The Future of Cardiovascular Healthcare Delivery (Part 1 of 2)

The U.S. healthcare system is changing rapidly. The following are thoughts on the future of how cardiovascular healthcare will be delivered, from the perspective of a clinical electrophysiologist. This first part is devoted to forecasting national changes to the delivery of care and the challenges that will come. It is not intended to be political, to address coverage, or to drive public policy. Part 2 of this editorial will address strategies that medical centers should consider in order to stay in front of the curve.

There are at least four national changes that can be expected in the delivery of cardiovascular healthcare over the next few years: further consolidation of hospital systems, increased emphasis on quality of care, evolution of the electronic medical record (EMR), and a greater focus on value (Figure). 

Hospital mergers and acquisitions are not new, but the pace has been variable by region. In some regions, consolidation has been extensive. For example, after Hurricane Katrina, Ochsner Medical Center in New Orleans partnered with several regional hospitals and clinics to create a large system based on a hub-and-spoke model. This type of arrangement allows for business efficiencies, improved purchasing power, and concentration of complex services, but comes with challenges. These challenges include managing multiple hospitals with variable sizes, cultures, physician compensation, and executive incentives. Managing such a network requires new approaches to triage and logistics, and continued investments in the hub to keep it healthy.

Consolidation in moderately sized American cities has resulted in only a few remaining local healthcare systems. For example, most hospitals in Cleveland appear to have partnered with either the Cleveland Clinic or Case Western Reserve University Hospitals. However, there are also limits to consolidation. In March 2017, the Federal Trade Commission stopped a merger between Advocate, a large healthcare system in the Chicago area, and NorthShore Hospitals, a smaller network in the North Chicago suburbs, over concerns that the merger would reduce competition and that consumers would ultimately pay more for healthcare. New issues will arise for healthcare providers as hospital systems grow, hospitals acquire physician practices, and insurance companies consolidate and limit choice for patients, including increased difficulty in referring patients to tertiary care centers that are out of network. 

The next few years will also see continued emphasis on quality in cardiology. Although there has already been an emphasis on quality over quantity, this patient-centric trend will continue, but with a renewed emphasis on local efforts. National efforts to improve quality have been centered around large registries, such as the ACC-NCDR ICD Registry. This approach provides benchmarks that some institutions find helpful, but requires a significant amount of effort and time relative to its impact, and is reliant on data of questionable reliability. A recent report from the PINNACLE Registry concluded that oral anticoagulation is underutilized in patients with atrial fibrillation, yet noted that despite “quality audits, which have shown much greater than 90% raw accuracy of data abstraction … due to a high rate of data missingness (44.4%), analyses specific to patient race/ethnicity were not performed”, and acknowledged that they could not “determine the validity of a reported contraindication.”¹ National registries have also created an army of data abstracters who are dissociated from those delivering the care and performing the procedures, rely on the registry employees for clarifications rather than the physicians taking care of the patients, and are simply focused on key word finding in the medical record. Local efforts can have a much greater impact with lower cost. For example, quality assurance (QA) meetings held regularly by medical directors of electrophysiology laboratories with the entire group present, where complications and outcomes related to electrophysiology procedures are systematically collected and reported, are more likely to identify local complication patterns that lead to targeted solutions, hold physicians accountable, identify outliers, and improve overall patient care. As hospital networks grow, these types of QA activities can expand to be more regional.

Quality improvement will also be helped by evolution of the EMR. There is no reason that the data in the EMR should have to be manually transferred by a data abstracter into a registry. One indicator that the EMR might change for the better is reflected in the ACC/ASE/ASNC/HRS/SCAI Health Policy Statement on Integrating the Healthcare Enterprise released last year.² In this document, the writers commented, “most healthcare information systems were developed with a focus on documentation to facilitate charge capture largely without regard to the needs or workflow of clinicians.” They concluded, “Using internationally recognized standards, Integrating the Healthcare Enterprise (IHE) provides a construct to create the technical frameworks to exchange healthcare data while maintaining the granular syntactic and semantic attributes needed to accommodate the needs of the diverse consumers of healthcare information.” These changes would allow for autopopulation of NCDR data already contained in the EMR systems.

Just as with quality of care, value has also been a focus in the delivery of cardiovascular medicine. But what is value? Unfortunately, the term “value” has been hijacked by hospital administrators as they narrowly focus on supply cost containment. “Value-added committees” have become a common approach by hospitals to vet new products requested by physicians. This system, driven by administrators and physicians who are not experts on the topics they are vetting, creates an unnecessary barrier. A better system to address value is to allow decisions on new products to be made by the local physician experts in the field, who work directly with the hospital administration and are held accountable for cost containment. Value should be centered on what is best for patients, and physicians should be incentivized to provide value to patients — “aligning reimbursement with value in this way rewards providers for efficiency in achieving good outcomes while creating accountability for substandard care.”³ Physician compensation is a challenge in large healthcare systems where the physicians are employees, but needs to move away from the current purely fee-for-service model.

As these changes occur in the delivery of cardiovascular healthcare, there will be strategies that centers of excellence should consider to become or remain leaders in the field. These strategies for leading cardiovascular programs include collocation of services, physician efficiency, closer partnerships with industry, expertise, and triage, and will be discussed in more detail next month in Part 2.

References

1. Hsu J, Maddox TM, Kennedy KF, et al. Oral Anticoagulant Therapy Prescription in Patients With Atrial Fibrillation Across the Spectrum of Stroke Risk: Insights From the NCDR PINNACLE Registry. JAMA Cardiol. 2016;1(1):55-62. 
2. Windle JR, Katz AS, Dow JP Jr, et al. 2016 ACC/ASE/ASNC/HRS/SCAI Health Policy Statement on Integrating the Healthcare Enterprise. J Am Coll Cardiol. 2016;68(12):1348-1364. 
3. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481.