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Session Offers Cardiologists Insights Into New Payment Models, ACOs

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Coverage of the 64th Scientific Sessions of the American College of Cardiology.

The Affordable Care Act (ACA) brought with it a host of provi-sions to change the way healthcare is delivered, all designed to make Americans healthier while making the system more accountable and less costly. Because cardiologists are more affected by these changes than most specialists their patients tending to be older, sicker, and more reliant on Medicare there is pressure on them to change the way they do business.

To teach cardiologists how to respond to new payment models, the 64th An-nual Scientific Sessions of the American College of Cardiology, held in San Diego, offered a March 15, 2015, session titled “Transforming Care: Innovations in Delivery and Payment Systems for Cardiovascular Care.”

Michael E. Chernew, PhD, professor of healthcare policy at Harvard Medical School and co-editor-in-chief of The American Journal of Managed Care, offered a policy overview to help cardiologists understand the forces behind new payment models, in particular accountable care organizations (ACOs). Because of federal fiscal concerns, it is important to understand that the policy dis-cussions surrounding payment reform are often motivated less by health and more by taxes, Chernew said, as policy makers seek to stem healthcare’s unsustainable share of federal spending.

Payment reforms represent one strat-egy to control spending growth, and one type of payment reform is simply to pay less, he said. But there is more enthusi-asm for developing a payment approach that moves away from the traditional fee-for-service (FFS) model and toward a system that bundles care across time and provider type. (For example, CMS recently announced that 30% of Medicare payments will need to be tied to value by 2016, and 50% by 2018.) Examples of such reforms include payment bundles for episodes of care and global payments for each patient.

An important step in the transition has been the creation of ACOs, which are healthcare systems that take responsibility for patients at all levels of care, while giving these systems opportunities to share in savings if they produce better than expected outcomes for their patient populations. While Chernew presented data showing significant ACO growth among Medicare ACOs, commercial insurers have also pursued risk-sharing models. As he explained later in the question-and-answer session, a challenge with ACOs is that while they are supposed to ensure coordination of care, it may not be in their interest to form direct relationships with post acute elements like skilled nursing facilties if the incentives are not in alignment.

ACOs were designed to slow spending growth, and Chernew presented data that showed this is happening for cardiologists. But ACOs have their problems, including patients not staying with the same ACO from year to year, or seeking care from non-ACO providers during the year. Another challenge is that currently, ACO payment is based on organization-specific performance, meaning that successful ACOs see a greater drop in benchmarks over the contract period. This discourages savings. Chernew noted CMS is likely to reform this part of the program in the future.

Andrew Ziskind, MD, a cardiologist and health system administrator now with Huron Consulting Group, Chicago, Illinois, discussed the specialty’s challenges due to its older patient population, whose costs run much higher than those of their European counterparts. Later, during the question-and-answer period, he elaborated on how this is largely due to American cultural differences that push medicine toward costly end-of-life care even when positive outcomes are unlikely. He subsequently called on fellow cardiologists to embrace and promote palliative care, an option which studies show is widely embraced by patients.

Controlling costs in the era of bun-dled payments, he said, will demand better management of outpatient care. As Chernew mentioned before him, trends toward consumerism happening in part because cost-sharing is being pushed down to patients mean that individual patients will have access to information about the price of tests and procedures that they would not have thought to ask for in the past.

The fundamental shift from FFS to payment for value is going to create more risk for providers, especially the govern-ment, which becomes a larger “payer” in the healthcare system.

Competition on price will come down to what is happening locally, Ziskind said. “We can talk about national trends, but the local market, each local metro area, is different.” How much provider compe-tition is there? What is the relationship with the hospital? Most critically, what is the culture of utilization: is it like the Northwest, with a culture of low utilization, or more like New York and Florida?

Shared savings will continue to be a force for change, he said, but it has a bottom. “The cost of care can’t go down to zero,” he said.

A key criterion for contractor relationships between providers and payers in the near term is, what are the exclusion criteria that allow payment to revert to fee-for-service? This is important to specialists.

Most of all, Ziskind encouraged cardiologists to become engaged in payment reform within their institutions, build better infrastructure, and demand a seat at the table. Cardiologists need to look for areas where they can help the systems they are in to improve, especially in chronic disease management. Tomorrow’s rewards will come from avoiding unnecessary costs. “You want to be preparing for the future. Protect your fee-for-service revenue, but at the same time, be preparing for the future,” Ziskind said. “If we as cardiovascular providers can do a better job of delivering care, the economic alignment is there.”

Cathleen Biga, CEO of Cardiovascular Management of Illinois, said the recent past has been a time of change in her organization. “When we left this conference 2 years ago we knew we had to do something,” she said. Navigating the transition from FFS to bundled payments is very difficult for providers, because “If you arrive too soon you might be penalized, and if you arrive too late you might be penalized.”

There’s no rule book, Biga said, “except the colleagues I call on a routine basis.”

CMS’ Center for Medicare and Med-icaid Innovation has models for acute, acute/post acute, and post acute care, and like Ziskind, Biga recommends that post acute care is where a health system’s focus has to be. Yet for cardiologists this represents a true change of mind-set, because many practitioners have spent careers performing procedures that had little to do with outpatient care. Today, Biga pays attention to what happens in nursing homes, because so much of a bundled payment can be consumed in that setting.

Cardiology, she said, is not a specialty like, for example, orthopedics, where a patient is treated, healed, and sent on his way. When a patient is diagnosed with cardiovascular disease, “You are part of our world forever.” This has meant “blowing up” a delivery of care model that Biga said “pigeonholed” caregivers. “We were not good at transitions of care.” It was hard to do but essential. Her organization worked with a convener, gathered tons of data, and had to learn to manage “this little thing called risk.”

Along the way came some interesting discoveries: it made more sense to keep a patient in the hospital an extra day than to send him to a nursing home and risk triggering a series of recertifications that would drive up costs. Cardiologists had to develop better relationships with hospitalists who controlled patients’ care. And the big one especially in the Chicago area has been gaining con-trol over decisions about which nurs-ing homes receive discharged hospital patients and ensuring that they receive quality care.

Details matter, Biga said. Paying attention to documentation and coding is essential. “The office is just as important to risk adjustment,” she said. “If you’ve got a sick, chronic patient, document it.” 

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