Author + information
- Received September 11, 2015
- Revision received October 5, 2015
- Accepted October 20, 2015
- Published online November 10, 2015.
- Lawrence Laslett, MD, Chair, ACC’s Board of Trustees’ Environmental Scanning Work Group (ESWG)∗,
- H. Vernon Anderson, MD, ACC’s Board of Trustees’ Environmental Scanning Work Group (ESWG) Member†,
- Bernard Clark III, MD, ACC’s Board of Trustees’ Environmental Scanning Work Group (ESWG) Member‡,
- Timothy A. Dewhurst, MD, ACC’s Board of Trustees’ Environmental Scanning Work Group (ESWG) Member§,
- Thad F. Waites, MD, ACC’s Board of Trustees’ Environmental Scanning Work Group (ESWG) Member‖,
- Sean Wilson, MD, ACC’s Board of Trustees’ Environmental Scanning Work Group (ESWG) Member¶,
- Steve Erickson, MS, CAE, Project Manager, ACC’s Board of Trustees’ Environmental Scanning Work Group (ESWG)# and
- Anne Marie Smith, MBA, Project Reviewer, ACC’s Board of Trustees’ Environmental Scanning Work Group (ESWG)∗∗
- ∗University of California Davis, Sacramento, California
- †UT Health Science Center at Houston, Houston, Texas
- ‡Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- §The Polyclinic, Seattle, Washington
- ‖Southern Heart Center, Hattiesburg, Mississippi
- ¶The Valley Hospital, Ridgewood, New Jersey
- #Erickson Communications, Washington, DC
- ∗∗Lifelong Learning Services, Washington, DC
- cardiology statistics
- cholesterol management
- clinical risk management
- information technology
- payment reform
Executive Summary D1
Key Findings from the ACC Member Satisfaction Survey D3
Emerging Payment Reform D6
Changes in Certification and Recertification Requirements D10
Healthcare Reform D12
CVD Cost and Reimbursement D16
Current and Emerging Workforce D20
Team-Based Care D24
Key Cardiovascular Statistics D28
U.S. Healthcare System D31
Information Technology D33
Changes in Clinical Risk Assessment and Management of Lipid Abnormalities D39
ACC Members Show High Level of Satisfaction
American College of Cardiology (ACC) members remain satisfied with the organization and its goals of transforming cardiovascular care and helping members thrive in any delivery or reimbursement environment. They are likely to recommend the College to others because of the perceived value of benefits such as the Journal of the American College of Cardiology (JACC) journals, educational resources, and clinical guidelines. Reimbursement, work-life balance, certification issues, keeping up to date clinically, and rising costs top the list of member challenges.
Shift Toward Value-Based Payment Continues
The federal government accelerated its shift away from fee-for-service and toward value-based payment, setting a goal of 30% of Medicare payments from value-based models by 2016 and 50% by 2018. Medicare payment structures are being modified over time to include more rewards based on performance, increasing both the risks and potential rewards for healthcare providers. The Medicare Sustainable Growth Rate (SGR) formula was finally repealed by Congress and a policy favoring value-based payments over quantity-based payments enacted. ACC members view this shift as a major practice focus, and many are participating in value-based pilot programs.
Proposed Changes in Certification Lead to Controversy
A decision by the American Board of Internal Medicine (ABIM) to stiffen its Maintenance of Certification (MOC) program led to significant resistance from physicians who found the new requirements to be burdensome, irrelevant to practice, and of questionable value in improving the quality of care. The debate spilled from professional journals into the consumer press, while the ACC and other medical professional organizations encouraged modifications of the new requirements. Early in 2015, the ABIM acknowledged its miscalculations, announced significant changes to the MOC program, and indicated a willingness to work more closely with the internal medicine community.
Affordable Care Act Hits Fifth-Year Anniversary, Survives Major Challenge
The Affordable Care Act (ACA) marked its fifth anniversary in 2015, providing health insurance to millions and driving a historic reduction in the percentage of uninsured Americans. Opinion polls showed favorable opinions of the ACA topping unfavorable opinions of the new law for the first time. A Centers for Medicare and Medicaid Services (CMS) report on the impact of the ACA showed increases in patient safety, reductions in hospital readmission, and new sources of consumer information about the quality of care. A mid-year ruling by the U.S. Supreme Court upheld a key part of the ACA that provides health insurance subsidies for all qualifying Americans.
Cardiovascular Disease Cost Remains High, Cardiology Reimbursement Declines
Cardiovascular disease (CVD) remains the nation’s single most costly diagnostic group, with a cost expected to top $1 trillion by 2030. However, after years of steady increases, compensation for cardiologists declined. The repeal of the SGR formula will bring small payment increases over the next 5 years, after which new value-based payment formulas will begin. The ACC and the American Heart Association (AHA) have begun to build value assessments as well as clinical efficacy into clinical documents. National investment in CVD research remains at relatively low levels.
Supply and Demand for Healthcare Workers Becoming Less Predictable
The World Health Organization (WHO) predicts significant future global shortages of healthcare workers, but the possibility of healthcare worker shortages in the United States is harder to predict. There will be some increases in the supply of healthcare workers in this country, and some predict future demand to exceed that supply. In cardiology, however, recent rapid changes in the practice landscape may mean that supply and demand may vary significantly by subspecialty and by geographic location. Cardiology groups have reported decreases in utilization for many of the historically high-volume diagnostic tests and cardiac procedures. Surveys of hospitals and health systems show the emergence of new types of healthcare workers such as care coordinators.
Team-Based Care Gains Traction
A move to team-based care is being driven by the increased complexity of medicine as well as regulatory and market factors. While in general, team-based care draws much support in the medical community, there are differing views about the level of independence for nonphysician clinicians and the need for physician supervision. Scope of practice for healthcare professionals varies by state. In cardiology, the ACC is pioneering the evolution of team-based care, and in 2015, the ACC issued a new policy statement that promotes flexibility regarding team leadership and focuses on shared goals and clear roles for the team.
Burden of CVD Remains High
There has been a significant decline in mortality rates for CVD since 1960, yet it remains the overall leading cause of death in the United States. There has been an increased focus in this country on healthy behaviors such as diet, physical activity, and not smoking and health factors such as control of blood pressure, blood sugar, and blood cholesterol. CVD is also the leading cause of death globally, and under the leadership of the WHO, all member states agreed in 2013 to reduce the number of premature deaths by noncommunicable diseases by 25% by 2025. Aging and population growth are causing an increase in global CVD deaths despite a decrease in age-specific death rates in most regions.
U.S. Healthcare System Continues to Underperform
The United States continues to have the world’s most expensive healthcare system while underperforming on some indices of quality compared with other industrialized countries. The rate of healthcare spending is expected to increase after a 5-year slowdown. Drivers of increased spending include administrative complexity, the increasing burden of chronic disease, and the use of technologically advanced equipment and procedures. Significant drivers of change in the system include consolidation, information technology, and consumerism.
Information Technology Rapidly Being Adopted, But Hurdles Remain
The adoption of information technology has grown rapidly, but much progress remains to be made in interoperability and information sharing. The availability of technical assistance, the use of financial incentives, board certification requirements, and the ability to exchange patient information are the top drivers of physician adoption of information technology. Barriers to interoperability include insufficient infrastructure, competition between information vendors, technology challenges, and unresolved policy issues. There is increasing frustration with the complexity of government financial incentive programs.
Significant Changes Taking Place in Clinical Risk Assessment and Cholesterol Management
New guidelines on the assessment of cardiovascular risk and the treatment of blood cholesterol have been released, along with a new online risk calculator. These new clinical tools have introduced broader assessment and prevention strategies, set a foundation for future value-based payment strategies, and stirred controversy. These significant departures from previous approaches generated controversy, but subsequent studies seem to provide support for the new approaches. The first drugs in a new class of cholesterol-lowering medications have been approved and are highly effective in reducing low-density lipoprotein (LDL) cholesterol but are extremely costly, causing concern about affordability.
Environmental Scanning Work Group Members
Appreciation is expressed to the following members of the Board of Trustees’ Environmental Scanning Work Group who contributed their time and expertise to organize, review, and ensure the completeness and accuracy of this report.
Lawrence Laslett, MD, FACC, Chair
H. Vernon Anderson, MD, FACC
Bernard Clark, III, MD, FACC
Timothy Dewhurst, MD, FACC
Thad F. Waites, MD, FACC
Sean Wilson, MD, FACC
Steve Erickson, CAE, Project Manager
Anne Marie Smith, MBA, Project Reviewer
Key Findings from the ACC Member Satisfaction Survey
Between October 15, 2014, and November 12, 2014, ACC conducted its annual online survey of members. A total of 9,933 e-mail invitations were sent to ACC members on October 15, 2014, and 3 reminders were sent subsequently. A total of 1,042 members participated in the survey, a 10.5% response rate. Respondents closely match overall ACC membership demographics. Highlights from the 2014 Member Satisfaction Survey, supplemented by 100 half-hour interviews with selected members and results from a monthly survey panel (CardioServe), are included in the following findings.
The ACC membership is nearly 50,000 strong worldwide. ACC member demographics are listed in Figure 1.
Two-fifths (40%) of members identify reimbursement as the biggest issue facing cardiovascular (CV) medicine. Challenges by percentage are listed in Figure 2.
ACC members remain satisfied with the ACC, see value for the price of their membership, and are likely to recommend ACC membership to others. Overall satisfaction with ACC at 74% and value for price at 62% represent 8-year highs in those categories. Worldwide, ACC is second only to the European Society of Cardiology (ESC) on key measures of member satisfaction. If members could only choose one association, over one-half (58%) would choose to be a member of the ACC. The average of number of concurrent memberships in 2014 is 2.5 with the AHA and the American College of Physicians being the top 2 concurrent memberships for ACC members. This has fallen from a 2.9 average number of concurrent memberships in 2012, indicating more selectivity.
The level of satisfaction for most members has not changed, and if there were changes, they were more likely to be increases in satisfaction rather than decreases in satisfaction (Figure 3).
Descriptions of ACC Membership Value
Various descriptions of membership value resonate with ACC members. “The ACC is working to transform cardiovascular care and improve heart health” resonates the most, followed closely by “The ACC is here to support CV professionals from residency to retirement,” and “The ACC is your professional home.”
Importance of ACC Goals
Of the 10 cardiologists interviewed, 9 believe that shaping the future of public health policies and helping members thrive and transform care any delivery or reimbursement environment are the most important goals of the ACC. Smartly using data, information, and knowledge to accomplish organizational goals also resonates with members, who realize the potential advantages of using database registries such as the National Cardiovascular Data Registry (Figure 4).
Of the ACC members, 70% are likely or extremely likely to recommend ACC membership to a team member.
Valuable ACC Benefits
Access to the JACC publications and clinical guidelines are the most valuable member benefits. The ACC website also provides high value followed by educational resources (including access to over 300 complimentary MOC activities) and representation in both government and certification-related arenas (Figure 5).
Value of FACC
More than 2 out of 3 cardiologists consider the FACC designation to be very/extremely valuable, with cardiologists in private practice and/or practicing internationally finding these designations most valuable. Slightly fewer (62%) say that it is very important to their institution that a cardiologist be an FACC. Moreover, almost three-quarters of hospital administrators and CV directors reported they were more likely to hire an FACC to fill their cardiologist positions. Almost all fellows (90%) post their designations.
How ACC Members Engage
Three-year trend figures show dues payment tops the list of how members engage, followed by use of the website. Paid section membership, collecting continuing medical education (CME), attending live programs, purchasing products, and attending the annual meeting are also ways that members engage. Less popular are committee participation and donating. Only 8% of members have donated to the political action committee in the past 5 years. Most donations were a single donation (50%), while 10% gave to the political action committee annually.
Members expressed the desire for more help from ACC in areas including:
• Advocacy: ABIM MOC requirements and cuts in reimbursements
• Education: MOC, self-assessment products, and patient education materials
• Short/Simple/Quick: summary of detailed information and concise tools and guidelines
• Ease of Use: easier access to journals and guidelines
• Updates: e-mail updates on CV issues, clinical updates
• Subspecialty Focus: more targeted clinical information
Emerging Payment Reform
Slowing of Growth in HealthCare Cost
The years 2011, 2012, and 2013 registered the slowest growth in real per capita national health expenditures on record, and slow growth continued into 2014 (1).
Variety of Value-Based Payment Programs Draws Provider Participation
Medicare is engaged in testing payment and service delivery models with more than 60,000 healthcare providers, affecting an estimated 2.5 million Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries (1).
Accountable Care Organizations (ACOs)
There are 424 organizations currently participating in Medicare ACOs covering more than 7.8 million Medicare beneficiaries. Participation in ACOs is voluntary, and these programs have varying levels of provider risk and reward. As existing ACOs add more providers and more organizations join existing and newer ACO models, participation in ACOs is expected to grow further (1).
Medicare Advantage plans
The ACA ties payment to private Medicare Advantage plans to quality ratings (1 to 5 stars). Approximately 40% of Medicare Advantage contracts received 4 or more stars in 2015, an increase from 6% in 2013 (1).
The Bundled Payments for Care initiative currently has 870 participants representing 6,424 providers in Phase I (preparation) and 105 participants representing 243 providers in Phase II (risk-bearing) (1).
CMS Plan to Accelerate Shift Toward Value-Based Payments
On January 26, 2015, Health and Human Services (HHS) Secretary Sylvia M. Burwell announced a set of measurable goals and a timeline to accelerate the shift toward value-based payment of healthcare providers. HHS has set the goal of tying 30% of Medicare payments to value-based models, such as ACOs, pay for performance, or bundled payment arrangements, by the end of 2016 and tying 50% of Medicare payments to these models by the end of 2018. To make these goals scalable beyond Medicare, Secretary Burwell also announced the creation of the Health Care Payment Learning and Action Network. Through the Learning and Action Network, HHS will “work with private payers, employers, consumers, providers, states and state Medicaid programs, and other partners to expand alternative payment models into their programs” (2) (Figure 6).
• Category 1: fee-for-service with no link of payment to quality
• Category 2: fee-for-service with a link of payment to quality
• Category 3: alternative payment models built on fee-for-service architecture
• Category 4: population-based payment
CMS Value-Based Payment Modifier in 2015 and 2016
Beginning in calendar year 2015, Medicare will apply the Value Modifier to physician payments under the Medicare Physician Fee schedule for participating and nonparticipating physicians in groups of 100 or more eligible professionals for the 2013 performance period.
Medicare will accelerate this approach in 2016, applying the Value Modifier to groups of 10 or more eligible professionals for the calendar year 2014 performance period.
The overall approach to implementing the Value Modifier is based on participation in the Physician Quality Reporting System (PQRS). Groups of physicians with 100 or more eligible professionals in 2015 and 10 or more eligible professionals in 2016 must participate in PQRS by self-nominating/registering for PQRS as a group and reporting at least 1 measure, or electing PQRS Administrative Claims Option to avoid the −1% downward Value Modifier payment adjustment. As an alternative, groups can elect to have their Value Modifier calculated using the quality-tiering methodology. For groups that make this election, Medicare will use the performance rates on the quality measures reported through PQRS reporting mechanisms (such as group practice reporting optional web interface or CMS qualified registries) and 3 outcome measures to calculate their Value Modifier resulting in upward, downward, or no payment adjustment based on performance (4).
CMS “Next Generation” ACO Model
On March 10, 2015, CMS announced a next generation voluntary ACO model that differs from the existing Medicare Shared Savings Program and Pioneer ACO models in several different ways:
• Provides higher levels of risk and reward than either the Medicare Shared Savings Program or the Pioneer ACO Model, using what CMS characterizes as more stable, predictable benchmarking methods that reward both attainment and improvement in cost containment;
• Offers a selection of payment mechanisms to shift from fee-for-service reimbursement to capitation; and
• Includes “benefit enhancement” tools to improve engagement with beneficiaries, including: 1) greater access to home visits, tele-health services, and skilled nursing facilities; and 2) opportunities to receive a reward payment for receiving care from the ACO (5).
ACC’s SMARTCare Program in First Year of 3-Year Pilot
Cardiologists in Wisconsin and Florida, working through the ACC, are in the first year of a 3-year pilot funded by a CMS Medicaid Innovation Grant. The Center for Payment Reform and the Partnership for Healthcare Quality and Payment Reform have been providing technical assistance. The pilot is intended to model better care for patients with stable ischemic heart disease.
The pilot uses an ACC electronic decision-support tool called FOCUS that is based on ACC appropriate use criteria. The FOCUS tool will inform and support decision making by the patient and the physician about the most appropriate care, but will not dictate a particular approach. Other tools available for use in the program include the ePRISM decision support software and the INDIGO risk management software. The choices made by physicians and patients will be recorded and analyzed in 2 important ways.
• Individual physicians will receive feedback on their own ordering patterns. For example, if a physician had a high rate of ordering stress tests for patients where those tests “may be” appropriate, the physician would be able to see whether other physicians were achieving similar or better results for similar patients by using fewer tests or less risky and invasive tests.
• Appropriate use improvement will be fostered. Through SMARTCare, the teams of physicians who develop and maintain the appropriate use criteria will have more detailed data available to use for refining the criteria and providing clearer guidance as to which tests and procedures are likely appropriate or inappropriate in more unusual cases. The data collected will be added to the PINNACLE registry and the National Cardiovascular Data Registry to support research about outcomes and the refinement of existing criteria (6).
National Scorecard on Payment Reform and Value-Based Payment Shift
On September 30, 2014, the most recent National Scorecard on Payment Reform showed a significant increase in the adoption of value-based payment methods by private payers in the United States. The Scorecard is published on an annual basis by Catalyst for Payment Reform, an independent, nonprofit employer coalition. The report showed that commercial healthcare plans are dramatically shifting how they pay physicians and hospitals with 40% of payments now based on some form of value-based care, far ahead of the original goal set by the Catalyst for Payment Reform. The 2014 Scorecard shows a 29 percentage point increase over 2013, when just 11% of payments were value-oriented.
Just over one-half (53%) of the payments that are value-oriented put providers at some financial risk if they fail to provide care or spend over budget. Much of the value-oriented payment is in pay-for-performance arrangements with providers, offering only potential financial reward and no financial risk. Hospitals are most impacted by value-oriented payment programs with 38% of payments, compared with the outpatient setting where 10% of payments to specialists and 24% of payments to primary care physicians are value oriented (7).
ACC Members and Value-Based Performance as a Major Area of Focus
ACC Members Familiarity With and Participation in ACOs on the Rise
ACC member familiarity with and participation in ACOs jumped significantly from 2011 to 2014. Familiarity with ACOs increased from 44% to 58% and participation in ACOs increased from 1% to 20% in that time period. Of ACC members surveyed, 33% of those familiar are very or extremely likely to join an ACO (9).
In Historic Vote, SGR is Repealed
On April 16, 2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act. The law permanently repeals the SGR formula and establishes a framework for rewarding physicians for high-quality care, streamlines quality-reporting programs into one system, and reauthorizes funding for CHIP. The law replaces the SGR with a plan to give clinicians an increase of 0.5% in each of the next 5 years as Medicare transitions to a system designed to reward physicians on the quality of care delivered rather than the quantity of services performed. The law does not require participation in MOC programs, nor does it establish any specific entity to administer MOC (10).
Changes in Certification and Recertification Requirements
JAMA Study Finds Lack of Support for MOC
A study headed by researchers at the Mayo Clinic and published January 2015 in the Journal of the American Medical Association Internal Medicine (JAMA) found that physicians believe that MOC requirements are cumbersome and provide little to no professional gain. In a grounded theory focus group study of 50 board-certified primary care and subspecialist internal medicine and family medicine physicians in an academic medical center and outlying community sites, participants identified gaps between the espoused purposes of MOC (e.g., to promote high-quality care, commitment to the profession, lifelong learning, and the science of quality improvement) and MOC as currently implemented. Participants in the JAMA study perceived MOC as being inefficient, logistically difficult for learning and assessment, often irrelevant to practice, and of little benefit to physicians, patients, or society (11).
ACC Details Cardiology Participation in MOC
ACC President Patrick T. O’Gara, MD, FACC, and Executive Vice President William Oetgen, MD, MBA, FACC, outlined in JACC the continuing efforts of the College to encourage ABIM to modify the MOC process. The journal article reported on the current status of MOC participation among CVD diplomates of the ABIM (12).
A survey conducted in September 2014 documented the MOC participation of ACC leadership. Of ABIM diplomates who are members of the ACC Board of Trustees, 100% are participating in MOC. Of ABIM diplomates who are members of the ACC Board of Governors, 92% are participating in MOC (12).
A more comprehensive look at ACC member participation in MOC activities in September 2014 showed 25,799 CVD diplomates on the ABIM rolls. Of these cardiologists, 74% were enrolled in MOC. By comparison, 68% of ABIM diplomates in internal medicine, 70% of diplomates in gastroenterology, and 73% of diplomates in oncology were enrolled in MOC. With respect to cardiology subspecialties, 86% of interventional cardiology specialists, 85% of electrophysiology specialists, and 87% of heart failure specialists were enrolled in MOC (12) (Figure 9).
New England Journal of Medicine (NEJM) Publishes Perspectives in MOC Debate
In January 2015, the NEJM published 2 contrasting perspectives in the ongoing controversy over the new ABIM MOC program. The articles reflect the tension between the American Board of Medical Specialties and ABIM missions to assure the public of professional commitments to integrity and accountability and the concern by physicians and their medical societies that the methods chosen to revise MOC have not been fully validated.
The first perspective, by Mira B. Irons, MD, and Lois M. Nora, MD, JD, MBA, representatives of the ABIM, details the history of the MOC and how the recently approved changes to the standards were developed. They note that the standards were modified after a comprehensive 2-year review, and they point out that “high standards of specialty certification are important to healthcare.” The authors “hope our medical community partners will work with us to continue to evolve our certification systems to ensure the standards they set continue to be highly valued in the future” (13).
In the second perspective, Paul S. Teirstein, MD, FACC, notes “many physicians are waking up to the fact that our profession is increasingly controlled by people not directly involved in patient care who have lost contact with the realities of day-to-day clinical practice. Perhaps it’s time for practicing physicians to take back the leadership of medicine.” Teirstein is founder of The National Board of Physicians and Surgeons, an alternative certification organization (14).
Financial Impact of MOC on Medical Boards Reviewed
A study in the Dermatology Online Journal focused on an analysis of publicly available Internal Revenue Service (IRS) form 990s of medical boards, revealing a general trend of increased revenue and end-of-year balance for the majority of the ABMS and its 24 medical boards after the 2006 approval of the ABMS MOC requirements. While exceptions do exist, the study’s authors point out that the majority of the medical boards have benefited financially from the establishment of MOC (15).
ABIM Announces Substantial Changes to MOC Program in Response to Controversy
On February 3, 2015, the ABIM announced substantial changes to its MOC program and indicated a desire to work more closely with the internal medicine community. The organization apologized by saying, “ABIM clearly got it wrong. We launched programs that weren’t ready and we didn’t deliver an MOC program that physicians found meaningful.” ABIM said the changes announced in 2014 had generated legitimate criticism among internists and medical specialty societies. ABIM announced the following steps:
• Effective immediately, ABIM is suspending the Practice Assessment, Patient Voice, and Patient Safety requirements for at least 2 years. This means that no internist will have his or her certification status changed for not having completed activities in these areas for at least the next 2 years. Diplomats who currently are not certified but who have satisfied all requirements for MOC except for the Practice Assessment requirement will be issued a new certificate this year.
• By August 2015, ABIM would change the language used to publicly report a diplomat's MOC status on its website from “meeting MOC requirements” to “participating in MOC.”
• ABIM is updating the Internal Medicine MOC exam. The update will focus on making the exam more reflective of what physicians in practice are doing, with any changes to be incorporated beginning fall 2015, with more subspecialties to follow.
• MOC enrollment fees will remain at or below the 2014 levels through at least 2017.
• By the end of 2015, ABIM will ensure new and more flexible ways for internists to demonstrate self-assessment of medical knowledge by recognizing most forms of ACCME–approved CME.
In June of 2015, ABIM announced the elimination of a requirement to maintain underlying certification in a foundation discipline in order to remain certified in a subspecialty. For cardiology, this elimination of the “double jeopardy” provision means that those specializing in interventional, electrophysiology, adult congenital, and advanced heart failure will no longer need to pass both the general cardiology and subspecialty boards to maintain certification (16).
ABIM is promising to work with medical societies and directly with diplomats to seek input regarding the MOC program through meetings, webinars, forums, online communications channels, surveys, and more. ABIM stated, “It remains important for physicians to have publicly recognizable ways—designed by internists—to demonstrate their knowledge of medicine and its practice. Internists are justifiably proud of their knowledge and skills” (17).
ACC President Patrick O’Gara said the ABIM decision comes as “welcome news to the internal medicine community.” O’Gara added that “last year’s significant changes to the program generated legitimate criticism and sparked heated discussions—including among members of the cardiovascular community.” The changes announced today are encouraging, and the ABIM should be recognized for listening to physicians and specialty societies, including the ACC (18).
Certification Controversy Reaches General Public
In the spring of 2015, a series of editorials in the national consumer magazine, Newsweek, and responses from ABIM pushed the certification controversy into the realm of the general public. A March 10, 2015, Newsweek editorial by Kurt Eichenwald detailed the controversy as a “bizarre war, one that could transform medicine for years.” Eichenwald recounted the ABIM decision to change its MOC program and the opposition from “tens of thousands of internists, cardiologists, kidney specialists and the like who say the ABIM has forced them to do busywork that serves no purpose other than to fatten the board’s bloated coffers.” He detailed the history of certification and the expansion to recertification that required additional testing over time. Eichenwald reported that according to some physicians, the tests were often outdated and not relevant to the physicians’ practices, resulting in a steady drop in the percentage of doctors passing recertification exams. He focused on ABIM’s finances, comparing ABIM’s revenue in 2001 at $16 million and total compensation for top officers and directors of $1.3 million to revenue at the end of 2013 of $55 million and a quadrupling of pay for top officers and directors (19).
ABIM quickly took issue with the first Newsweek article in a statement from Board Chairman David H. Johnson, stating that the article “contains numerous and serious misstatements, selective omissions, inaccurate information and erroneous reporting.” ABIM disputed Eichenwald’s reporting of a steady drop in the percentage of physicians passing recertification exams, saying that passing percentages in fact “rise and fall over the years and across disciplines” and pointing out that in total, 96% of physicians whom ABIM certifies passed an exam to maintain their certifications. ABIM also took issue with Eichenwald’s assertion that ABIM has a monopoly on certifying internists, stating, “In reality internists have a choice among certifying boards that certify internal medicine and its subspecialties” (20).
A follow-up Newsweek editorial by Eichenwald suggested that the ABIM’s expansion of MOC is in response to the organization’s severe financial crises, which are caused by questionable accounting practices. He also reported that congressional passage of legislation designed to rectify problems caused by the SGR formula includes a provision to require participation in MOC (21).
The ACC, in an April 10, 2015 letter to its members, refuted what it called “speculation and misinformation that is a potentially damaging distraction” from the effort to repeal the SGR. The ACC said the House legislation “does not require participation in maintenance of certification (MOC), nor does it establish ABMS, ABIM or any specific entity to administer MOC. No one would be forced to participate in MOC” (22).
Maintenance of Licensure Impact
The Federation of State Medical Boards continues to develop and pilot test a framework for Maintenance of Licensure. A current fact sheet from the organization says Maintenance of Licensure is still years away from being adopted by any state medical board. The framework being proposed by the Federation of State Medical Boards would not require examinations to comply with Maintenance of Licensure. State medical boards also do not require specialty certification or recertification for licensure or licensure renewal, and that is not expected to change (23).
Impact of Multiple Certifications
Fellow-in-Training Ryan J. Maybrook, MD, in a recent article in JACC, gives an early career view of a “new, less-stable world of cardiovascular medicine.” Maybrook expresses concerns about a future career consisting of “expensive board review courses and endless recertification exams.” Maybrook suggests that questions about the viability of taking multiple board exams revolve around affordability, motivation for taking the exams, and the effect they have on one’s career, with the overarching question of “What kind of cardiologist am I building?” He includes an overview of general and subspecialty cardiovascular board certification exams detailed in Figure 10 (24).
Nearly 12 Million Enroll in 2015 Health Insurance Marketplace
HHS announced that 11.7 million American consumers selected or were automatically re-enrolled in health insurance coverage through the Health Insurance Marketplace as of February 22, 2015. Of those, 8.84 million (76%) were in states using the HealthCare.gov platform and 2.85 million (24%) were in the 14 states (including Washington, DC) using their own Marketplace platforms. Highlights of the announcement included:
• More than 4.1 million consumers under the age of 35 are signed up for Marketplace coverage.
• Of the more than 8.8 million plan selections in HealthCare.gov states, 87% (nearly 7.7 million individuals) qualified for an average tax credit of $263 per month.
• More than one-half of the individuals selected a plan with a premium of $100 or less after tax credits (25).
ACA Marks Fifth Anniversary With Historic Reduction in the Uninsured Rate
As the ACA marked its fifth anniversary, data from the Gallup HealthWays Well-Being Index showed a historic reduction in the number of Americans without health insurance. Since the ACA coverage provisions took effect, approximately 16.4 million uninsured people have gained health insurance coverage, and the uninsured rate stands at a low of 12.9% for the fourth quarter of 2014. This uninsured rate is down slightly from a 13.4% rate in the third quarter of 2014 and down significantly from a 17.1% rate in the first quarter of 2014 (26). Figure 11 details the change in the uninsured rate from the first quarter in 2008 through the fourth quarter in 2014. Figure 12 shows additional detail on percentage drops in the uninsured rate by race and ethnicity.
Hospitals Save Billions in Uncompensated Costs in 2014
On March 23, 2015, HHS Secretary Silvia Burwell announced that U.S. hospitals saved $7.4 billion in uncompensated care costs in 2014 as a result of patient enrollment through the health insurance exchanges and Medicaid. HHS attributes $5 billion of the savings to Medicaid expansion (27).
Gap Between Favorable and Unfavorable Opinions of ACA Narrows
An April 2015 Kaiser Family Foundation tracking poll found that the gap between favorable and unfavorable opinions of the ACA has narrowed to the closest margin in over 2 years, with 43% saying they have a favorable view of the law and 41% saying they have an unfavorable view. These percentages in July of 2014 were 53% unfavorable and 37% favorable. When those who say they view the ACA favorably are asked to say why in their own words, the most commonly mentioned reason is that it will expand access to health care and health insurance (61%). When those with an unfavorable view are asked the same question, the most commonly mentioned reasons are financial considerations, including concerns that health insurance and healthcare costs are increasing. Consistent with previous Kaiser polls, the majority of the public (57%) said that the health reform law has had no direct impact on their families. If they do cite an impact, almost equal shares report that the law has helped them (19%) or the law has hurt them (22%). Of those who would like to see the law repealed, 11% are Democrats, 30% are Independents, and 57% are Republicans (28) (Figure 13).
Congressional Budget Office (CBO) Revises Downward Health Reform Costs
In March 2010, the CBO projected that the insurance-related provisions of the ACA would cost the federal government $710 billion from fiscal year 2015 through fiscal year 2019. The most recent projections, in March 2015, indicate that the cost will be $506 billion for that same time period, a reduction of 29% (29).
CMS Outlines Areas of Impact Under the ACA
A January 2015 report from CMS detailed the impact of the ACA on patient safety, reduction in hospital readmissions, integration of care, physician and hospital reporting, and increases in the use of electronic health records (EHRs) (30). Specific areas of impact cited by CMS included:
Increases in Patient Safety
The Partnership for Patients, funded by the ACA, includes 26 hospital engagement networks representing 80% of the American population. An HHS report on the program as of December 2014 showed an estimated 50,000 fewer patients died in hospitals and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital acquired conditions from 2010 to 2013, translating into a 17% decline over the 3-year period.
Reduction in Hospital Readmissions
In 2012, CMS implemented an ACA program that ties some Medicare penalties for hospitals to 30-day readmission rates for certain conditions. After holding constant at 19% from 2007 to 2011 and decreasing to 18.5% in 2012, the Medicare all-cause readmission rate has further decreased to approximately 17.5% in 2013. This translates into a reduction of 8% in the rate representing an estimated 150,000 fewer hospital readmissions among Medicare beneficiaries between January 2012 and December 2013.
Coordination of Care
Under 2015 rule-making, the Medicare Fee Schedule will include a new chronic care management fee beginning next year. This separate payment for chronic care management will support physician practices in efforts to coordinate care for Medicare beneficiaries with multiple chronic conditions. In addition, 12 states have entered into agreements with CMS to integrate care for Medicare-Medicaid dual enrollees.
Websites created by the ACA provide information to consumers about hospitals and healthcare professionals. Hospital Compare has information about the quality of care at over 4,000 Medicare-certified hospitals and includes measures such as access to timely and effective care, readmissions, and the incidence of hospital-acquired conditions. In FY 2015, hospitals with high rates of hospital-acquired conditions will see their Medicare payments reduced. Physician Compare provides general information for up to 3 group practices. This information includes names, addresses, and distance from the search location specialty, Medicare assignment, and affiliated healthcare professionals. The first quality measures were added to Physician Compare in 2014, and since then the number of groups reporting data through the PQRS has doubled. In 2015, CMS plans to expand Physician Compare to include quality information results for all physician groups.
Electronic Health Records
Adoption of EHRs continued to increase among physicians, hospitals, and others serving Medicare and Medicaid beneficiaries. The proportion of U.S. physicians now using any kind of EHR increased from 18% to 78% between 2001 and 2013, and 94% of hospitals now report use of certified EHRs.
ACA Survives Supreme Court Challenge
On June 24, 2015, the Supreme Court ruled 6 to 3 to uphold a key part of the ACA that provides health insurance subsidies to all qualifying Americans. The ruling was in the case of King v. Burwell, which challenged the availability of the ACA’s premium subsidies in states with a federally run Marketplace—including states with a federally facilitated Marketplace (FFM) or a State Partnership Marketplace (SPM). The case did not challenge premium subsidies in states with a state-run Marketplace.
The King v. Burwell petitioners challenged the legality of the IRS regulation allowing premium subsidies in states with an FFM as contrary to the language of the ACA that stated that subsidies were only available to “an exchange established by the state.” The Supreme Court majority concluded that the disputed phrase is ambiguous when read in context, and therefore does not have to be interpreted literally. Chief Justice Roberts wrote “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible we must interpret the Act in a way that is consistent with the former, and avoids the latter.” Justices Kennedy, Bader Ginsburg, Breyer, Sotomayor, and Kagen joined Roberts in the majority. Opposing the decision were Justices Scalia, Thomas, and Alito Jr.
The Supreme Court’s decision about the availability of premium subsidies in states with an FFM has significantly affected the number of people who have access to subsidies. If the IRS rule had been overturned by the Supreme Court, people in the 27 states relying on an FFM and the 7 states with an SPM would have lost access to subsidies, affecting an estimated 12.5 million people (30) (Figure 14).
CVD Cost and Reimbursement
CVD and HealthCare Expenditures
The economic costs of CVD and stroke in the United States have never been higher. CVD is the nation’s single most costly diagnostic group, with a total economic cost of $320.1 billion in 2011. This total includes $195.6 billion in direct costs (hospital services, physicians and other professionals, prescribed medications, home health care, and other medical durables) and $124.5 billion in indirect costs, including lost future productivity (cardiovascular and stroke premature deaths). By comparison, the estimated cost of all cancer and benign neoplasms was $216 billion ($86 billion in direct costs and $130 billion in indirect costs). The projected total cost of CVD is expected to rise from $656 billion in 2015 to more than $1.2 trillion in 2030 (31) (Figures 15, 16, and 17).
Spotlight on Variation in Charges for Cardiovascular Procedures
The New York Times, in a feature titled “The Odd Math of Medical Tests: One Scan, Two Prices, Both High,” focuses on the case of Len Charlap, who had 2 outpatient echocardiograms in the past 3 years. The first, performed by a technician in a community hospital in central New Jersey, lasted <30 min. The next, at a premier academic medical center in Boston, took 3 times as long and involved a cardiologist. When Mr. Charlap received the charges, the numbers seemed backward; the community hospital had charged approximately $5,500, and the teaching hospital billed approximately $1,400 for the much more elaborate test.
The article, part of a larger series on medical testing, focused on the wide variety in pricing for echocardiograms and the failure of prices to fall even though the costs for testing machines have dropped considerably. Dr. David Weiner, the chairman of the advocacy committee of the American Society of Echocardiography (ACE), acknowledged the wide price disparities, but said they were aligned with other health services and procedures and attributed the variation to multiple factors, including the need to subsidize poorly reimbursed services. The article points out that the major medical societies, including ACE and the ACC, have developed guidelines for the appropriate use of the test.
The Times article notes that in some other countries, regulators set what are determined to be fair charges that include a built-in profit ($80 in Belgium, $115 in Germany, and from $50 to $80 in Japan). On the other hand, the article also notes that in the United States, Medicare only pays in the hundreds for the procedure and that the vast majority of patients (and their insurers) pay less than the listed prices.
The article concludes with information about the newest miniature echocardiogram machines, which sell for well under $10,000 and are widely being used in other countries and at some pilot programs in U.S. medical schools. The article quotes Dr. Erick J. Topol, a cardiologist at Scripps Health in San Diego who studies echocardiography: “It brings $350,000 imaging technology to the bedside as a screening test, at almost no cost … but it is not being embraced because of our model of payment” (32).
William A. Zoghbi, MD, MACC, past president of the ACC, responding to the Times article in a blog post, countered that the article focuses so much on charges that it loses sight of echocardiography as a valuable front-line tool for the diagnosis and management of CVD. Zoghbi also refers to the development of appropriate use criteria and ACC’s participation in Choosing Wisely, a patient-focused initiative by the American Board of Internal Medicine Foundation that highlights tests and procedures that patients and providers should question. The ACC’s Choosing Wisely list includes several items involving appropriate use of imaging tests, including echocardiography (33).
Wide variation of cardiovascular charges is also explored in a 2014 cross-sectional analysis in charges and prices across California for percutaneous coronary intervention with a drug-eluting stent and without major complications (MS-DRG-247). Adjusted charges for the average California patient admitted for uncomplicated percutaneous coronary intervention ranged from $22,047 to $165,385 (median: $88,350), depending on which hospital the patient visited. Hospitals in areas with the highest cost of living, those in rural areas, and those with more Medicare patients had higher charges, while government-owned hospitals charged less. Overall, the study’s model explained 43% of the variation in adjusted charges. Estimated discount prices paid by private insurers ranged from $3,421 to $80,903 (median: $28,571) (34).
After years of steady increases, cardiology compensation overall dropped by nearly 8% from 2012 to 2013, according to the 2014 Medaxiom Provider Compensation and Productivity Report. Between 2010 and 2012, the overall median compensation rose from $456,110 to $548,587. In 2013, compensation fell to $505,266. Median compensation per relative value unit remained the same in 2012 and 2013 at $54.
Most cardiologists overall saw decreases, but the losses were not felt equally. Physicians who worked in an integrated model received more compensation than physicians in a private practice setting. Overall median compensation for integrated cardiologists was $548,630 compared with $424,380 for clinicians in private practice. Private practice experienced a more significant decline in compensation per full-time cardiologist, slipping 8.9% compared with 6.9% for those in an integrated model.
Despite a drop of $27,000, interventional cardiologists in the integrated model continue to be the top earners among all cardiologists, with a median compensation of $558,824. Electrophysiologists, by comparison, earned $525,664, invasive cardiologists received $504,398, and general cardiologists earned $454,837.
Physicians in the Midwest fared best for compensation despite a 5.8% drop, with a median of $559,829. The Northeast had the steepest drop at 10% and the lowest pay at $466,235. Compensation in the South dropped 4.5% to $525,496 (35). Other compensation studies for the cardiologist population show different absolute values though the trends are similar.
Medicare Access and CHIP Reauthorization Act
On April 16, 2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that permanently repeals the SGR formula (see the Emerging Payment Reform section for announcement). The new law affects a broad range of stakeholders, including cardiologists. In addition to the repeal of the SGR, the law:
• Establishes a period of positive payment increases by providing annual 0.5% increases for clinicians beginning July 1, 2015, and ending December 31, 2018, in order to support a smooth and predictable transition from fee-for-service to quality-based payments.
• Beginning in 2019, provides for 2 new payment pathways for clinicians: the new Merit-Based Incentive Payment System (MIPS) or an Alternative Payment Model (APM).
Eligible clinicians who elect to participate in MIPS will receive yearly payment increases or decreases based on their performance. Beginning in 2019, MACRA replaces the existing quality reporting programs of PQRS, Meaningful Use (MU), and the Value-Based Payment Modifier (VM) with the MIPS. Instead of having 3 reporting systems with 3 separate reporting deadlines, there will be 1 system.
Under the new law, each clinician will receive a composite score (of 0 to 100) based primarily on 4 categories—clinical quality, meaningful use, resource use, and clinical practice improvement. These 4 categories will use quality measures already in place under the existing Medicare quality reporting programs, and additional measures will be defined and further developed. The clinical practice improvement category will recognize clinicians for activities that contribute to the advancement of patient care, safety, and care coordination, such as registry participation and tele-health services.
Performance will be assessed against benchmark composites issued to clinicians at the beginning of a performance year, based on the previous year’s performance. Clinicians with the highest MIPS composite could earn additional payments. Those clinicians receiving a score below the threshold will receive a reduced payment. Maximum bonus payments will begin at 4% in 2019 and gradually increase to 9% in 2022 and beyond. The maximum payment penalty will start at 4% in 2019 and gradually increase to 9% in 2022 and beyond. The total amount of penalties under the new system is less than the combined total amount of penalties under the previous reporting programs.
The new law incentivizes participation in Medicare and private payer APMs. Clinicians who opt to participate in an APM and receive at least 25% of their Medicare revenue through an APM beginning in 2018 will receive a 5% payment bonus. The threshold for receiving APM bonuses will increase over time. The new law recognizes that the administrative and financial responsibilities of participation in an APM have been a barrier to small practices, and $20 million annually has been allocated to assist APM participation by practices of 15 or fewer and practices serving rural and underserved areas (36).
ACC/AHA to Assess Value in Practice Guidelines and Performance Measures
On March 27, 2015, citing accelerating healthcare costs and finite resources, the ACC and the AHA announced they would begin building value assessments into their clinical documents. Historically, the societies have only considered clinical efficacy and outcomes when drafting clinical documents. Now, a proposed level of value will be added with categories that include “high value,” “intermediate value,” “low value,” “uncertain value,” and “value not assessed.” The level of value will be accompanied by a level of value evidence ranking (A, B, C) that shows the type of information used to make the value decision.
To determine the level of value, the societies propose using the “quality-adjusted life year” (QALY), a standard outcomes measure in economic evaluation. They further propose using the WHO’s cost-effectiveness benchmark—3 times a country’s gross domestic product (GDP) per capita—as an upper threshold. Using these benchmarks in the U.S. system, treatments that have a cost-effectiveness ratio of $150,000/QALY or more would be considered low value.
The societies acknowledge the challenges associated with determining value assessments, including the fact that treatment costs vary over time and location. There is no national consensus as to how cost should influence treatment decisions and only a limited number of cost-effectiveness studies exist to provide an evidence base (37).
Despite the costs and burden of CVDs and the significant return on investment in National Institutes of Health (NIH) research in helping to reduce morbidity and mortality related to these conditions, NIH only invests a highly disproportionate 7% of its budget on CVD research (38) (Figure 18).
Current and Emerging Workforce
Global Workforce Shortage Predicted
According to the most recent report from the WHO, the world will be short some 12.9 million healthcare workers by the year 2036, posing possible serious implications for the health of billions across all regions of the world. The shortage figure stands at 7.2 million currently. The report, “A Universal Truth: No Health Without a Workforce,” identifies a number of key causes for a shortage. These include an aging workforce, not enough young people entering the profession, a growing world population with significant increases in noncommunicable diseases such as CVD, and internal and international migration of healthcare workers. The report does include some encouraging developments, such as more countries moving toward a basic threshold of 23 skilled health professionals for every 10,000 people, although there still are 83 countries below that threshold. The report makes recommendations for actions to lessen the projected shortage, including:
• Increased political and technical leadership that will support long-term human resources development in healthcare;
• Collection of reliable data and strengthening health databases and registries;
• Maximizing the role of mid-level and community health workers to make front-line health services more accessible (39).
Possible U.S. Shortages of HealthCare Workers Less Easy to Predict
Healthcare is possibly the most complicated industry in the United States, and, as such, it is difficult to predict changes in supply and demand for the country as a whole and for more than several years in the future. For example, Figure 19, a 2013 analysis from the Association of American Medical Colleges (AAMC) of physicians per 100,000 in the population shows how only 1 factor, geography, may play a significant role in whether a market is over-or understaffed with physicians.
Some Increases in U.S. HealthCare Worker Supply are Predicted
Predictions for a modest increase in the supply of U.S. healthcare professionals (without accounting for demand) can be found in a 2014 report from the Health Resources and Services Administration within the HHS. This report predicts the supply of physicians in all nonprimary care fields will grow by 21% between 2010 and 2025. The per-capita supply of physicians, however, is expected to vary, with per-capita declines projected in the fields of cardiology, psychiatry, and general surgery, and per-capita growth projected within the pediatric subspecialties and in obstetrics-gynecology. The report also predicts the supply of nonprimary care advanced practice nurses to grow more rapidly (141% over the period) than physicians, and the supply of nonprimary care physician assistants (PAs) to grow more rapidly (more than double over the period) than physicians but less than advanced practice nurses (40). The corresponding increase in supply for primary care physicians during the same period is expected to be at 8% (41).
AAMC Predicts U.S. Demand to Exceed Supply
AAMC, for its part, does predict overall shortages of U.S. physicians in a March 2015 study. To reflect future uncertainties from a variety of variables, the study presents ranges for its projected shortage of physicians, rather than specific numbers. The study predicts demand for physicians in this country to grow faster than supply. Although it predicts physician supply will grow modestly between 2013 and 2025, it says demand will grow more steeply, with demand exceeding supply by a range of 46,000 to 90,000 physicians. These predicted shortages in 2025 will vary by specialty grouping, including a shortfall of between 12,500 and 31,100 primary care physicians and a shortfall of between 28,200 and 63,700 nonprimary care physicians. AAMC predicts these shortages under every modeled scenario, including increased use of advanced practice nurses; greater use of alternate settings such as retail clinics; delayed physician retirement; and rapid changes in payment and delivery. AAMC points to a rapidly expanding Medicare population and limits on support for physician training as significant factors driving the projected shortage (42).
Rapid Changes in Cardiology Landscape
In a President’s Page article in JACC, then-ACC president Patrick T. O’Gara detailed how rapidly the landscape of cardiology had changed in less than a decade. He recalled a 2009 ACC workforce survey that predicted significant shortages of cardiovascular specialists and called for a rapid increase in supply. Just a year later, the global economy took a turn for the worse and massive Medicare expense cuts for cardiovascular services led to a surge in the number of physician practices integrating with hospitals and other large healthcare systems. More recently, O’Gara points out, the transition of the healthcare system to a focus on value rather than volume, Medicare’s efforts to bundle payments, increasingly high deductibles in tiered health plans, and a decline in cardiovascular tests and procedures has resulted in a “relative oversupply of highly compensated individuals, especially in prime geographic locations” (43).
In an interview in CardioSource WorldNews: Focus on Fellows in Training and Early Career Cardiologists, Zachary M. Gertz, MD, Director of Structural Heart Disease at Virginia Commonwealth University, noted that it is a very competitive market for incoming cardiovascular professionals interested in structural heart disease, valve disease, advanced electrophysiology, and other procedure-intensive areas. He did note, however, that general cardiology and heart failure opportunities are looking more plentiful (44).
Changes in Cardiology Testing and Procedure Utilization
Cardiology groups across the country have reported a decrease in utilization patterns for many of the historically high-volume diagnostic tests and cardiac procedures. In fact, according to Medaxiom’s 2014 annual survey (2013 data), the number of new patients entering into a cardiology practice on a per-cardiologist basis—perhaps the strongest indicator of future testing and procedure volumes—is at a 10-year low (45) (Figure 20).
Medical School Enrollment
In 2006, as a response to concerns of a future U.S. physician shortage, the AAMC recommended a 30% increase in the U.S. medical school enrollment by 2015. The AAMC recommended meeting this goal by increasing enrollment at existing medical schools and, where appropriate, creating new medical schools. Results of the AAMC 2014 Medical School Enrollment Survey shows that an increase of 30% in first-year enrollment has almost been attained. The survey results suggest that first-year medical enrollment from 2019 to 2020 will reach 21,304, a 29.2% increase over the 2002 to 2003 levels used as a baseline (Figure 21).
Other key findings from the survey include increases in the number of schools reporting concerns about their number of clinical training sites (an increase of 26% in concerns reported from 2010 to 2014) and concerns about enrollment growth outpacing growth in graduate medical education (GME) (Figure 22). Many schools are continuing to develop and implement initiatives to increase student interest in primary care, and enrollment increases at D.O.-granting schools continues to accelerate (46).
IOM Report Recommends Better Aligning of GME Funding With Workforce Needs
In 2012, the Institute of Medicine (IOM) began to conduct an independent review of the governance and financing of the nation’s GME system. Their report in 2014, Graduate Medical Education That Meets the Nation’s Health Needs, recommends significant changes to the GME system to address current deficiencies and better shape the physician workforce for the future. The report reiterates that the vast majority of public financing for GME comes from the Medicare program, but notes that the statutes and regulations governing GME financing date from 1965, a time when hospitals were the central, if not exclusive, site for physician training. The report says although hospital services remain essential, the burden of chronic disease, the increased emphasis on prevention, and modern technologies means that, increasingly, health care takes place in community and outpatient settings. Yet, as the report notes, the GME payment system discourages physician training outside the hospital, where much of health care is delivered (47). The IOM recommendations, which would require legislative changes, include:
• Maintaining total federal GME funding at the current level for the next decade, with the core of funding remaining with Medicare to ensure stability as the nation transitions to a recommended new system of payment policy;
• Ending the current system of basing GME payments on Medicare inpatient days, the resident-to-bed ratio, and other factors. The Report recommends an easier to understand basic per-resident amount for each resident, with geographic adjustments;
• Elimination of the current separate funding streams for direct GME expenditures and indirect costs. The total available funds would be divided into an operational fund to support existing GME programs and a new GME transformation fund to support innovation, as well as new GME programs in needed specialties and underserved areas.
• Directing funds to the institutions that are responsible for the actual educational content of GME—the GME sponsors (such as educational institutions, community health centers, or GME consortia)—rather than just to teaching hospitals (48).
ACC Reacts to IOM Report
The ACC, in providing requested feedback to Congress regarding GME, says the IOM report is “an important effort to move the conversation forward, but does little to address the projected shortfall in the medical workforce.” The ACC, in its letter to Congress, said it supports the AAMC’s overarching workforce policy recommendations, which include:
• Increasing the number of federally supported GME training positions by at least 4,000 new positions a year to meet the needs of a growing, aging population and to accommodate the additional graduates from accredited medical schools.
• Continuing federal investment in delivery system research and evidence-based innovations in healthcare delivery.
• Educating lawmakers about the need to not only expand support for GME, but also leverage clinical reimbursement and other mechanisms to achieve geographic distribution of physicians and influence specialty composition.
• Targeting funding for new residency positions based on population growth, regional and state-specific needs, and evolving changes in delivery systems (49).
Trends in Hiring and Training New and Emerging HealthCare Positions
A 2014 survey of human resources and clinical operational leaders in hospitals and health systems provided information about changes in the healthcare workforce. The survey was distributed via e-mail with a link to an online survey tool and received responses from 323 clinical and human resources leaders from healthcare organizations in the United States. Key findings include:
• Some 86% of survey respondents say they are aware of a growing need for new types of healthcare workers;
• Survey response on planning for new roles was strongest for ICD-10 coders, a position critical to proper documentation and reimbursement for the mandated change from ICD-9 to ICD-10. Forty-four percent of respondents say they are currently recruiting or planning to recruit for this position.
• Care Coordinator, a key position for improving patient satisfaction and care quality, ranked as the second most sought-after new position. Forty-one percent of respondents are currently recruiting or planning to recruit for Care Coordinators.
• Expanding the need for tele-health services was clearly reflected, with nearly one-quarter of respondents recruiting or planning to recruit tele-health–trained physicians and 21% seeking or planning to seek tele-health–trained registered nurses.
• Reasons given by respondents as to why the new roles are important include improving patient-care quality, reducing errors and readmissions, improving patient satisfaction, and accommodating new reimbursement structures that incentivize value-based care (50).
Increasing Complexity of Healthcare Drives Need for High-Functioning Teams
In the introduction to the IOM discussion paper “Core Principals & Values of Effective Team-Based Care,” the authors say that a team-based approach to healthcare in the United States is being driven by exponential increases in the complexity of medicine, with nearly 3,000 clinical practice guidelines and more than 25,000 new clinical trials published each year. The paper goes on to point out that team-based care gained momentum with the passage of the ACA and other national initiatives as well as many “deeply considered, well-executed initiatives in team-based care in pockets across the United States.” The paper also points out factors restraining the adoption of team-based care including lack of experience and expertise, cultural silos, deficient infrastructure, and inadequate or absent reimbursement (51). The IOM itself gave support to team-based care in its 2011 report “The Future of Nursing: Leading Change, Advancing Health” with the assertion that “advanced practice registered nurses should be able to practice to the fullest extent of their education and training” (52).
This section will include references to Advanced Practice Providers (APPs), which include advanced practice registered nurses (APRNs), PAs, and pharmacists (PharmDs). APPs have the requisite education, training, and experience to allow them greater autonomy. The high value of other team members (including registered nurses, licensed practical nurses, medical assistants, nurse aides, technologists, nutritionists, genetic counselors, social workers, and chaplains) should also be recognized (53).
Scope of Practice Issue Draws Differing Views
While, in general, team-based care draws much support in the medical community, there are questions about the levels of independence for nonphysician practitioners and the need for physician supervision. These questions lead to licensing differences at the state level, policy differences at the national level, and viewpoint differences at the practice level.
The American Medical Association (AMA), at its annual meeting in 2014, adopted a policy to define physician-led, team-based health care as “the consistent use by a physician of the leadership knowledge necessary to identify, engage and elicit from each team member the unique set of training, experience and qualifications needed to help patients achieve their goals, and to supervise the application of those skills.” AMA restated its belief that the ultimate responsibility of care rests with the physician and advocated that physicians maintain authority for care in any team arrangement to ensure patient safety and quality (54).
The Federal Trade Commission (FTC), on the other hand, has consistently urged state legislatures to avoid imposing restrictions on the scope of practice of advanced practice nurses, unless those restrictions are necessary to address well-founded patient safety concerns. The FTC states that because APRNs and other practitioners, including physicians, may be trained and licensed to provide many of the same healthcare services, scope of practice restrictions can limit the supply of those primary healthcare services. The FTC goes on to say that “new or extended layers of mandatory physician supervision may not be justified” (55).
A 2013 study published in the New England Journal of Medicine highlights the differences of opinion between primary care physicians and nurse practitioners in primary care. The survey of 467 nurse practitioners and 505 physicians found both groups agree that nurse practitioners should practice “to the full extent of their education and training.” However, only 17% of physicians agreed that nurse practitioners should coordinate a patient’s care as a leader of a “medical home” versus more than 82% of the nurse practitioners, and only 3.8% of doctors felt that a nurse practitioner should be paid the same for providing the same service as a physician, compared with 64% of the nurse practitioners (56).
A 2014 ACC survey of its Board of Governors also sheds light on the issue of physician leadership and practice independence for advanced practice nurses. Almost all survey respondents (92%) support incorporating advanced practice nurses into clinical practice and most of this support is strong (80%). However, almost three-quarters (72%) oppose the independent practice of advanced practice nurses without physician supervision, with over one-half voicing strong opposition (57).
Scope of Practice Varies by State
Only approximately one-third of the nation has adopted full practice authority licensure and practice laws for advanced practice nurses. Figure 23, from the American Association of Nurse Practitioners, shows the 2015 nurse practitioner state practice environment.
ACC Membership Shows Evolution of Team-Based Care
The College formally reached out to nonphysician members of the cardiac care team in 2003, when it approved a new cardiac care associate membership category for cardiovascular registered nurses (RNs), clinical nurse specialists, nurse practitioners, and PAs. Soon after, the Nursing Education Work Group was established, and the ACC was awarded a Certificate of Accreditation as a provider of continuing nursing education from the American Nurses Credentialing Center. In 2007, cardiac care associate membership was extended to clinical cardiovascular PharmDs. In 2009, the ACC approved the designation of Associate of the American College of Cardiology (AACC) for licensed APPs with board certification in their respective disciplines, at least 5 years of experience in a clinical area of expertise within cardiology, at least 2 years of ACC membership, and upon review of 3 formal letters of recommendation from current FACCs or AACCs. The ACC also approved the awarding of the title of FACC to APPs with exceptional academic achievement. ACC bylaws were amended to allow APPs to be eligible for Board membership, and in 2010 an APP was added to the Board of Trustees, the first nonphysician member of the Board. Currently, the College has over 4,600 cardiac care associate members, reflecting an enduring commitment to the concept of cardiovascular team-based care (58).
ACC Practice Census Shows Advantages of and Obstacles to Team-Based Care
To better understand the changing practice landscape and evolution of team-based care, the ACC conducted a large survey of cardiovascular practices in 2010. Over 2,400 unique practices in the United States participated in this research, representing almost 14,000 cardiologists.
Four-in-seven (57%) reported that their approach to care delivery was “team-based,” using nonphysician practitioners and clinical staff to participate in the decision making, coordination of care, and shared responsibility for the quality of care. Solo practitioners were less likely to employ a team-based care model, while hospital-based, multi-specialty, and academic practices were more likely to utilize physician extenders in their care delivery.
Those practices that had implemented team-based care identified a number of improvements, including: increased efficiency (63%), improved quality of care (53%), and increased patient satisfaction (50%). Other benefits of the team approach included increased staff satisfaction (36%) and improved financial outcomes (19%).
Although there seemed to be clear benefits to providing team-based care, many practices report that they did not provide team-based care because of no or minimal reimbursement (34%) and the inability to break the more traditional view of practicing medicine held by patients and providers (33%). Lack of tools (18%) and no clear practice model (19%) were also cited as hurdles to more utilization of physician extenders.
The research also explored some of the team-based care systems or functions established as part of the provider infrastructure as well as the ways that physician extenders are utilized. Team-based care providers are most likely to implement patient education (69%) and internal communications (63%) as a part of their care protocols. These findings suggested that while most cardiovascular providers are practicing team-based care, opportunities exist for more interdisciplinary roles and responsibilities, increased tools for feedback and quality improvement, and increased responsibility for physician extenders (53).
JACC Looks at the Multi-Specialty Approach of the Heart Team
The concept of a Heart Team (different medical disciplines formally working together) has become the subject of increasing interest in treating CVD. A 2013 state-of-the-art paper in JACC states that the rationale for team-based care is to optimize the management of complex patient care issues. These issues have been made ever more difficult as a result of the development of new devices and approaches, increasing information from clinical trials and large registries about novel strategies, and a focus on patient groups at higher risk for adverse outcomes because of age or comorbidities.
The Heart Team is especially useful in meeting a central goal of patient-centric care: that the patient and family be sufficiently educated about the alternatives available so that their expectations can be met as fully as possible. Given the wide range of information available from different cardiovascular specialties and the potential for individual physician bias, Heart Teams have great potential merit. Indeed, the Heart Team has emerged as a Class 1 indication in both the 2010 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery Guidelines for Coronary Revascularization, as well as the 2012 ACC/AHA Guidelines for Coronary Artery Bypass Grafting surgery. The Heart Team also is a Class 1 indication for valvular heart disease intervention per ACC/AHA valvular disease guidelines. These teams offer a balanced approach to patient care by emphasizing joint decision making among different medical care stakeholders such as cardiac surgery and interventional cardiology. By exploring multiple options available and discussing with patients and families when appropriate, a tailored recommendation can be made to a more informed and engaged patient. The paper states, “the Heart Team approach is timely and has become mandatory in light of evolving options in therapeutics, in the resurgence of focus on patient-centered care, and for optimizing delivery of care and its reimbursement strategies” (59).
ACC Cardiovascular Team Council and Section Leading a Transformation in Care
In a May 2013 blog post in the ACC In-Touch Blog, members of the ACC Cardiovascular Team Council and Section outline the culture change and paradigm shift that is required to make the cardiovascular team operation more efficient. The group says that “now is the time to foster team-based cardiovascular care, given the survival of practices will likely depend on how well cardiology practices can adapt to the changes occurring in health care.” Cardiovascular teams can be comprised of a diverse group of skilled professionals including physicians, nurses, nurse practitioners, clinical nurse specialists, PAs, and PharmDs. The group advocates for moving toward a culture where team members encourage, educate, and collaborate with each other. They say this will lead to “passionate, knowledgeable care delivery, increased patient satisfaction and an increase in the practice capacity to deliver excellent care to a larger patient base” (60).
ACC Develops Health Policy Statement on Team-Based Care
In a pioneering policy statement on cardiovascular team-based care in May of 2015, the ACC clarified the College’s position on the role of APPs within the cardiovascular care team. Key points from the health policy statement are summarized below.
• All cardiovascular APPs are taught problem-solving algorithms, protocols for treatment, procedures, and standards for general cardiovascular care. Some APPs are taught to practice in a focused area of cardiovascular care, such as heart failure. The tasks of PAs can be modeled on the technical and clinical tasks of the physicians, expanding the overall capacities of physician-led teams. PharmDs may focus on medication reconciliation during care transitions, improving adherence, providing preventive care, and managing complex drug regimens.
• Historically, the leader of a cardiovascular team has been a cardiologist. It is the position of the policy statement-writing group that team leadership should be flexible, reflecting the specific needs of a patient at a particular time and in a particular setting. The leader should be the team member with the greatest knowledge, experience, and qualifications for the task at hand. For example, a nurse or PharmD might lead a team that organizes a chronic anticoagulation clinic.
• A useful motto for cardiovascular team care is “shared goals and clear roles.” The team functions most effectively when each member has a clear understanding of his or her function and responsibilities and what is expected of him or her.
• Differences at the state level in regulations defining prescriptive authority among practitioners can become a barrier to a broad-based implementation of cardiovascular care teams, and can create impediments to the development of national standards for team-based care.
• Payment rules by Medicare and commercial payers, and different standards for billing in inpatient and outpatient settings, can also be a barrier to effective team-based care. In the office, the APP can provide services that give greater access to patients and support greater practice income. In the hospital, the APP does not submit a bill for a shared visit, but the cost of the APP’s activity can be justified by a gain in physician efficiency. Going forward, cardiovascular team-based care will need to successfully navigate a transition to new models of payment.
• Some good examples of effective cardiovascular team-based care include: chronic heart failure management; clinics for lipids, hypertension, and anticoagulation; exercise stress laboratories; arrhythmia management of pacemakers and implantable defibrillators; and outreach to rural and remote locations.
• Broad acceptance of cardiovascular team care paradigms can be realized by further educating the cardiology community about their components, characteristics, and potential to improve patient outcomes (58).
Key Cardiovascular Statistics
U.S. Burden of Disease
Although the decline in mortality rates for CVD in the United States is 60% since the mid-1960s, CVD is still the overall leading cause of death in this country. The risk factors remain alarmingly high. CVD claims more lives than all forms of cancer combined, with over 2,000 Americans dying each day from these diseases—1 every 40 seconds.
From 2001 to 2011, death rates attributable to CVD declined 30.8%. Yet in 2011, CVD still accounted for 1 in every 3 deaths in the United States. The CVD death rate that year was 229.6 per 100,000 Americans. The death rates were 275.7 for males and 192.3 for females. The rates were 271.9 for white males, 352.4 for black males, 188.1 for white females, and 248.6 for black females.
Approximately 85.6 million Americans are living with some form of CVD or the after-effects of stroke. Nearly one-half of all African Americans age 20 and older have some form of CVD: 48% of women and 46% of men. Direct and indirect costs of CVD and stroke total more than $320.1 billion. This total includes health expenditures and lost productivity. The projected total cost of CVD is expected to rise from $656 billion in 2015 to more than $1.2 trillion in 2030 (61).
CVD Prevention and Cardiovascular Health
There has been an expanded focus in the United States on CVD prevention and cardiovascular health with an emphasis on healthy behaviors (diet, physical activity, weight control, and not smoking) and health factors (control of blood cholesterol, blood pressure, and blood sugar). The AHA 2015 Statistical Update offers details about these behaviors and health factors (61).
Although there has been a substantial decline in tobacco use in the United States, it remains the second leading cause of total death and disability. In adults, cigarette use declined from 24.1% in 1998 to 17.9% in 2013. Among high school students, the decline was from 36.4% in 1997 to 15.7% in 2013. Still, almost one-third of coronary heart disease deaths are attributable to smoking and exposure to second-hand smoke.
According to the 2013 National Health Interview Survey, only one-half of American adults meet the current goal of more than 150 min of moderate aerobic physical activity or 75 min of vigorous aerobic physical activity weekly. Women (46.1%) were less likely to meet the goal than men (54.2%). Between the National Health and Nutrition Examination Survey (NHANES) 1988 to 1994 and NHANES 2001 to 2006, the non–age-adjusted proportion of adults who reported engaging in >12 instances of physical activity per month declined from 57.0% to 43.3% in men and from 49.0% to 43.3% in women. The AHA recommendation for overall cardiovascular health is at least 30 min of moderate-intensity aerobic activity at least 5 days per week for a total of 150 min; or at least 25 min of vigorous aerobic activity at least 3 days per week for a total of 75 min; or a combination of moderate- and vigorous-intensity aerobic activity and moderate- to high-intensity, muscle-strengthening activity at least 2 days per week for additional health benefits.
Diet and nutrition
The leading risk factor for death and disability in the United States is suboptimal diet quality, specifically insufficient intake of fruits, nuts/seeds, whole grains, vegetables, and seafood, as well as excess intake of sodium. Although more healthful diets cost modestly more than unhealthful diets, the difference is not always prohibitive. In a study comparing 20 fruits and vegetables versus 20 common snack products, such as chips, cookies, pastries, and crackers, the average price per portion of fruits and vegetables was 31 cents, with an average of 57 calories per portion, compared with 33 cents and 183 calories per portion for snack foods.
Although the overall prevalence of obesity in U.S. youth was unchanged between 2003 to 2004 and 2011 to 2012, the prevalence did decrease among those age 2 to 5 years. Obesity decreased among those with higher socioeconomic status but increased among those of lower socioeconomic status. The overall prevalence of severe obesity in U.S. youth (5.9%) continued to increase, especially among adolescent boys.
In a report published in JAMA Internal Medicine, researchers from Washington University School of Medicine in St. Louis studied data from 2007 to 2012 of a nationally representative group of 15,208 people ages 25 or older. The researchers estimate that during that time period, 40% of men were overweight and 35% of men were obese. They estimate that 30% of women were overweight and 37% were obese (62).
High blood pressure
Based on 2009 to 2012 data, 80 million U.S. adults have hypertension (32.6% of adults over 20 years of age). African American adults have among the highest prevalence of hypertension in the world, with age-adjusted prevalence of hypertension of 44.9% for men and 46.1% for women. NHANES data from 2009 to 2012 revealed that among U.S. adults with hypertension, 54.1% were controlled, 76.5% were currently treated, 82.7% were aware of the condition, and 17.3% were undiagnosed. The trend in the control of blood pressure has improved among hypertensive adults, resulting in a higher percentage with blood pressure at the optimal or prehypertension level and a lower percentage in stage 1 and stage 2 hypertension.
High blood cholesterol and other lipids
A total of 75.7% of children and 46.6% of adults have ideal cholesterol levels. Prevalence of ideal levels has improved over the past decade in children but remained unchanged in adults. According to 2009 to 2012 NHANES data, more than 100 million U.S. adults over 20 years of age have total cholesterol levels >200 mg/dl and almost 31 million have levels >240 mg/dl.
Diabetes affects 1 in 10 U.S. adults, with 90% to 95% of cases being type 2. Diabetes disproportionately affects racial and ethnic minorities. Type 2 diabetes, historically diagnosed primarily in adults over 40 years of age, is becoming increasingly common in children and adolescents. The prevalence of type 2 diabetes in children and adolescents has increased by 30.5% between 2001 and 2009, and it now constitutes one-half of all cases of childhood diabetes.
Global Burden of Disease
CVD is the leading cause of death globally. An estimated 17.5 million people died from CVD in 2012, representing 31% of all deaths. Of these deaths, an estimated 7.4 million were due to coronary heart disease and 6.7 million were due to stroke. More than three-quarters of CVD deaths occur in low- and middle-income countries. Figure 27 from the WHO shows the global burden of CVD in men as measured in disability-adjusted life years (63).
WHO Action Plan for Noncommunicable Disease (NCD)
Under the leadership of the WHO, all member states (194 countries) agreed in 2013 to reduce the number of premature deaths from NCD by 25% by 2025 through 9 voluntary global targets. Two of the global targets directly focus on preventing and controlling CVD. The sixth target in the Global NDC action plan calls for a 25% reduction in the global prevalence of high blood pressure. The eighth target in the plan states that at least 50% of eligible people should receive drug therapy and counseling (including glycemic control) to prevent heart attacks and strokes. In 2015, countries will begin to set national targets and measure progress based on 2010 baseline data. In 2018, the UN General Assembly will convene a third high-level meeting on NCD to take stock of national progress in attaining the voluntary global targets (64).
Drivers of Global CVD Mortality
A 2015 study published in the New England Journal of Medicine found that the aging and growth of the population resulted in an increase in global cardiovascular deaths by 41% between 1990 and 2013, despite a 39% decrease in age-specific death rates in most regions. The study, using data from the Global Burden of Disease Study of 2013 (including data on 188 countries), found the increase in global cardiovascular deaths was driven by a 55% increase in mortality due to the aging of the populations and a 25% increase due to population growth. The relative contributions of these drivers were found to vary by region. Only in Central Europe and Western Europe did the annual number of deaths from CVD actually decline, suggesting gains in cardiovascular health that were sufficient to overcome demographic forces. The authors speculate that declines in cardiovascular deaths due to epidemiologic change “are probably due to the combined effect of birth cohorts’ decreased exposure to tobacco smoking, improvements in diet, identification of cardio-metabolic risk factors, increased focus on prevention and improved treatment of cardiovascular disease” (65).
U.S. HealthCare System
Commonwealth Fund Update Shows U.S. Healthcare Continues to Underperform
In a 2014 update of its multi-year comparison of healthcare systems in industrialized countries, The Commonwealth Fund reports that while the United States has the world’s most expensive healthcare system, it continues to underperform relative to other countries on most dimensions measured. Among the 11 nations studied in the report (up from 7 in previous versions), the United States ranks last overall, as it did in the 2004, 2006, 2007, and 2010 editions. The report says the United States fails to achieve better health outcomes than several of the other counties and is last or near last on dimensions of access, efficiency, and equity. The report incorporates patient and physician survey results on care experiences and ratings on various dimensions of care.
The most notable way the United States differs from other industrialized nations, according to the report, is the absence of universal health insurance. The report notes that the ACA is increasing the number of Americans with coverage and improving access to care. Much of the data in the report are from years prior to the full implementation of the ACA, and thus it is not surprising that the United States underperforms on measures of access and equity (Figure 28). Major findings of the 2014 update include:
Indicators of quality include effective care, safe care, coordinated care, and patient-centered care. The United States fares best on preventive and patient-centered care, while lower scores on safe care and coordinated care pull the U.S. quality score down.
Americans are most likely to say they have had access problems related to cost. Patients in the United States have rapid access to specialized health services, but are less likely to report rapid access to primary care. In some countries, such as Canada, patients have little to no financial burden, but may experience wait times for specialized services. The Netherlands, U.K., and Germany provide universal coverage with low out-of-pocket costs, while maintaining quick access to specialized services.
The United States ranks last in efficiency, with poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, avoidable emergency room use, and duplicative medical testing.
The United States ranks a clear last on measures of equity. Americans with below-average incomes were much more likely to report not visiting a physician when they are sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses because of cost (66).
Many Drivers of Increased Spending
There are many forces driving healthcare spending. An annual series of Commonwealth Fund-sponsored analyses of Organization for Economic Cooperation and Development (OECD) health data dating back to 1999 has explored a number of potential factors, including: administrative complexity, the aging of the population, the practice of “defensive medicine” under threat of malpractice litigation, the burden of chronic disease, healthcare supply and utilization rates, resource allocation, and the use of technologically advanced equipment and procedures. These and other studies have found, contrary to often-cited explanations, the United States has a relatively young population, average or below average rates of chronic conditions, and comparatively few doctor visits and hospitalizations compared with other industrialized countries. Instead, these studies suggest major reasons for higher spending in the United States include substantially higher prices and more fragmented care delivery, a higher percentage of specialists, higher hospital spending per discharge, and the highest levels of drug utilization, prices, and spending (67) (Figure 29).
JAMA Article Outlines Anatomy of U.S. Healthcare
A study titled “The Anatomy of Health Care in the United States, published in JAMA, uses publicly available healthcare data from 1980 to 2011 to build a U.S. healthcare trend profile. The study shows 2011 spending on healthcare topping $2.7 trillion, doubling since 1980 as a percentage of the U.S. GDP at almost 18%. In the same year, U.S. healthcare employed 15.7% of the workforce.
Although the average life expectancy of U.S. citizens has lengthened by 30 years since 1900, averaging 81 years for women and 76 years for men, the study authors said the rise of healthcare expenditures has little to do with the aging population. Between 2000 and 2011, increase in price (particularly of drugs, medical devices, and hospital care) as opposed to increased demand for services or demographic change produced most of the increase in the healthcare sector's share of GDP, according to the study’s authors. In addition, the study found personal out-of-pocket spending on healthcare actually fell by one-half, from 23% in 1980 to 11% in 2011. The study says chronic illness accounts for 84% of the costs overall.
Study authors point out 3 factors that have caused the most change in the period studied:
1. Consolidation—with fewer general hospitals and more single-specialty hospitals and physician groups, producing financial concentration in larger healthcare systems, insurers, pharmacies, and benefit managers;
2. Information technology—in which investment has been made, but with value proving elusive and mass-scale resulting in better coordination of care not yet produced; and
3. Patients as consumers—with patients seeking new sources of information and demanding more accountability and transparency, and patient satisfaction being tied to financial metrics for many organizations (68).
HealthCare Spending Expected to Increase After 5-Year Slowdown
Estimates from the Office of the Actuary at CMS, in a study published in Heath Affairs, predicts that U.S. healthcare spending will increase faster in the next decade than it did during the Great Recession. Healthcare spending increased by 3.6% in 2013, by 5.6% in 2014, and is projected to increase by 6% a year from 2015 to 2023. The increased rate of growth is based on the continued implementation of the ACA coverage expansions, faster projected economic growth, and the aging of the population. This rate of increase, however, is lower than during the period from 1990 to 2008 when the average annual growth rate was 7.2%. The healthcare share of GDP is expected to rise to nearly one-fifth of the nation’s economy by 2023.
Economists on the study attributed the recent slowdown to a number of factors, including the sluggish economy during the recession as individuals and state and local governments curbed their spending on healthcare, slower growth per person in Medicare, increases in cost sharing for the privately insured, changes in medical practice, and a shift from high-priced prescription drugs to less costly generics.
Specifically for Medicare, study projections show that from 2016 to 2023, an increase in enrollees and the likelihood they will use more services as they age will cause Medicare spending to grow by an average of 7.3% per year, which is still 2.2 percentage points lower than in 2008. By 2023, health expenditures financed by federal, state, and local governments are projected to account for 48% of national health spending, up from 44% in 2012 (69). Figures 30 and 31 give additional detail from the CMS national health expenditure projections, including distribution of spending and average annual growth by type of service and type of payer.
ACA Total Projected Costs Lower
The CBO announced in March 2015 that the ACA would cost $142 billion, or 11% less than the most recent earlier projection because health insurance premiums are rising more slowly, thus requiring less of a government subsidy. Projections of the cost of the law have been falling for several years, and now analysts are beginning to assess the law’s impact from its first full year of implementation (70).
Medicaid Expansion Spreading but Costs More Per Person Than Expected
As of July 16, 2015, 31 states including the District of Columbia have adopted the expansion of their Medicaid programs under the ACA and 19 states are not currently adopting the expansion (71) (Figure 32). The CMS Office of the Actuary reported that Medicaid costs per person were significantly higher than expected (approximately $1,000 per person higher) due to the newly covered individuals’ pent up need for health services (72).
Report to Congress Details EHR Adoption Process
In October of 2014, the Office of the National Coordinator for Health Information Technology (ONC) in its annual Report to Congress outlined the rapid growth of EHR technology since the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009. According to the report, the health information technology infrastructure has grown rapidly and become more flexible and resilient, but much progress remains to be made, particularly in health information interoperability and the “sharing of patient information electronically across organizational, vendor and geographic boundaries.”
According to the report, in 2013, 59% of hospitals and 48% of physicians have a basic (meeting minimum standards related to clinical information order entry and results management) EHR system, recording respective increases of 47 percentage points and 26 percentage points since 2009. There also is widespread participation among eligible hospitals and professionals in the CMS EHR incentive programs.
The report says despite progress in establishing standards and services to support the Health Information Exchange (HIE), there is not yet sufficient standardization to allow seamless interoperability because it is “still inconsistently expressed through technical and medical vocabulary, structure and format, thereby limiting the potential uses of the information to improve health and care” (73) (Figure 33).
ONC Outlines Drivers of EHR Adoption
According to the data released by ONC in late 2014, the use of financial incentives, the availability of technical assistance, board certification requirements, and the ability to exchange patient information with other providers were among the top drivers of EHR adoption. Data from the 2013 National Ambulatory Medical Care Survey showed that 80% of physicians said they were already using an EHR or were planning to implement the technology. Some 62% of physicians who adopted health IT tools identified financial incentives and penalties as a major influence on their decisions to adopt, compared with only 23% of physicians who adopted before 2009. Of the EHR adopters, 82% were using a meaningful use-enabled EHR. For those who did not plan to adopt an EHR, lack of time and other resources was most often cited as the reason (Figures 34 and 35).
According to the data, with an EHR adoption rate of 77%, primary care physicians outpaced physicians in medical specialties (68%) and surgical specialties (63%). Practice size made a difference in adoption rates, with approximately 92% of physician practices with >11 physicians adopting EHRs, compared with 67% of practices with 2 or 3 physicians and just 47% of solo physicians (74).
EHR Adoption High, but Barriers to Health Information Exchange Exist
Despite rapid adoption of EHR systems, the ONC in its report to Congress said that electronic health information is not sufficiently standardized to allow seamless operability, limiting the ability of healthcare professionals to share patient health information across organizational, vendor, and geographical boundaries (72). Frustration at the slow progress of EHRs was also brought out at a recent Senate hearing to find legislative improvements to assist EHR adoption. Witnesses at the hearing put some of the blame on the vendor community, citing reports of vendors establishing proprietary standards that effectively turn their medical records into walled gardens, undermining interoperability by design. Senators suggested that the industry needs some measure of harmonization to ensure that privacy and security features hold from one system to the next (75).
The American Hospital Association has formed the Interoperability Advisory Group (IAG) and has issued a report, “Achieving Interoperability That Supports Care Transformation,” which identifies and addresses barriers to interoperability in 3 major categories: insufficient infrastructure, technology challenges, and unresolved policy issues. The American Hospital Association's report recommends that health systems identify priorities and make these priorities clear to vendors. The report also urges the federal government to emphasize standards, certification, and testing and discourages state governments from establishing unique requirements (76).
Cardiology Study Shows Significant Adoption but Room for Improvement
An August 2014 ACC study of benefits and challenges associated with information technology says nearly 8 of 10 (78%) cardiologists indicated they have been using EHRs for 2 years or more, and 9 of 10 survey respondents said they have a fully functioning EHR program or are in the process of implementing one. In addition, nearly 80% of respondents said they are participating in the EHR incentive program, up from 58% in 2011.
Nearly all of the respondents said their EHRs allowed for patient/clinical notes (95%), ordering of prescriptions (93%), and electronic tracking of patient medications (92%). In addition, 76% of those surveyed said their EHRs are capable of importing lab results, and 50% report EHRs capable of reporting imaging results. Respondents said their EHRs had the greatest impact on timely access to medical records and prescription refills, helping to avoid medical errors, and assisting in communication with other providers. However, only approximately one-third of cardiologists indicated they were extremely/very satisfied with their EHR systems overall, most often citing lack of interoperability with other software and lack of integration with medical devices as sources of dissatisfaction (77).
Beyond Stage 1: Frustration Grows Over MU Program
The American Recovery and Reinvestment Act of 2009 authorized the CMS to provide financial incentives to providers and hospitals for adopting MU of certified EHR technology. Under this authority, the ONC set standards, implementation specifications, and certification criteria for electronic medical record technology. MU is a 3-stage compliance program that requires providers to show that they use EHRs in measurable ways. To receive financial incentives (and, over time, to avoid financial disincentives), physicians and hospitals must attest to reaching different stages of MU (78). Stage 1 was designed to drive adoption of EHR and has achieved substantial success. Stages 2 (advanced clinical processes) and 3 (improved outcomes) are proving to be more difficult.
Although a majority of physicians have implemented EHRs, the AMA says most are not getting what they expected from the technology, and the organization is encouraging clinicians to share their perspectives on EHRs and the MU program. The AMA in late 2014 released a framework to prioritize EHR usability woes. The organization said its members are complaining about ill-conceived EHR workflows, time-consuming data entry, interference with face-to-face patient care, and overwhelming fatigue with electronic messages and alerts. The AMA says a “one-size-fits-all” approach “diminishes the ability of the technology to perform the most critical function—helping physicians care for their patients” (79).
The adoption of Stage 2 of the MU program has been lackluster—as of mid-2015, only approximately one-quarter of eligible physicians and less than one-half of hospitals had participated. Disagreements over MU may only escalate in 2015, with eligible professionals seeing a 1% decrease in Medicare reimbursements for each year they do not meet MU requirements. That penalty will rise by 1 percentage point each year to a maximum of 5%. Responding to concerns in April 2015, CMS proposed easing of Stage 2 regulations, eliminating approximately 12 measures that were considered redundant and providing more flexibility in MU reporting (80).
In March of 2015, CMS issued proposed rules for Stage 3, which is scheduled to go into effect in 2017. This final stage requires providers to send electronic summaries for 50% of patients they refer to other providers, receive summaries for 40% of patients referred to them, and reconcile past patient data with current reports for 80% of such patients. The AMA and the Medical Group Management Association (MGMA) have sought a delay in Stage 3 rules, and Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor and Pensions Committee, said his committee would also push to delay implementation of Stage 3 rules (81).
ACC Active in EHR Adoption Process
The ACC, a long-time supporter of EHR adoption as a driver of improved patient care quality, has been active in helping members move through the information technology adoption process. The College’s Informatics and Health Information Technology Task Force addresses data interoperability, promotes EHR adoption, coordinates EHR vendor engagement, and develops tools and strategies to improve the effectiveness of ACC registries (82). The ACC regularly submits comments to CMS on the ever-evolving MU program, urging shorter reporting periods, more flexibility for incentive program participants, and less constricting requirements on some portions of the program (83). Interoperability remains a significant concern to the ACC, and in July of 2015, ACC Task Force member Michael J. Mirro, MD, testified about information blocking before a hearing of the Senate Health, Education, Labor and Pensions (HELP) Committee. Mirro said in his testimony that “many EHR vendors provide the functionality needed by the healthcare community, but also require the purchase of the specific company’s health IT products to make the elements of the EHRs fully interoperable.” Mirro added, “In emergency situations, the rapid secure exchange of health information is critical. We must work toward rewarding interoperability and discouraging information blocking” (84).
Report Highlights State Experiences in Establishing HIEs
In 2009, the ONC created the State HIE Program, offering states and territories $564 million in funding and providing guidance for states to enable secure electronic information exchange. To understand the effects of this program on HIE progress, the ONC contracted with the University of Chicago to conduct a multi-year evaluation. The evaluation report, issued in late 2014 highlights an in-depth assessment of 6 representative states (Iowa, Mississippi, New Hampshire, Utah, Vermont, and Wyoming) regarding their experiences establishing HIEs at the state level. One key finding was the importance of ACOs. In those states where there was an increase in ACOs, HIEs were found to be fundamental. This was the case in Vermont and Iowa, which had made more progress than some of the other states in the report. Successful states found that marketing their services to ACOs, or requiring ACO participation in state-led services, bolstered demand and participation. Another key factor was stakeholder engagement. States that were able to get large health systems on board early in the process made more progress than those that did not. Participation also increased in response to financial incentives at the state and federal level (such as MU) as well as to state-level requirements for participation. In a few states, legislative action was needed to address privacy concerns (85).
No More Delays on ICD-10 Transition
After 3 significant delays, the controversial transformation to ICD-10, the WHO’s medical classification system, began in October 2015. Some are saying the transition could be incredibly detrimental to small physician practices and others believe implementation is overdue because it may help healthcare providers better respond to health threats such as Ebola, better monitor the severity of diseases, and improve patient safety. ICD-10, used for diagnosis and procedure reporting, has been delayed 3 times—in 2009, 2012, and 2014—due in large part to vocal opposition from the AMA. For years, the AMA has been saying that the ICD-10 switchover “will create significant burdens on the practice of medicine with no direct benefit to individual patients’ care.” The estimated cost of ICD-10 implementation for small physician practices is approximately $8,167 but can reach tens of thousands of dollars, according to the Professional Association of Health Care Office Management. Previous estimates in 2014 had been significantly higher, but new educational and training materials now available should help providers lower implementation costs (86).
In response to AMA concerns in July of 2015, CMS and AMA announced efforts to continue to help physicians prepare for ICD-10 implementation. These revisions to ICD-10 policy include:
• For a 1-year period starting October 1, 2015, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes. In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. Medicare Administrative Contractors and Recovery Audit Contractors will follow this policy.
• To avoid potential problems with midyear coding changes in CMS’s quality programs (PQRS, VBM, and MU) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS has difficulties in accurately calculating quality scores (i.e., for PQRS, VBM, or MU). CMS will continue to monitor implementation and adjust the duration if needed.
• CMS will establish an ICD-10 ombudsman to help receive and triage physician and provider problems that need to be resolved during the transition.
• CMS will authorize advanced payments if Medicare contractors are unable to process claims within established time limits due to problems with ICD-10 implementation (87).
Technology Expertise Needed for ACO Growth
The estimated number of Americans covered by ACOs increased more than 30%, and provider organizations face technological challenges as they try to expand these value-based delivery models, according to Modern Healthcare’s annual list of ACOs by state. While some ACOs have EHRs that communicate well with each other and can track where care is delivered, others have dozens of EHRs among their participating groups that often are not interoperable. According to David Muhlestein with Levitt Partners Center for Accountable Care Intelligence, ACO healthcare platforms should have functions for population health management as well as staff trained in how to use these tools to coordinate care and keep patients healthy (88).
Health Information Technology Predictions for 2015
International Data Corporation (IDC), a global technology provider of market intelligence, recently released its IDC Health Insights annual list of health information technology predictions. This list of predictions for the period 2015 to 2020 includes:
• With healthcare costs rising, operational inefficiency will become critical at 25% of hospitals, resulting in the development of a data-driven digital hospital strategy that requires budget in 2016.
• By 2015, 50% of healthcare organizations will have experienced 1 to 5 cyberattacks in the previous 12 months with 1 of 3 attacks deemed successful, requiring healthcare organizations to invest in a multi-prong security strategy to avoid disruptions to normal operations and incurring fines and notification costs.
• Driven by the increased pressure to improve quality and manage costs, 15% of hospitals will create a comprehensive patient profile by 2016 that will allow them to deliver personalized treatment plans.
• By 2020, 80% of healthcare data will pass through the cloud at some point in its lifetime, as providers seek to leverage cloud-based technologies and infrastructure for data collection, aggregation, analytics, and decision making.
• To control spiraling healthcare costs related to managing patients with chronic conditions, 70% of healthcare organizations worldwide will invest in consumer-facing mobile applications, wearable technology, remote health monitoring, and virtual care by 2018, which will create more demand for big data and analytics capability to support population health management initiatives.
• As a result of increased pressures to deliver better outcomes of care more efficiently, payers will implement newer reimbursement models for 35% of their payments to providers in North America and the European Union within the next 36 months, resulting in related investments in quality measurement, payment, and billing systems.
• By 2020, 42% of all healthcare data created in the digital universe will be unprotected but needs to be protected, as use of data and analytics continues to proliferate and more stakeholders are involved in delivery of care (89).
Changes in Clinical Risk Assessment and Management of Lipid Abnormalities
ACC/AHA Release Prevention and Cholesterol Management Guidelines
On November 12, 2013, the ACC and the AHA jointly released both the Guideline on the Assessment of Cardiovascular Risk and the Guideline on the Treatment of Blood Cholesterol as well as a CV risk calculator as a companion to the new guidelines. The risk calculator can be accessed at http://tools.acc.org/ASCVD-Risk-Estimator/. These clinical documents introduced broader assessment and prevention strategies, made significant changes in recommendations for cholesterol management, laid the groundwork for possible future value-based payment strategies, and stirred controversy among clinicians and in the general public.
The new Guideline on the assessment of risk was broadened to include assessment of risk for stroke as well as heart attack, and it provided new gender- and ethnicity-specific formulas for predicting risk in African American and white women and men. An online risk calculator, which requires input of age, sex, information about smoking, total and high-density lipoprotein cholesterol levels, and systolic blood pressure, is designed to enable clinicians to generate 10-year risk estimates for specific patients. The Guideline also provided additional methods of determining a patient’s lifetime risk and weighed in on the usefulness of newer markers of risk (conditions that can be measured in urine, in blood, or by computed tomography). The Guideline did not support using these new risk measures routinely in risk management, but 4 markers showed promise if used after quantitative risk assessment to help inform treatment decisions. These markers include family history of premature CVD, coronary artery calcium score, high sensitivity C-reactive protein levels, and ankle brachial index (90).
The new Guideline on the treatment of cholesterol established new protocols for lowering blood cholesterol to help diminish cardiovascular risk in adults. The guideline no longer recommended treating to traditional LDL cholesterol targets, instead saying that clinicians should focus on assessing patients’ risk of atherosclerotic cardiovascular disease (ASCVD) events and whether they fall into 1 of 4 high-risk patient groups, for which moderate- or high-intensity statin therapy is recommended. These groups include:
• Patients with clinical ASCVD
• Patients with LDL cholesterol levels ≥190 mg/dl
• Older diabetic patients (age range, 40 to 75 years) with LDL cholesterol levels of 70 to 189 mg/dl and without clinical ASCVD
• Patients without clinical ASCVD or diabetes but with LDL cholesterol levels of 70 to 189 mg/dl and estimated 10-year ASCVD risk ≥7.5%
With few exceptions, the use of lipid-modifying drugs other than statins was discouraged and lifestyle modifications were recommended. Guideline authors acknowledged that some patients would not tolerate high-dose statins and that patient preferences should be discussed, particularly in primary prevention (91).
Break with Traditional Cholesterol Management Strategies Generates Controversy
Taken together, these new guidelines represented a major departure from previous approaches and generated significant controversy in both the clinical and lay press. Harvard Medical School researchers Paul M. Ridker and Nancy R. Cook reported their findings that the online calculator greatly overstated a patient’s risk of developing a heart problem and that the new guidelines would lead millions of additional people to take statins, exposing them to side effects with little potential gain (92). A study published in the New England Journal of Medicine estimated that 56 million American adults, or almost one-half those age 40 to 75 years, would be advised to take statins under the new guideline, compared with 43.2 million or 37.5% under the older guidelines (93). A The New York Times article gave voice to critics who said the drafting committee, in a departure from previous practice, relied solely on randomized-controlled clinical trials, ignoring other valuable data. The article included others who were critical of the sudden release of guidelines that would so greatly change existing practice (94).
Two Studies in 2015 Lend Support to the New Guidelines
In July of 2015, 2 separate studies were published that may lend support to the new guidelines: one suggesting that these guidelines are better at identifying who is truly at risk of a heart attack, and the other suggesting that treating more people with statins would be cost effective, even with a significant increase in use.
The first study, published in JAMA and funded by the NIH, looked at 2,400 individuals who participated in the Framingham Heart study and did not take statins to determine which of these participants would have been eligible for statins under the new guidelines versus who would be eligible under the older guidelines. As expected, more people were eligible under the new guidelines (39%) than under the old (14%). Then they looked at how often individuals in each group experienced a heart attack or stroke, or died from cardiovascular causes. The rate between the 2 groups was roughly equal (6.9% vs. 6.3%), suggesting that the new guidelines did not result in treatment of many more people who did not need statins. In addition, only 1% of participants deemed ineligible for statins under the new guidelines had a heart attack or stroke over 9 years, compared with 2.4% of those ineligible under the older guidelines, suggesting that the new guidelines may do a better job of identifying individuals who need statins and those who do not (95).
The second JAMA study from researchers at Harvard’s T.H. Chan School of Public Health found that treating patients who have a 7.5% risk of heart attack or stroke over the next decade was cost-effective, even though more people would be treated. They calculated that every QALY gained cost $37,000, a number considered acceptable. Even more lenient thresholds of 4% risk ($100,000 QALY) and 3% risk ($150,000 QALY) would prove cost-effective because of a projection of 125,000 to 160,000 fewer heart attacks and strokes each decade. An editorial accompanying the 2 studies said, “Available evidence indicates that statins are both effective and cost-effective for primary prevention, even among low-risk individuals” (96). The QALY is a generic measure of disease burden including both the quality and the quantity of life lived. An intervention with a lower cost to QALY, saved incremental cost effectiveness ratio (ICER) is preferred over an intervention with a higher ICER. In the United States, the acceptable value of a QALY is often set at $50,000 to $100,000 or higher (97).
Risk Calculator Forms Basis for CMS Risk Reduction Value-Based Payment Model
In May of 2015, CMS announced a request for applications for the Million Hearts® CVD Risk Reduction Model randomized-controlled trial to target incentives for providers to engage in individual CVD risk calculation and population-level risk management. Instead of focusing on the individual components of risk, participating practices will use the ACC/AHA Risk Calculator to engage in risk stratification across a patient panel to identify those at highest risk for ASCVD.
The model is designed to identify successful prevention and population health interventions for CVD implemented within the following framework:
• Universal risk stratification of all Medicare-eligible beneficiaries who meet the inclusion criteria using the ACC/AHA ASCVD Pooled Cohort 10-year Risk Calculator.
• Evidenced-based risk modification using shared decision making between beneficiaries and care teams in order to reduce ASCVD risk scores.
• Use of prevention and population health management strategies based on needs identified during risk stratification of beneficiaries.
• Reporting of continuous risk calculator variables, ASCVD 10-year risk score, and a cardiovascular PQRS measure set through a data registry provided as part of the model test. As an added benefit, participating practices will also have the option of reporting on additional PQRS measures to meet both the PQRS and VM reporting requirements (98).
FDA Approves First in New Class of Costly Cholesterol-Lowering Drugs
In July 2015, the FDA approved the first of a new class of drug that can sharply lower cholesterol levels: the PCSK9 (proprotein convertase subtilisin/kextin 9) enzyme inhibitors. The approved drug is alirocumab (brand name, Praluent), developed by Sanofi and Regeneron Pharmaceuticals. A second drug in the class, evolucumab (brand name, Repatha), which was developed by Amgen, was approved in August 2015.
The medication is injected, generally once or twice a month, and evidence from randomized-controlled trials suggests it is well tolerated and highly effective in reducing LDL cholesterol. The efficacy and safety of Praluent were evaluated in 5 placebo-controlled trials, involving 2,476 participants exposed to Praluent. All participants were at high risk for heart attack or stroke, and were taking maximally tolerated doses of a statin, with or without other lipid-modifying therapies. Participants taking Praluent had an average reduction in LDL cholesterol ranging from 36% to 59%, compared with placebo. The FDA approval for alirocumab is for patients who have had heart attacks, strokes, chest pain, or related conditions, or have a genetic condition that causes high cholesterol and who require additional lowering of LDL despite taking the highest dose of a statin that they can tolerate (99).
Regulators in Europe, where evolucumab recently was approved and alirocumab was recommended for approval, would allow broader use by people who have high risk but have not yet had a heart attack or stroke. Studies aimed at showing that the drugs prevent heart attacks and strokes are under way, but results are not expected until approximately 2018. However, results from current trials do suggest mortality benefits (100).
The approval of this new class of medications rekindled an ongoing concern about the high cost of so-called specialty medications. The list price for alirocumab is $560 per injection, equivalent to $40 per day or $14,600 per year. While these drugs are considered highly effective at significantly lowering blood cholesterol, the high cost and the fact that they will be prescribed for maintenance therapy for one of the world’s most prevalent medical conditions is generating major concern among health plans and pharmacy benefit managers (101,102).
CVS Urges Rewrite of Cholesterol Treatment Guidelines
In August 2015, CVS Health, the nation’s second largest pharmacy benefit manager, called on the ACC and the AHA to revamp the new cholesterol treatment guidelines to provide more clarity on the use of the new, more expensive PCSK9 medications. A letter from the company, published in JAMA, urged the medical professional societies to return to specific target levels for LDL cholesterol. The unusual move from CVS is the latest example of an escalating concern over ever-rising pharmaceutical prices, with insurers using aggressive tactics to obtain steep price discounts from pharmaceutical companies and tightly controlling patient access to the most expensive medications. CVS had indicated earlier that the company would demand evidence through blood tests if a patient wanted the new medications and claimed to be unable to tolerate statins because of side effects (103).
Ezetimibe Added to Statin Therapy after Acute Coronary Syndrome Shows Improvement
A study published in the June 18, 2015 edition of New England Journal of Medicine suggests that the addition of ezetimibe to statin therapy after acute coronary syndrome resulted in incremental lowering of LDL cholesterol levels and improved cardiovascular outcomes. The double-blind randomized trial involved 18,144 patients who had been hospitalized for an acute coronary syndrome within the preceding 10 days and had LDL cholesterol levels of 50 to 100 mg/dl if they were receiving lipid-lowering therapy or 50 to 125 mg/dl if they were not receiving lipid-lowering therapy. The combination of simvastatin (40 mg) and ezetimibe (10 mg) was compared with simvastatin (40 mg) and placebo. The median time-weighted average LDL cholesterol level during the study was 53.7 mg/dl (1.4 mmol/l) in the simvastatin–ezetimibe group, as compared with 69.5 mg/dl (1.8 mmol/l) in the simvastatin-monotherapy group (p < 0.001). The Kaplan-Meier event rate for the primary end point at 7 years was 32.7% in the simvastatin–ezetimibe group, as compared with 34.7% in the simvastatin-monotherapy group (absolute risk difference, 2.0 percentage points; hazard ratio: 0.936; 95% confidence interval: 0.89 to 0.99; p = 0.016) (104).
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 11, 2015.
- Revision received October 5, 2015.
- Accepted October 20, 2015.
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- Key Findings from the ACC Member Satisfaction Survey
- Emerging Payment Reform
- Changes in Certification and Recertification Requirements
- Healthcare Reform
- CVD Cost and Reimbursement
- Current and Emerging Workforce
- Team-Based Care
- Key Cardiovascular Statistics
- U.S. HealthCare System
- Information Technology
- Changes in Clinical Risk Assessment and Management of Lipid Abnormalities