Author + information
- Kim Allan Williams Sr., MD, FACC, ACC President∗ ()
- ↵∗Address correspondence to:
Kim Allan Williams, Sr., MD, FACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
“No outcomes, no income.”
—David Nash, MD, founding dean of Thomas Jefferson University’s School of Population Health in Philadelphia, summarizing the future of health care (1)Last month was unofficially “advocacy month” at the American College of Cardiology (ACC). It was the month when nearly 400 cardiovascular professionals descended on Washington, DC, as part of the College’s annual Legislative Conference. For 3 days, participants heard from ACC leaders and staff, lawmakers, representatives from federal agencies like the Centers for Medicare & Medicaid Services (CMS) and the Food and Drug Administration, and congressional staff about the largest issues facing the cardiovascular community. More importantly, they went to Capitol Hill to meet face-to-face with their members of Congress to advocate for policies that protect patient access to quality, cost-effective care.
Unlike previous years, when much of the College’s advocacy efforts were focused on temporarily halting the flawed Sustainable Growth Rate and encouraging a permanent solution, the College now has an opportunity to be more forward-thinking in discussions with lawmakers. The historic passage earlier this year of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the permanent repeal of the Sustainable Growth Rate that came with it means we can focus on how best to create a value-driven health system and drive down costs that are expected to reach $4.8 trillion in 2021, constituting 19.6% of the gross domestic product or $1 of every $5 spent (2).
The reasons behind these health care costs are many. We have an aging population that in no small way is a result of our successes in treatment of heart disease and a nearly 50% reduction in cardiovascular mortality over the past few decades (3). However, this success in treatment, rather than reduction of disease, has led to an increasing prevalence of chronic diseases and comorbidities in the face of limited funding for preventive services. The high cost of new technologies, accelerating costs of both new and generic drugs, increased administrative costs, and fragmentation of the health system also contribute to this rising tide. There is no 1 solution to counter all of these issues, but Congress, CMS, and other stakeholders have started to transition the current reimbursement system to one that rewards value over volume as a first step.
How this new system will look in its final iteration remains to be seen, but we do know that reform is under way. CMS targets have 90% of payment tied to quality by 2018 (4). Since 2019 is the first payment year, 2017 will likely be the first performance year for the merit-based incentive payment system or alternative payment models (APMs) under MACRA. The merit-based incentive payment system will combine the physician quality reporting system, meaningful use, and the value-based payment modifier—all 3 of which currently have separate systems and reporting deadlines—into 1 system. Under this program, eligible professionals, including physicians, physician assistants, nurse practitioners, and clinical nurse specialists, who elect to participate will receive annual payment increases (or decreases) on the basis of their performance. In terms of APMs, clinicians choosing to participate in a private payer APM and/or who receive at least 25% of their Medicare revenue through an APM beginning in 2018 will receive a 5% payment bonus. The threshold for receiving the bonus will increase over time as CMS and payers move toward value-based payment models. Accountable care organizations and patient-centered medical homes are current examples of APMs. Other models that incorporate quality measurement, the use of certified electronic health records, and the assumption of financial risk will be considered moving forward.
With the magnitude of these changes and the importance of getting things right, the College is following all of this closely and engaging with CMS, lawmakers, and other stakeholders about details and time lines. The need to develop relevant and reliable measures that can be used for quality improvement is one of the most important elements, followed by ensuring that clinicians receive the technical assistance necessary to succeed. The ACC’s vast experience in developing and running clinical data registries can play an important role here, given the need for reliable access to data and timely feedback on quality performance and variations in care. The ACC’s leadership in the development of performance measures working with other societies, the Physician Consortium for Performance Improvement Foundation, and the National Quality Forum will inform measure selection for use going forward. Alignment of measures used across federal, state, and private payers is of the utmost priority, as is ensuring that electronic health records, registries, and other health information technology networks are using the same datasets and terminology.
Care coordination both among clinicians and with patients is another critical element that needs to be considered as we move from a volume- to value-based system. This is also an area where the ACC can play a role. Just this past May, the ACC released a health policy statement focused on cardiovascular team-based care and the role of advanced practice providers. The basic premise: building teams that include advanced practice providers can help meet the challenges of cardiovascular workforce shortages, an aging patient population with growing complexities in cardiovascular care, and a payment system in transition. The College is also developing a comprehensive strategy, working in collaboration with key stakeholders, to improve population health. The ACC’s Diabetes Collaborative Registry and STS/ACC TVT Registry are also great examples of how the health care community can come together to track and improve care coordination across specialties.
On the patient front, the College continues to grow its CardioSmart patient-focused efforts with the recent launch of the “Find Your Heart a Home” hospital comparison tool (FindYourHeartaHome.org), as well as an online shared decision-making tool for anticoagulation for nonvalvular atrial fibrillation (www.cardiosmart.org/SDMAFib). Through the development of these and other resources over the last several years, the ACC can offer unique insights on how to effectively engage patients and their families in their care.
Engagement in advocacy is part of our professional responsibility. To paraphrase President John F. Kennedy, I like to think of advocacy as accepting our own responsibility for the future. For those cardiovascular professionals who attended the 2015 Legislative Conference, I thank you for taking time out of your schedules to represent your patients and colleagues on Capitol Hill and for sharing the many ways the cardiovascular community can continue to lead the way as we transition to a value-based system. For those who could not make it but have written letters or called your members of Congress; hosted lawmakers at your practice as part of our legislative practice visit efforts; provided expertise and feedback to ACC Advocacy staff on policy proposals; contributed to the ACC’s Political Action Committee; and/or filled in for colleagues to participate in advocacy efforts, thank you as well. Let us grab hold of our future and make sure we and our patients get the most value out of a value-based system.
- 2015 American College of Cardiology Foundation
- Versel N.
- Mangan D.
- Weisfeldt M.L.,
- Zieman S.J.
- ↵U.S. Department of Health & Human Services. Better, smarter, healthier: in historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value. Press release. January 26, 2015. Available at: http://www.hhs.gov/news/press/2015pres/01/20150126a.html. Accessed September 24, 2015.