practices, because they—and we—know that the current system disproportionately rewards facility fees over evaluation and management.
Can we regulate these things while maintaining convenience for patients or efficiently managing a medical complaint? Can we make timely changes in regulations in a setting in which clinical guidelines, appropriate use criteria, and even the technology itself change more rapidly than regulations can be updated? Will it really be possible to fix the many deficient parts of our health care system, while at the same time aligning payment accurately with change to avoid unintended consequences, and do this in a way that motivates change?
For all of these reasons, I believe the College must target its message to both the reformers and to our members on the few things that we can control and that we believe will make a difference and improve the health care that we deliver. Whatever we do, we need to remember that not all of our medical and surgical partners will agree with what we are doing. Medicine does not have a single voice of professionalism. There are many constituencies—some of whom act and talk as trades—and we have no consensus because each physician organization realizes that change is likely to be incremental, and a small improvement for one group will most likely gore another.
Contributing to today's situation is a medical system of delivery in which millions of people are uninsured or underinsured. The U.S. spends $2.3 trillion each year on health care. The cost per capita for health care in our country is $6,800. The average insurance premium of $12,580 for a family is rising rapidly, and individual contributions for care have more than doubled in the past 10 years to more than $3,500 a year. These amounts are at least twice that of other Western countries, including Germany, Switzerland, and Australia, yet the statistics show that the U.S. is dropping in the general measures of health of its population. We rank last or 19th among industrialized countries on the number of preventable deaths and 29th among 37 in infant mortality—almost double that of France or Germany.
Health care expenses are rising at an unsustainable rate, and the government is empowered to change that because it presently picks up the tab for more than 40% of the health care that is delivered. We are not going to be successful in convincing others to maintain the current reimbursements when the variation in utilization of cardiac procedures is as much as 8-fold.
Costs Are Not the Only Issue
Despite the richness of our system, patients are unhappy with the money that they spend on health care and do not want to spend more. They are dissatisfied with the piecemeal care they receive and are unhappy about the lack of access. In hospitals, patients do not know who their doctor is, and throughout the system handoffs happen by chance. The average national patient readmission rate is 15% within a month after discharge, and for heart failure, it is even higher.
Their income may be relatively higher than that of physicians in other countries, but doctors in the U.S. are also dissatisfied. They are frustrated with the bureaucracy associated with physician payment, the escalating costs of overhead, the high administrative costs that benefit neither providers nor patients, and the increasing pressure to do more each year to maintain their own compensation and pay for office overhead, malpractice insurance, and new technology costs.
How the College Should Move Forward
Today specialists make up 68% of the U.S. physician workforce compared with 50% in similarly developed countries. Despite the concentration of specialized knowledge and skills, data show that in those areas with the greatest number of specialists, outcomes are in fact worse—including even mortality.
In my mind, this period in our history offers a defining moment for the College and for cardiologists. We can lead in one important area—improving quality. We can demonstrate to other branches of medicine how to improve quality and even take the bold step of self-regulation.
Yes, we can chime in and support many of the issues articulated by others—universal insurance, comparative effectiveness research, medical education enhancements, and loan programs that favor the pathway to primary care. We can call for increased support of medical and public health research, prevention and wellness programs, increased and interoperable health information technology or electronic records, and greater coordination of care and transparency. But the area in which we can provide the most guidance and set the best example resides with quality of care or shifting from volume to value.
For many years, the College has worked on quality initiatives with our clinical practice guidelines, appropriate use criteria, and consensus documents—defining and benchmarking the quality of care that patients have a right to expect. We have developed registries that allow hospitals and now individual physicians to measure their performance and be able to compare themselves with others. We have taken some of these findings and initiated quality improvement programs such as the Door-to-Balloon Alliance, with which we have had an enormous impact on improving the care of heart attack patients. We have learned from these activities and further refined our guidelines and other recommendations for care. With all of our efforts, we are providing a “Circle of Quality.”
What we are doing is important to all, and our voice can be a loud one because cardiovascular care is the largest budget item for Medicare and for other insurers.
Despite our efforts, we have not rung out all of the waste because we have not implemented either the many clinical recommendations for care or the performance measures for each practicing physician in a way that affects every patient encounter. The reasons are simple. We have not had the funding to expand our registries and other infrastructure to develop point-of-care decision aids for physicians, and we do not have a payment system that rewards physicians adequately for doing these things. In fact, many physicians would take a financial bath if they were to do so with the current payment incentives. If these aids and measures were fully deployed we could provide feedback to individuals, and I would suggest that given good clinical data, we could even self regulate.
The recent attempts by the Centers for Medicare and Medicaid Services to provide physician report cards on use and outcomes using administrative data that could neither risk adjust nor describe a patient condition were woeful. Even more important, they could not profile or match a physician accurately enough to discriminate a subspecialist doing procedures all day from a general practitioner doing an occasional in-office procedure. Reports such as these would be so inaccurate and misleading that they could never gain the traction needed to enact change. The fact is that the College can do this better and provide data that could demand real change.
I believe that our main message has to be about supporting quality and value and providing funding for the gaps in our data infrastructure so that it can evolve more rapidly, and we must advocate for payment reform that rewards adherence to clinical recommendations.
The College can set an example for others as a professional society. In both health care and payment reform, our voice will not make a defining difference in how this nation deals with the uninsured, in solving the high administrative costs of insurance, or in changing malpractice policy. However, we can have a very strong voice and lead the message on how to improve and pay for quality. If our message is focused on the roadmap to improve quality, and it points out the needed infrastructure and payment requirements to get there, we can be out in front and we can make a difference. The time is now for all of us to be the professional society that we portend to be, lest we be considered a trade.
- American College of Cardiology Foundation