Author + information
- Siqin Ye, MD, MS∗ ( and )
- Deepa Kumaraiah, MD, MBA
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
- ↵∗Reprint requests and correspondence:
Dr. Siqin Ye, Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH 9-320, New York, New York 10032.
“Every successful organization has to make the transition from a world defined primarily by repetition to one primarily defined by change.”
— Bill Drayton (1)
For young cardiologists, this adage may be concerning, as the fee-for-service healthcare system most familiar to us is transformed into one that emphasizes population health management and value-based care (2). Here we argue, however, that population health has always been integral to cardiovascular medicine, and that the ongoing changes can be highly advantageous to young cardiologists. We further offer suggestions for how young cardiologists can seize potential opportunities to thrive during this transformative period.
Cardiovascular medicine has long been a pioneer in population health (3), defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (4). Seminal cardiovascular studies, like the Framingham Heart Study, elucidated the population burden of cardiovascular risk factors such as tobacco use, hypertension, and hyperlipidemia (5), leading to their better management and to a reduction in the toll of cardiovascular diseases (6). Undertakings sponsored by the American College of Cardiology and/or the American Heart Association, such as the Get With The Guidelines registries and the National Cardiovascular Data Registry (7,8), are early examples of large-scale data collection and quality improvement that have become key features of population health management. As cardiovascular disease remains the leading cause of death in the United States as well as the health condition with the highest cost (9), its management will remain a prime focus of any population health strategy. This emphasis is reflected in new payment models such as accountable care organizations, which continue to rely on cardiovascular outcomes and quality metrics to assess performance and calibrate incentives through measures such as heart failure readmission rates, evidence-based medication prescriptions for ischemic heart disease and heart failure, and screening and control of cardiovascular risk factors such as hypertension and diabetes (10).
Nonetheless, the new focus on population health has led to some uncertainty and anxiety for young cardiologists. Expectations for future clinical roles have changed, as cardiology practices are increasingly acquired by hospitals and converted to salaried positions (11). We have often heard concerns from our peers and colleagues that payment reforms will result in decreased reimbursement and that increasing reporting mandates will result in physicians being held responsible for outcomes that are more determined by care team processes or by patient engagement. However, although approaches to care delivery transformation and payment reform remain an imperfect science, it is our firm belief that young cardiologists should be more encouraged than concerned by the shift toward population health.
One fundamental reason for our confidence is that young cardiologists receive rigorous, evidence-based training that allows them to deliver high-quality cardiovascular care, which, as highlighted previously, is a key aspect of population health. In addition, part of this training involves immersion within team-based, metrics-driven care processes, as any cardiology fellow rushing an ST-segment elevation myocardial infarction patient from the emergency department to the cardiac catheterization laboratory might attest. Our training also requires familiarity with the electronic health records and their benefits and limitations, and thus young cardiologists are likely to intuitively grasp how ordering and documentation can be tightly integrated with decision support and with reporting to data registries and payers. Young cardiologists, therefore, will be prepared with the essential tools to adapt to the transforming healthcare system and are poised to succeed in the new world in which rewards will be on the basis of better patient care and outcomes rather than volume. Future disruptions that could affect population health, such as mobile health, telemedicine, or wearable patient monitor devices, only further play to the generational strengths of young cardiologists who tend to be more technology and data savvy.
This is not to say, however, that the transition toward a healthcare system focused on population health management will always be smooth or seamless. Considerable challenges remain that will require innovative approaches to identify high-risk patients and to deliver efficient, effective, and patient-centered care so that patients receive the right care at the right time in the right setting. As Louis Pasteur once remarked, “fortune favors the prepared mind” (12). We, therefore, offer the following suggestions, partly on the basis of our own experiences, for young cardiologists to learn, engage, and lead, so as to invest in their own future career success in the era of population health.
The young cardiologist should be proactive and seek out knowledge pertaining to new payment and delivery models, how they are structured, and how performance is rewarded, especially for programs and metrics that are related to cardiovascular medicine. Such models might include state-based delivery system reform incentive payment programs or the various accountable care organization tracks, pay-for-performance, and value-based purchasing programs from Medicare, including the recently announced Million Hearts Cardiovascular Risk Reduction Model (13). Furthermore, given the increasing reliance on “big data” and the complexity of clinical operations, young cardiologists should take advantage of opportunities, when available, to pursue further training in areas such as statistics, informatics, financial modeling, predictive analytics, and process/outcome measurement, potentially through MS, MPH, MBA, or similar degree programs.
Young cardiologists should strive to participate in quality improvement and population health initiatives at their institutions or through professional organizations. Many hospitals and healthcare organizations are just starting to join the aforementioned population health-based programs, and young cardiologists, both because of their clinical training and familiarity with on-the-ground operations, can play valuable and important roles, especially during the start-up stage. The ancillary benefits of such engagement also include networking and a deeper understanding of quality improvement operations and implementation science, as well as potential for research and publications.
In addition, young cardiologists who find passion in these areas should seek out roles and positions for which quality of care, outcomes, and population health management are part of the job description. With the myriad changes to care delivery and payment systems, opportunities are ripe for leadership. We have no doubt that young cardiologists will be at the forefront of innovations in clinical operations and healthcare technology that will dramatically transform how healthcare is delivered and improve the health of our population.
- Salim Yusuf, MBBS, DPhil ()
RESPONSE: Why Are Population Health, Health Systems, and Clinical Medicine Equally Important?
The health of individuals depends upon the health of the entire community in which they live. For example, poor people in wealthy societies, on average, have longer life expectancies than wealthy people in some poor societies. Therefore, improving the health of the individual requires improving both individual health and that of the entire community (or for that matter, the larger community in their country and the world, which is why global health matters to all of us, including those who live in rich countries).
Clinicians intuitively understand that they can affect the health of an individual. But, how relevant is population health to the health of an individual? Take smoking as an example. Quitting or avoiding tobacco use at the individual level is a clinician’s task, which benefits the adherent individual. However, the rates of quitting—despite best efforts—are relatively modest, but nevertheless remain important. Population-level approaches to curb tobacco use, such as increased taxes or banning advertising, have a large effect as they affect the entire community, and moreover are sustained in entire populations. (It is even possible to eliminate diseases from entire countries, e.g., malaria or smallpox as a worldwide example.) Furthermore, the individual who wants to quit smoking tobacco can do so more easily when fewer people around him/her are smokers and when social or cultural norms, community laws, and the environment discourages smoking.
Population health is not just important for prevention, but it is also important in the treatment of various conditions. For example, in acute myocardial infarction, knowledge of its symptoms (achieved through mass health education) can prompt patients to seek earlier and rapid care, and health systems that favor rapid transportation of the individual to the appropriate center and the centralization of specialized care lead to the best outcomes for patients. After discharge from the hospital, continuity of care (in particular, prevention of recurrent events) depends on the organization of accessible and efficient systems geared toward prevention, but this depends equally on the health system and the environment in the community. Although the skills of individual physicians (or other health professionals) matter, the efficiency of the entire healthcare system has a larger effect. Thus, when individualized care (clinical medicine) is organized in the most cost-effective manner (health systems) embedded in a community (or nation or world) that promotes health through appropriate laws, agricultural, and food policies and has an educated population, these factors all work synergistically to lead to the greatest health benefits to both individuals and to the populace at large.
The future physician (or health professional) will not only know how to diagnose and manage specific conditions in individual patients, but also understand and participate in improving the organization of care of entire groups of patients, and equally importantly, understand how population-level strategies are just as vital to improving the health of individuals. All 3 approaches need to be fostered, appreciated, recognized, and rewarded. This will lead to the best health for all.
Dr. Ye is supported by a National Institutes of Health K23 career development award (K23 HL121144). Dr. Kumaraiah has reported that she has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- ↵Ludwig A. Ashoka chairman Bill Drayton on the power of social entrepreneurship. Forbes. Available at: http://www.forbes.com/sites/techonomy/2012/03/12/ashoka-chairman-bill-drayton-on-the-power-of-social-entrepreneurship/. Accessed October 21, 2015.
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