Preparing for a Value-Based Health Care System

Over the last several years, health care reform efforts have compelled us to rethink how we deliver care. Economic pressures related to health care costs (1), concerns about quality, evolving medical technology, and improvements in metrics have combined to change the environment. These changes were clearly reflected in the bipartisan passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015. In addition to finally eliminating the flawed Sustainable Growth Rate formula used to calculate physician reimbursement, MACRA was also intended to move the United States toward the goal of a quality-based health care payment system that focuses on value (2). In large part, the basis of the law is the triple aim of improved outcomes, lower costs, and improved health of populations. This triple aim has become a cornerstone of U.S. health care delivery and has been incorporated into the strategic plan of the American College of Cardiology (ACC) (3).

How to best help cardiovascular professionals succeed in the transition from volume to value was a major topic of discussion at the ACC’s Board of Trustees (BOT) meeting in August. Taking center stage was an overview of MACRA-related issues, including the effect on the College, its members, and our patients. Many of the details of implementation of this complex legislation are not yet finalized. Highly engaged academic and nonacademic members of the College have worked tirelessly to review MACRA on behalf of our members and patients. The result has been the ACC’s detailed submission of comments to the Centers for Medicare and Medicaid Services (CMS) regarding its proposed MACRA rule (4).

The proposed rule by CMS includes positives, such as the opportunity to earn bonus points for reporting “high-priority” quality measures via a Qualified Clinical Data Registry (such as the ACC’s PINNACLE Registry and Diabetes Collaborative Registry). It also includes a menu approach to clinical practice improvement activities and recognition of all national medical specialty registries for clinical practice improvement. Additionally, the rule proposes incentives for participation in advanced payment models (APMs) and a movement away from “all or nothing” or “1 size fits all” scoring on electronic health record use. Incorporation of recognition of ongoing quality activities represents a significant advantage to ACC members, who are generally known among specialists to be engaged in this type of activity already.

The rule is not without its challenges as well. Over the next several months, the College will be working with CMS and fellow cardiovascular and medical specialty societies to engage with clinicians and practice administrators to ensure that they understand the reporting requirements and the scoring methodology. We will also be encouraging CMS to continue exploring options that would allow cardiology performance to be better reflected in group-level Merit-Based Incentive Payment System reporting, as well as ensure opportunities for specialists to participate in APMs. The College is also advocating for reduced Merit-Based Incentive Payment System reporting thresholds for small practices.

MACRA updates, as well as member tools and resources, continue to be built and promoted via the College’s online MACRA hub at ACC.org/MACRA. This continues to be 1 of the ACC’s top strategic priorities. Members of the MACRA Task Force have already provided recommendations for 2017 curriculum development and member communications and will continue to provide input to the BOT going forward. The College also remains engaged with CMS and other governmental agencies to help ensure that regulations stemming from MACRA are manageable for clinicians and are in the best interest of improved care.

Closely linked to MACRA, and another topic of strategic discussion at the BOT meeting, was population health management (PHM). The goal of PHM—as defined by the Institute for Health Technology Transformation—“is to keep a patient population as healthy as possible, minimizing the need for expensive interventions such as emergency department visits, hospitalizations, imaging tests, and procedures” (5). PHM activities in a value-based system reward efforts to prevent or reduce risks associated with chronic diseases like cardiovascular disease.

Over the last several years, as part of its strategic plan, the ACC has focused broadly on the concept of population health and on finding ways to partner with consumer groups; state, federal, and international agencies; and other medical specialty societies and nonprofit patient groups to improve the heart health of populations around the world. Thanks to the leadership of member leaders like John Gordon Harold, MD, MACC; William Zoghbi, MD, MACC; Kim Allan Williams, MD, MACC; Pamela Morris, MD, FACC; and so many others on the ACC’s Population Health Policy and Health Promotion Committee, Board of Governors, Member Section Councils, and Assembly of International Governors, we have made great strides in advocating for stricter tobacco policies, informing development of U.S. Dietary Guidelines, and making progress toward the World Health Organization’s goal of reducing mortality from noncommunicable diseases by 25% by 2025 (6–8).

Efforts toward promoting prevention of cardiovascular disease are vital to our overarching mission and will continue to be a focus of our advocacy and international efforts. In addition, the BOT feels that a stronger emphasis on PHM is needed in light of the looming MACRA implementation timeline and the very real need to help members thrive in a value-driven health care system. In its PHM report “A Roadmap for Provider-Based Automation in a New Era of Healthcare,” the Institute for Health Technology Transformation notes that PHM “is the key to accountable care and healthcare reform” (5).

The report argues for “applying technology to population health strategies to continually identify, assess, and stratify provider panels” (5). If done correctly, the authors suggest that “physician groups can use technology and automation to augment the role of care teams, manage the patient population more effectively and efficiently, drive better outcomes, and decrease overall cost, as demanded by new payment incentives focused on value” (5). The College leadership is sensitive to the fact that members have been expertly trained in the science and art of caring for individual patients, but most of us have not had experience or training in assuming responsibility for groups of patients. PHM moves us in this direction.

What does this mean for the ACC? The BOT feels strongly that our PHM initiative should focus on accountability for the quality, outcomes, and cost of the delivery of cardiovascular care for populations served by cardiovascular specialists. This includes developing and implementing member education, tools, and products that support clinicians, practices, hospitals, and health systems in their efforts to provide value-based health care and optimal team-based care. Tools and products also need to be developed that ensure quality and patient access to cardiovascular care in new payment and delivery models. There are also important opportunities to contribute to the evidence base for improving population health by advancing the knowledge and science of PHM in cardiovascular care. Collaboration with the growing network of partners in PHM both within and outside of the cardiovascular community will also be key. Ongoing engagement with CMS and other government agencies regarding implementation of PHM (including related evolution of payment models) is of the utmost importance.

The scope of potential activities relevant to PHM is very broad. To maximize the chance of success, we need to thoughtfully set priorities for action and strategic investment. In the near term, the College will be assessing member needs in this area. Additionally, the College will be actively exploring opportunities to engage in the development and implementation of APMs and episode payment models.

The recent CMS Bundled Payments Proposal for acute myocardial infarction and coronary artery bypass graft surgery is an area of intense focus. The 5-year demonstration project, which would start July 1, 2017, in 98 randomly selected areas, is part of efforts by the CMS to encourage coordinated care, improve the quality of care, and decrease costs for patients. Although the ACC supports the concepts of improving care and value, it is crucial that the implementation of these new payment systems, such as bundled care models, be carried out in such a way that clinicians are given the time and tools to positively affect patient care. We are optimistic that CMS will listen to comments, incorporate feedback from clinicians, and provide ample time for implementation of these new reimbursement models.

The evolving health care environment presents opportunities for dedicated clinicians to provide expert care at lower cost. At the same time, such change presents real challenges and certainly is associated with significant anxiety. We need to move from providing care for individual patients to also thinking more broadly about populations of patients and how to minimize their risks before major illness occurs. Change is never easy, but cardiology as a profession has long been on the forefront of change and innovation. It is the obligation of cardiovascular specialists to continue to strive toward providing the best care possible to our patients. It is the obligation of the ACC to facilitate members’ ability to do so in these challenging times.

• American College of Cardiology Foundation