Author + information
- Rishi K. Wadhera, MD, MPhil∗ ()
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Rishi K. Wadhera, Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115.
International efforts to emphasize training in health policy research and implementation are underway with the aim of tackling cardiovascular disease (1). Cardiovascular training programs in the United States should do the same, as fellows-in-training (FITs) are currently immersed in a rapidly evolving health care environment. As the U.S. health policy milieu becomes increasingly complex, it is vital that future cardiologists have a seat at the policy table and a strong voice in national efforts (2).
Cardiovascular training programs will need to evolve in parallel with a dynamic national health landscape to ensure the development of capable health policy leaders. Although the primary focus of fellowship programs is to ensure that trainees are prepared to care for patients with cardiovascular disease, many also have established pathways to develop academic cardiologists with expertise in clinical or basic science research. But, now more than ever, we also need to develop FITs who can navigate, formally study, and drive evidence-based shifts in policy to enhance cardiovascular health on a population level.
This paper will highlight why developing cardiovascular leaders in policy is imperative in the current U.S. health care climate and will also describe the role training programs can play to create the next generation of health policy leaders.
Why Develop Cardiovascular Policy Leaders?
Over the last decade, U.S. health policy has evolved dramatically on several fronts, especially regarding health care access, quality, and spending. More recent national policy initiatives will likely have a significant effect on cardiovascular disease epidemiology, care delivery, as well as the daily practice of cardiovascular medicine in the United States.
The Affordable Care Act (ACA), for example, was passed in part to address the high rates of uninsured individuals in the United States (3). Lack of insurance is clearly associated with a lower likelihood of screening for and treatment of cardiovascular risk factors, and as a result, a greater burden of cardiovascular disease (4,5). Following the ACA’s implementation, nearly 20 million predominately low-income individuals in the United States gained insurance (6). In the first year alone, 7 million of these individuals had or were at risk of cardiovascular disease (7). Consequently, FITs now and in the future have a unique opportunity to examine how large shifts in insurance coverage affect long-term cardiovascular disease epidemiology. Furthermore, although we know that uninsured patients with established cardiovascular disease are less likely to receive appropriate care and more likely to have worse outcomes, has this changed with insurance expansion (8,9)? And, most importantly, how has greater insurance coverage affected population-level cardiovascular health and outcomes (10)? As the contentious national discussion on whether to repeal, replace, or revise the ACA continues, training programs need to contemplate whether FITs are being equipped with the skills not just to investigate the ramifications of policy, but also to inform and influence policymakers during periods of debate and uncertainty.
The United States is also in the midst of health payment reform, the implications of which will clearly impact FITs. National efforts are underway to shift from the traditional paradigm of reimbursement per service provided to value-centric models for payment. For example, the mandatory hospital value-based purchasing program, enacted by the Centers for Medicare and Medicaid Services, puts a portion of hospitals’ revenue at risk based on performance on both costs of care and outcomes for common conditions. These efforts to enhance care quality while curbing spending are especially pertinent to cardiology, as costs associated with acute myocardial infarction and heart failure care have risen in the United States, and care for patients with heart failure in particular accounts for a significant portion of Medicare expenditures (11,12). As a result, payment models such as cardiac episode “bundled” payments now target cardiologists, and will hold hospitals financially accountable for care quality and spending for acute myocardial infarction care. In this context, it is critical that FITs with an interest in policy are capable of intimately engaging and examining the intended and unintended effects of payment reform. Furthermore, future cardiologists should spearhead the creation, development, and evolution of payment models that affect their own practice of cardiovascular medicine.
Beyond ongoing national health policy initiatives, it is increasingly evident that factors outside of the hospital walls contribute significantly to the incidence, progression, and outcomes of cardiovascular disease (13,14). Major gains still need to be made to address the social determinants of cardiovascular disease. And although the cardiovascular community has made great advances in preventative care and novel therapeutics, lack of health access, costs, or other socioeconomic and behavioral factors can mitigate the real-world effectiveness of these interventions (15). Future cardiovascular policy leaders, in collaboration with other disciplines, are needed to address factors beyond hospital walls that impede the prevention and treatment of cardiovascular disease.
How to Develop Cardiovascular Policy Leaders?
To be effective cardiovascular health policy leaders, trainees require nontraditional, multidisciplinary skillsets. Cardiovascular training programs can employ several strategies to encourage, support, and nurture the development of FIT leaders in health policy.
Medical education has generally not evolved in parallel with the rapidly changing U.S. health care system. However, medical schools and residency programs have recently begun to implement health policy curricula (16). Cardiovascular training programs should also make efforts to incorporate health policy topics into the longitudinal curricula of FITs. As an example, FITs should understand the factors that drive high heart failure readmission rates, evidence-based interventions to diminish readmissions, and the institutional repercussions of high readmission rates. After all, cardiologists as individuals collectively influence institutional performance on such quality measures. A basic understanding of contemporary topics, such as the ACA, novel cardiac reimbursement models, initiatives to tackle disparities in cardiovascular care, and public reporting of outcomes, amongst others, could empower and inspire FITs to examine and engage large-scale issues through policy. Cardiovascular disease and care does not occur in a silo, and a knowledge base of “big-picture” health policy issues and initiatives is essential not just for FITs with a burgeoning interest in policy, but also for the FIT community in general.
Establish a health policy pathway
Formally establishing a health policy track during cardiovascular training may serve as an impetus for prospective applicants and FITs to consider a career in policy. A focused pathway would direct FITs to seek out the tools, resources, and mentorship necessary to build a policy skillset at the start of training. It also provides an opportunity for programs to explicitly demonstrate support for and investment in this nontraditional career path, with the intent of developing future cardiovascular policy leaders.
Encourage diverse, collaborative mentorship teams
Of course, health policy is expansive, complex, and encompasses a broad range of issues including health systems, quality, value, equity, and politics and law. Furthermore, cardiovascular FITs with a passion for policy may choose to develop the skills needed to serve a variety of expert roles, such as researcher, educator, advisor, and/or physician advocate. As such, it is vital that FITs extend beyond the cardiovascular community to understand and delineate their potential role in the policy world, and better define the skills necessary to do so. FITs should be encouraged to engage interdisciplinary faculty, such as economists, business experts, sociologists, and/or health policy analysts within and outside of their university system. Collaborative, interdisciplinary mentoring can provide cardiovascular FITs with novel perspectives, new skills, and unique opportunities to engage health policy issues.
Support interdisciplinary training
Training programs also should encourage and provide trainees with time to pursue interdisciplinary educational paths. A Master of Public Health program, for example, could provide the quantitative biostatistical training necessary to carefully evaluate the effect of policy initiatives on cardiovascular care. Alternatively, a Master of Public Policy program might lay the groundwork for a career in health economics, health policy analysis, or even politics. Or, a Master of Business Administration program could help cultivate FITs who are adept at strategy, management, and marketing—skills that are all necessary to lead institutions and agencies through a changing policy environment. Cardiovascular FITs might also choose to pursue PhDs or further post-doctoral training in these fields or others that are deeply intertwined with health policy. Additionally, other advanced fellowships, such as the National Clinical Scholars Program or White House Fellowship, provide unique avenues for policy training. Irrespective of the path chosen, FITs who aspire to garner diverse skillsets beyond traditional cardiovascular training should receive the full support of a training program and departmental leadership to facilitate their development into a policy leader.
To improve cardiovascular health on a large scale, cardiologists need to have a strong voice in health policy. To do so, we need to start reinventing traditional paradigms for training, and fellowship programs should take steps to explicitly support the development of cardiovascular leaders in health policy. In this rapidly evolving national health environment, it is critical that FITs with a passion for policy be equipped with the skills to examine, create, and implement innovative, evidence-based policies that tackle cardiovascular disease.
- John Z. Ayanian, MD, MPP ()
RESPONSE: Charting a Path to Train Health Policy Leaders in Cardiology
With the passage of the Affordable Care Act in 2010, the U.S. health care system has experienced a more rapid and pronounced change than at any time since Medicare and Medicaid were launched in 1965. The proportion of nonelderly Americans who are uninsured has dropped by nearly one-half from 18.2% in 2010 to 10.3% in 2017 (1). Although coverage has expanded substantially, high-deductible health plans have grown from 25.3% among those with private insurance in 2010 to 42.3% in 2017 (1), requiring consumers to bear a rising share of their health care costs.
In parallel with these changes in insurance coverage, many physicians have become concentrated in larger provider organizations that are often integrated with hospitals, and electronic health records have been widely adopted. New models of value-based payment to promote better coordinated care, such as accountable care organizations, patient-centered medical homes, and bundled payments, are becoming more prevalent (2–4), as the long-standing fee-for-service system has begun to decline.
Amid these extensive changes in the financing and delivery of health care, Dr. Wadhera makes a strong case for cardiology fellowship programs to play a proactive role in preparing their trainees to become leaders in the rapidly evolving fields of health policy and health systems reform. As Dr. Wadhera notes, medical schools have begun incorporating basic concepts of health policy in their curricula. To gain a deeper understanding of health policy and health system reform, a small proportion of medical students complete joint degree programs in public health, public policy, or business. However, few physicians entering cardiology fellowship programs have had substantial exposure to health policy, and only a limited number of cardiology faculty members may be well suited to teach about health policy issues.
To achieve Dr. Wadhera’s goal of preparing cardiology fellows to influence health policy, cardiology fellowship directors can partner with faculty colleagues in health services research, health economics, and social epidemiology to provide the learning opportunities that he recommends. This training can also be integrated with leadership development efforts in cardiology (5). To address key policy issues in cardiovascular care more deeply, a subset of fellows can be encouraged to pursue advanced training in health services research or quality improvement, such as the National Clinician Scholars Program that Dr. Wadhera highlights (6). They also can be supported to attend and present their findings at national meetings focused on policy-relevant research, such as the annual Quality of Care and Outcomes Research Scientific Sessions of the American Heart Association (7) and the Annual Research Meeting of AcademyHealth (8).
The ideas that Dr. Wadhera has outlined will help to ensure that newly trained cardiologists are not just passive observers of changes in the health care system, but active participants in helping to lead and shape these changes. By blending strong clinical training with a broader and deeper understanding of health policy and the systems in which they practice, emerging cardiologists will be better equipped to promote health policies that benefit the patients and communities they serve.
- ↵Cohen RA, Martinez ME, Zammitti EP. Health insurance coverage: early release of estimates from the National Health Interview Survey, January–March 2017. National Center for Health Statistics, August 2017. Available at: https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201708.pdf. Accessed September 4, 2017.
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- ↵National Clinician Scholars Program. Available at: http://clinicianscholars.med.ucla.edu. Accessed September 4, 2018.
- ↵American Heart Association. Quality of Care and Outcomes Research Scientific Sessions, 2018. Available at: http://professional.heart.org/professional/EducationMeetings/MeetingsLiveCME/QCOR/UCM_316906_QCOR-Scientific-Sessions.jsp. Accessed September 4, 2018.
- ↵AcademyHealth Annual Research Meeting. Available at: http://www.academyhealth.org. Accessed September 4, 2018.
Dr. Wadhera is supported by National Institutes of Health Training Grant T32HL007604-32, Brigham and Women's Hospital, Division of Cardiovascular Medicine, and by the Jerome H. Grossman, MD, Fellowship in Healthcare Delivery Policy at the Harvard Kennedy School’s Healthcare Policy Program; and has served as a consultant for Sanofi and Regeneron.
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- ↵Kaiser Family Foundation. Key facts about the uninsured population. 2016. Available at: http://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/. Accessed September 12, 2017.
- ↵Garrett B, Gangopadhyaya A. Who gained health insurance coverage under the ACA, and where do they live? Urban Institute, 2016. Available at: http://www.urban.org/sites/default/files/publication/86761/2001041-who-gained-health-insurance-coverage-under-the-aca-and-where-do-they-live.pdf. Accessed September 12, 2017.
- ↵Ku L, Steinmetz E, Bruen B, Bysshe T. Effects of the Affordable Care Act on health insurance coverage of Americans at risk of cardiovascular disease. American Heart Association/American Stroke Association. Available at: http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_480864.pdf. Accessed September 12, 2017.
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