Feature article

Coordination, Consolidation, and Cost: Factors Cardiac Service Lines Should Consider in a Value-Based Environment

Despite modest declines in deaths from heart disease in 2017, cardiovascular disease (CVD) remains the leading cause of death in the United States, accounting for approximately 800,000 deaths annually, eclipsing all types of cancers and serious respiratory diseases1. CVD also carries a tremendous financial cost and is currently the most expensive condition for the American healthcare system to treat.2,3

Fueled by an aging population, a rise in type 2 diabetes, untreated high blood pressure, poor diet, and exercise, the incidence and costs of CVD are estimated to continue to soar in the coming decades4. Recent projections from the American Heart Association estimate that by 2035 approximately 45 percent of US population will have some form of CVD, with the total direct and indirect health care costs reaching $1.1 trillion3.

Dire statistics aside, the good news is that many CVD risk factors, such as obesity and high blood pressure, can be prevented or modified. Equally encouraging is the evolution of value-based systems of care --- programs that are shifting the focus of cardiac care from a traditional fee-for-service system to value-based care systems centered on quality, coordinated, evidence-based care, and improved patient outcomes5.  

The concept of value in healthcare is not new. Since the release of the Institute of Medicine’s landmark reports on the state of healthcare quality, To Err Is Human: Building a Safer Health Care System (1999) and Crossing the Quality Chasm:  A New Health System for the 21st Century (2001), improving the quality of healthcare in the U.S. has emerged as a national imperative. Multiple studies reinforced the call for quality improvements designed to address documented indicators of inadequate quality and wasteful utilization of healthcare resources6.

In 2010, the passage The Affordable Care Act (ACA) sought through legislation to ensure quality, affordable healthcare, and reduce healthcare costs by establishing initiatives that linked Medicare reimbursement to quality metrics. The cornerstone of this transformation was the provision of the “Triple Aim”: improving population health, reducing per-capita costs, and improving patient experiences.  

Medicare, the biggest purchaser of healthcare in the U.S., and CVD, the most common chronic condition among Medicare beneficiaries, were important factors these efforts7. Innovative payment and delivery models such as Accountable Care Organizations (ACOs), medical homes, and bundled payments were created to provide more coordinated care, limit unnecessary spending, and engage provider organizations in sharing both risk and outcomes8. Unlike fee-for-service, value-based care is data-driven, since providers are required to report specific metrics on value-based measures, such as hospital readmissions, adverse events, population health, among others.  While the ACA has had the most direct impact on Medicare, the law has also laid the groundwork and provided incentives for other payers to follow suit9.

While value-based payment provisions for cardiac care, such as bundled payments, are currently in flux, cardiac centers of care have continued to take on the challenges and opportunities of providing quality care to their patients. New delivery models have been designed to shift from providing high-intensity, expensive in-patient care to preventing, coordinating, and managing CVD through:

  • Intensive care coordination
  • Appropriate use of electronic health records
  • Implementation of new technologies, such as telemonitoring and other clinical decision support tools10

As cardiac care centers continue to evolve toward even greater consolidation, opportunities for expanded geographies of care and access to state-of-the-art technologies and enhanced clinical services increase exponentially. However, consolidation of cardiac services requires careful planning to avoid overlapping services and higher costs for patients11. If effectively integrated, both clinically and financially, consolidation among cardiac centers of care can result in a value-based framework that provides quality, cost-effective cardiology services on a regional level-—and more complex procedures, such as heart transplantation, in larger, more centralized hospitals with more advanced technology and coordinated care teams11.

Meaningful advances in value-based cardiac care will require the proper economic incentives to support changes in delivery and services, as well as address challenges for both primary-care and specialist physicians diagnosing and managing cardiac patients. In this new environment, high performing cardiac hospitals are well suited to provide a continuum of high-quality, value-based care10.

References:

  1. Heart disease and stroke deaths decline slightly, new statistics find. American Heart Association. https://news.heart.org/heart-disease-and-stroke-deaths-decline-new-statistics-find/. Accessed March 25, 2018. 
  2. Heart Disease and Stroke Statistics---2017 Update: A Report from the American Heart Association. Circulation. http://circ.ahajournals.org/content/early/2017/01/25/CIR.0000000000000485. Accessed March 25, 2018. 
  3. Heart Disease and Stroke Statistics: 2017 Update. American College of Cardiology. http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/02/09/14/58/heart-disease-and-stroke-statistics-2017. Accessed March 25, 2018. 
  4. Cardiovascular Disease: A Costly Burden For America Projections Through 2035. American Heart Association. https://healthmetrics.heart.org/wp-content/uploads/2017/10/Cardiovascular-Disease-A-Costly-Burden.pdf. Accessed March 25, 2018. 
  5. Thriving in a Value-Based World. American College of Cardiology. http://www.acc.org/latest-in-cardiology/articles/2015/06/08/09/39/thriving-in-a-value-based-world. Accessed March 25, 2018.  
  6. The Urgent Need to Improve Healthcare Quality, JAMA. https://jamanetwork.com/journals/jama/article-abstract/187987?redirect=true. Accessed March 25, 2018 
  7. Prevalence and Health Care Expenditures among Medicare Beneficiaries Aged 65 Years and Over with Heart Conditions. Medicare Current Beneficiary Summary. https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/Downloads/HeartConditions_DataBrief_2017.pdf. Accessed March 25, 2018.  
  8. Medicare System Delivery Reform: The Evidence Link. Henry J. Kaiser Family Foundation. https://www.kff.org/medicare-delivery-system-reform-the-evidence-link/. Accessed March 25, 2018.   
  9. Value-based care: Winning the Shift from Volume to Value. Deloitte Insights. https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles. Accessed March 20, 2018.
  10. Thriving in a Value-Based World. American College of Cardiology. http://www.acc.org/latest-in-cardiology/articles/2015/06/08/09/39/thriving-in-a-value-based-world. Accessed March 25, 2018.
  11. Rationalizing Cardiology Care in an Era of Hospital Consolidation. American College of Cardiology http://www.acc.org/latest-in-cardiology/articles/2015/06/02/13/03/business-consult-rationalizing-cardiology-care-in-an-era-of-hospital-consolidation. Accessed March 25, 2018.