Changing Models of Physician Organization and Payment
The past several years have seen a dramatic shift in the way physicians are organized—away from privately owned solo and small practices to employment in larger, organized practice groups. More than 50 percent of the physicians in the United States are employed by hospitals or practice in integrated delivery systems, and the trend is increasing (Kocher and Sahni, 2011). Younger physicians view employment by health systems as providing greater lifestyle flexibility, albeit at a potentially lower salary (Harris, 2010). At the same time, the administrative costs of maintaining a small private practice, including those of bill collection and transitioning to electronic health records, are increasing. The move to risk-based payment such as that proposed for integrated delivery systems and other accountable-care organizations (ACOs) may also drive this trend as practice consolidation enables more effective management of financial risk (Kocher and Sahni, 2011). The chief executive officer (CEO) of the ACC estimated in 2010 that Medicare’s 2009 cuts to payments for cardiologists may have reduced the share of cardiologists working in private practice by half in only one year (Harris, 2010).
If the shift from private practice to large group practice entails a shift to a salaried payment model, organizations that bear financial risk may have strong incentives to maximize the use of OMT and target the use of PCI to patients who are most likely to benefit. These programs may involve appropriateness reviews, performance measurement, or financial incentives and thus may reduce the likelihood of using PCI for patients with stable CAD.
Conflicting Interpretations of Results by Professional Societies
Paradoxically, divisiveness among subspecialists may have inadvertently helped disseminate the COURAGE results. Many noninterventional cardiologists were concerned about overuse of PCI in the years preceding publication of the COURAGE findings. They therefore embraced the findings, while interventionists tended to criticize the study as flawed. At scientific meetings where the results were discussed, divisions between the specialties were observed to be particularly acute. Journalists took note, and a number of media stories appeared, raising questions among the public about the appropriateness of PCI.
Refined Appropriateness Criteria and New Efforts to Increase Their Use
Appropriateness criteria for the use of coronary revascularization existed before COURAGE, and most of our discussants believed the trial did not lead to the updates of the criteria that were published in 2009 (Patel, Dehmer, et al., 2009). Nevertheless, appropriateness criteria may be an important step toward reducing variation in the use of PCI, and COURAGE may have stimulated interest in integrating their use into clinical practice. Our discussants identified few contexts in which appropriateness criteria were being used consistently by providers as part of a quality improvement program or payment initiative. Some insurers, however, may be starting to embrace appropriateness criteria for diagnostic imaging procedures, which constitute a key step in the diagnostic pathway leading to PCI. Payers have come under fire for using radiology benefits managers (RBMs) with strict prior authorization requirements for cardiac imaging. Blue Cross Blue Shield (BCBS) of Delaware, for example, has been the subject of investigation for contracting with an RBM that has denied nuclear stress tests even when the decision did not agree with the ACC’s appropriateness criteria (Miller, 2011). The health plan is now moving to implement a clinical decision support tool that provides direct feedback to ordering clinicians based on appropriateness criteria (Mississippi Chapter of the ACC, 2011).
Some of our discussants were enthusiastic about the role of appropriateness criteria, while others argued that they have limited clinical utility because of the high proportion of indications rated as “uncertain.” One expert suggested that appropriateness criteria are not more widely used because only 40 percent of the indications in current appropriateness criteria are associated with objective evidence and define with clarity what is appropriate or inappropriate.
Growing Prominence of Clinical Registries
Numerous cardiovascular disease registries have emerged and evolved over the past several decades into large-scale quality improvement initiatives that many experts consider to be important potential drivers of practice change. For example, the NCDR Cath/PCI registry has updated its data collection form to be able to capture elements needed to rate the appropriateness of PCI procedures. Providers participating in this registry will soon receive feedback reports on the appropriateness of their cardiac interventions, along with benchmarking data. This will be the first time this type of reporting has been performed on such a large scale and at regular intervals. Efforts are under way within the VA health system to implement a similar technology. The ability to provide this type of information to providers is seen as a key element of outpatient quality improvement initiatives, and it can also help to improve the validity of the appropriateness criteria. Experts indicate that registries will become much more useful for CER as clinical end points are rigorously collected and audited.
Unlike their inpatient counterparts, which have a much longer history, outpatient cardiac registries are only now gaining in prominence. The ACC Pinnacle registry, which contains data from 700 providers, is a key source of data for improving the quality of outpatient care in cardiology—not least because it includes data on utilization both before and after patients undergo coronary intervention. The registry has evolved and now provides feedback reports at the individual-provider level at regular intervals; it is moving to a dashboard model in the next few months that will allow providers to have even more timely data for quality improvement.
Online Dissemination Tools
Experts have pointed to a wide range of online resources cardiologists can use to learn about new research, including Medscape, theheart.org, and Cardiosource (which is sponsored by the ACC). These websites not only present data from new trials but may offer features that are particularly valuable for the dissemination of research findings. The editors of Cardiosource are currently developing a point/counterpoint discussion between two experts about findings from research studies and their implications for practice. The intent is to address controversies head on, to discuss the limitations of each study, and to determine the types of patients to which the results apply. The website is also developing an interactive forum in which physicians can engage in discussions about research findings. Neither of these features is linked with continuing medical education (CME) credits; rather, they are designed for clinicians interested in a deeper understanding of the research and its implications for practice.
Growing Availability of Patient Decision Aids
Previous studies have shown that a substantial percentage of patients believe incorrectly that PCI improves their prognosis (Diamond and Kaul, 2007). Many cardiologists we spoke with believe that patients may not be adequately informed about the benefits of modern OMT, and if they were, many might decide to forgo PCI. Decision aids developed using CER results and other evidence may create a context for improved decisionmaking by patients. Although currently there are few financial incentives to support the use of patient decision aids, experts acknowledge that they would be more likely to be used if an ACO model were adopted.
Shared-decisionmaking demonstration projects are under way, but the approach appears to have made few inroads in cardiology. Nevertheless, stakeholders we spoke with indicated that two separate coalitions are seeking to launch shared-decisionmaking initiatives for patients with stable CAD. These efforts are taking place within systems where payment models are conducive to such a program. Patient decision aids are being used in some interventional cardiology practices to generate individualized predictions of risks and benefits based on data extracted electronically from a provider’s electronic health record (EHR). While this level of sophistication may not be necessary to successfully implement these types of decision aids, few practice settings would be able to implement such tools today. Apart from shared-decisionmaking aids, patient portals such as the ACC’s Cardiosmart.org are available to inform patients generally of the risks and benefits of different cardiac tests and procedures. However, the frequency with which patients use this information and its impact are unclear.
Increased Attention to Risks of Procedures
While there is broad consensus that PCI is relatively safe, cumulative exposure to radiation from various tests and imaging procedures is a growing concern. Performance measure developers such as the AMA Physician Consortium for Performance Improvement (PCPI) have begun discussing quality measures relating to assessment of radiation exposure, and implementing such measures might promote more awareness of these harms in the future. In addition, an editorial accompanying the release of the COURAGE trial’s quality-of-life results highlighted the small, but real, mortality risks associated with PCI. CER trial results that include data on the risks of each strategy, in addition to comparing the marginal benefit of each, may be useful for physicians and patients, who may assign different values to various benefits and risks.
Experimentation with Value-Based Insurance Design
Value-based insurance design is a strategy for increasing the use of high-value medical care through the use of cost-sharing levels that are inversely proportional to the amount of clinical benefit. In such schemes, copayments for OMT might be lower than those for PCI or might be waived altogether. For example, Aetna and other insurers have offered free preventive medications to diabetes and heart-disease patients (Diamond and Kaul, 2007). In the past, this approach has not been widely adopted, but one large insurer is currently laying the groundwork to implement value-based benefit plans, in which reimbursement levels would be linked to the most cost-effective treatment, and patients would pay the difference. The insurer is planning to implement this policy across a wide range of clinical conditions, all of which have strong enough evidence to justify its use.